Confused by Medicare? Here’s a Helpful Overview

By Jason D. Lazarus, J.D., LL.M., MSCC, CSSC

The following is adapted from The Art of Settlement.

The Medicare program—and the related Social Security Disability Income/Retirement benefit (SSDI)—is one of the primary benefit programs available to those who are injured and disabled. Understanding the basics of this program is imperative to protecting the client’s eligibility for their benefits.

Medicare and SSDI benefits are an entitlement and are not income or asset sensitive. Clients who meet Social Security’s definition of disability and have paid enough quarters into the system can receive disability benefits regardless of their financial situation.

The SSDI benefit program is funded by the workforce’s contribution into FICA (Social Security) or self-employment taxes. Workers earn credits based on their work history and a worker must have enough credits to get SSDI benefits should they become disabled. Medicare is a federal health insurance program. Medicare entitlement commences at age sixty-five or two years after becoming disabled under Social Security’s definition of disability. Medicare coverage is available again without regard to the injury victim’s financial situation.

The Medicare program is made up of different parts. Part A and Part B are thought of as traditional Medicare, which includes hospital insurance and medical insurance. Part A is the hospital insurance which covers inpatient care in hospitals and skilled nursing facilities (it does not cover custodial or long-term care—only Medicaid does). Part B benefits cover physician visits, durable medical equipment, and hospital outpatient care. It also covers some of the services Part A doesn’t cover, such as physical and occupational therapies as well as some home healthcare. Part D is prescription drug coverage that is provided by private insurers approved by and funded by Medicare. Part C—Medicare Advantage Plans or MAOs, offers all of the coverages through Parts A, B, and D but through a private insurer approved by Medicare. It is an alternative to the service fees for Parts A and B coverages, which can be elected and purchased by a Medicare beneficiary.

There is a connection between Medicare eligibility and SSDI. SSDI beneficiaries receive Part A Medicare benefits, which covers inpatient hospital services, home health, and hospice benefits. Part B benefits cover physicians’ charges, and SSDI beneficiaries may obtain coverage by paying a monthly premium. Part D provides coverage for most prescription drugs, but it is a complicated system with a large copay called the donut hole.

SSDI is the only way to get Medicare coverage prior to retirement age. This is pertinent as many injury victims become Medicare eligible by virtue of disability. Medicare and Social Security Disability Income benefits are an entitlement and are not income or asset sensitive like Medicaid/SSDI. Clients who meet Social Security’s definition of disability and have paid in enough quarters into the system can receive disability benefits without regard to their financial situation. The SSDI benefit program is funded by the workforce’s contribution into FICA (Social Security) or self-employment taxes. Workers earn credits based on their work history and a worker must have enough credits to get SSDI benefits should they become disabled. Medicare is our federal health insurance program and as discussed above, is broken up into multiple parts. Medicare entitlement commences at age sixty-five or two years after becoming disabled under Social Security’s definition of disability.

For more advice on Medicare, you can find The Art of Settlement on Amazon.

Jason D. Lazarus, J.D., LL.M., CSSC, MSCC is the founder and Chief Executive Officer of Synergy Settlement Services.  Synergy offers healthcare lien resolution, Medicare secondary payer compliance services, pooled trust services, settlement asset management services and structured settlements.  He is also the managing partner and founder of the Special Needs Law Firm; a Florida law firm that provides legal services related to public benefit preservation, liens and Medicare Secondary Payer compliance.  Jason is an Amazon Best-Selling author and his book; Art of Settlement is a detailed guide for trial lawyers related to regulatory compliance when resolving catastrophic claims.  His written work has been cited, as authoritative on Medicare compliance, by the Supreme Court of Florida and the United States Southern District of Florida.   Mr. Lazarus received his B.A. from the University of Central Florida and his J.D. with high honors from Florida State University. He received his LLM in Elder Law with Distinction from Stetson University College of Law.