By Divya Jose, MSN , CCRN, CCM , ACM-RN
Case Managers are not just coordinating care; they are often the lifeline that helps patients navigate a complex and frequently confusing healthcare system. We are the ones providing resources to patients when they face a new diagnosis, transition from a hospital stay to home care, or deal with insurance-related issues. A big part of this job is ensuring that their care is effective and covered by insurance.
For patients 65 and older or those with disabilities, Medicare is a significant part of the picture. However, the system can be tricky to understand, with multiple parts, coverage limits, and rules that vary depending on the situation. As a case manager, we need to have a solid grasp of Traditional Medicare—its benefits, what it covers, and where it falls short. Without this knowledge, it's much harder to advocate for the patients, ensure they're getting the services they need, and avoid delays that could affect their recovery or quality of life.
What is Traditional Medicare?
Traditional Medicare, or Original Medicare, is the basic federal health insurance program comprising two main parts: Part A (Hospital Insurance) and Part B (Medical Insurance). It is available to U.S. citizens and permanent residents who are 65 and older, and to those under 65 who have specific disabilities or conditions like end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS).
The federal government manages traditional Medicare, and recipients can visit any doctor or hospital that accepts Medicare, without the need for referrals or network restrictions.
The Two Main Parts of Traditional Medicare
Medicare Part A: Hospital Insurance
Medicare Part A helps cover:
- Inpatient hospital care
- Skilled nursing facility care –short-term skilled nursing or rehabilitation services.
- Hospice care – Palliative care and support for both the patient and family.
- Home health care – For homebound patients
Cost: Most people don't pay a premium for Part A if they or their spouse have worked and paid Medicare taxes for at least 10 years. However, there may still be deductibles and coinsurance costs for the services covered by Part A.
Medicare Part B: Medical Insurance
Part B covers services outside the hospital:
- Doctor visits
- Outpatient care
- Preventive services
- Durable medical equipment (DME)
Cost: Part B requires a monthly premium, which can vary based on your income. Most people pay a standard monthly premium, but higher-income individuals may pay more. There is also an annual deductible, and you typically pay 20% of the Medicare-approved amount for services covered under Part B after the deductible is met.
What Traditional Medicare Does Not Cover?
While Traditional Medicare offers extensive coverage, it doesn't cover everything. Here are some things that are not covered under Part A or Part B:
- Prescription drugs (unless you're in a hospital setting)
- Routine dental care and dentures
- Routine vision care (like eyeglasses or contact lenses)
- Hearing aids
- Long-term care (such as nursing home care beyond short-term rehabilitative services)
- Cosmetic surgery
Beneficiaries often turn to Medicare Advantage plans (Part C) or Medicare Prescription Drug Plans (Part D) to cover these services.
How to Enroll in Traditional Medicare - Medicare Enrollment Periods:
Medicare has specific enrollment periods to ensure everyone gets the necessary coverage. Here are the key periods you should be aware of:
- Initial Enrollment Period (IEP) – This is the first time you can sign up for Medicare, and it lasts for 7 months: 3 months before your 65th birthday, the month of your 65th birthday, and 3 months after your birthday. It's important to enroll during this time to avoid late penalties and ensure there's no gap in your coverage. If you're already receiving Social Security benefits, you'll be automatically enrolled in Part A and Part B when you turn 65. If not, you can sign up for Medicare through the Social Security Administration
- General Enrollment Period (GEP) – If you miss your Initial Enrollment Period, you can sign up between January 1 and March 31 each year. However, keep in mind that if you sign up during the General Enrollment Period, your coverage will begin on July 1, and you may face late enrollment penalties.
- Special Enrollment Period (SEP) – If you or your spouse is still working and have employer-based health insurance when you turn 65, you may delay enrolling in Medicare without facing penalties. In this case, you can sign up for Medicare during a Special Enrollment Period when you retire or lose employer coverage. The SEP lasts for 8 months after the month your employer coverage ends.
- Open Enrollment Period for Medicare Advantage and Part D (Annual Enrollment Period) – Every year, from October 15 to December 7, you can make changes to your Medicare Advantage or Medicare Prescription Drug plan. This includes switching plans or returning to Original Medicare. Changes made during this period take effect on January 1 of the following year.
- Medicare Advantage Open Enrollment Period – If you're enrolled in a Medicare Advantage plan, you can make a one-time switch to a different Medicare Advantage plan or revert to Original Medicare from January 1 to March 31 each year.
Key Benefits of Traditional Medicare
- Flexibility: You can choose any doctor or hospital that accepts Medicare, without worrying about network restrictions.
- Nationwide coverage: Medicare is accepted by a large number of healthcare providers across the U.S.
- Comprehensive coverage: With both Part A and Part B, you get coverage for a wide variety of health services, from hospital stays to outpatient care.
Is Traditional Medicare Enough?
While Traditional Medicare offers broad coverage, many beneficiaries choose to supplement it with additional plans to fill in the gaps. There are two primary options for additional coverage:
- Medicare Advantage (Part C) – This is an alternative to Traditional Medicare and is offered by private insurance companies. It often includes extra benefits like prescription drug coverage, dental, vision, and hearing benefits.
- Medicare Supplement (Medigap) – These are private plans that help cover some of the costs that Original Medicare doesn't, such as copayments, coinsurance, and deductibles. Medigap plans only work with Original Medicare.
Conclusion
Traditional Medicare is an essential part of the U.S. healthcare system, providing reliable health coverage for millions of older adults and people with disabilities. By being having the knowledge in what Medicare covers and how it works, we can ensure that patients receive the right care at the right time, potentially reducing unnecessary hospital stays and helping them transition more smoothly to post-hospital care.
Reference:
Kalainov DM, Barnard C, Walradt J. Medicare in the 21 st Century: Understanding the Program to Promote Improvements. J Am Acad Orthop Surg. 2024 May 15;32(10):427-438. doi: 10.5435/JAAOS-D-23-00464. Epub 2024 Apr 9. PMID: 38595137; PMCID: PMC11042511.
Am J Manag Care. 2024;30(9):e266-e273. https://doi.org/10.37765/ajmc.2024.89605
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Bio: Critical Care Nurse turned to Case Manager professional who strongly believes which is the best profession to help others. Highly motivated Case Manager working at one of the Trauma level 3 County hospitals; Lyndon B. Johnson Hospital since 2021. Had 5 years of experience in Critical Care Unit at the HCA Hospital Healthcare West. Adapt at work effectively and quickly mastering the new skills. Utilizing case management education, skills and competencies to assist and empower patient and families. Obtained Bachelor of science in Nursing from Rajiv Gandhi University of Health science, India and MSN in Clinical System leadership from University of Arizona. Holding critical care certification CCRN and Case Management certifications: CCM and ACM-RN. Additionally Certified Lean Six Sigma Yellow Belt [ CLSSYB]. Active member in the organizations; CMSA, AACN and IANAGH. I am a proud employee selected as “Champion of the Quarter “in Harris Health System August 2022. In 2023, I was chosen as one among the Top #200 Nurses by Houston Chronicle and Excellence in Nursing Awards Bronze Medalist 2023. I take pride in the work that I do and believe that integrity should come first in every aspect in career.