Medicare and Social Security

Social Security's Medicare Coverage Works Like Private Insurance

If I Pay for Insurance, Why Do I Still Have Medical Bills

If I Pay for Insurance, Why Do I Still Have Medical Bills


   I think that all caregivers hate to deal with insurance and medical bills, whether they have private insurance, Medicare (Social Security’s insurance), Medicaid, or military coverage.  All insurance coverage is full of rules and restrictions, making it difficult for those unfamiliar with the language to understand their coverage limits and what they must do to comply. Furthermore, many of them reimburse payments slowly and require hours of extra paperwork for exception requests.  


Be Prepared for Denial


     Why is it so difficult to receive the benefits we need? I wish I knew the answer to that one. I know that usually, if you submit requests for something different (i.e., something not listed in the benefit book), be prepared to get a denial. It’s “common knowledge” that the first pass by a Medicare agent or Insurance adjuster is to find a way to say “No.”


Coverage Options 


   When it comes to paying for medical care, the options available include:

  • private insurance (provided by an employer, an affiliated organization, or purchased through the marketplace),
  • the government provided insurance (Medicare, Medicaid, or Military),
  • partially insured – limited coverage due to low income
  • Uninsured – unable to pay or afford to enroll in government-provided insurance


    All of the above options are heavily regulated and require their members to follow their rules closely or claims.


   If you were previously approved for disability benefits under Social Security, you may already be enrolled in Medicare when you reach age 65.  If that is not the case, then you need to enroll during the seven-month window surrounding your 65th birthday to avoid a late enrollment penalty. If you don’t enroll during the initial open-enrollment period, you must wait until the annual open enrollment to make changes. The only exception to this rule is when you have a significant life event such as a marriage, death, divorce, or job loss.

Social Security Facts

To qualify, you must meet the earnings test based on your age and how many months you contributed earnings to social security over the years. Go to the Social Security website    to find out when you can apply. It will be somewhere between two years and ten.  

If you qualify under earning, apply online with social security:  It takes three-five months for them to process the application. Warning! Your application won’t get processed unless you send them EVERYTHING requested on the form. Get a copy of this form and complete everything it tells you that you need to do. Otherwise, you get an automatic denial letter. 

You hear a lot of comments about how easy it is to get on disability, but I didn’t find that to be the case. You must answer the following questions to their satisfaction, or they will deny your request for approval.

  1. Are you working? Request denied if your earnings equal a certain threshold or even if you do not work, and you have income from another source that meets that threshold.
  2. Is your medical condition “severe”? Severe means that it significantly limits your ability to do necessary work activities such as lifting, standing, walking, sitting, and remembering for at least 12 months. Request denied if your disability is less than 12 months duration or you can perform your job with an accommodation. Therefore, if you are still working in any capacity you will not be eligible for Social Security Disability
  3. Does your medical condition meet or medically equal a listing? They have a listing of impairments they consider severe enough to warrant disability. If your condition does not appear on the list, you do not qualify.  Here’s the list.
  4. Can you do the work you did before? If you can still do the same job, with accommodation at a different location or the same location, but at reduced hours, you don’t have a qualifying disability.
  5. Can you do any type of work? They look at what jobs might be like what you do now and consider whether you could do them with your limitations. If they think you can, then you are disqualified from receiving disability. 

Social Security notifies you of the good news; they approved you for benefits. The letter explains you are to receive a monthly benefit based on lifetime average earnings of [amount] effective [date].  You read further and discover your first check should arrive in six months from the Social Security Approval effective date. That’s right; it takes six full months to cut that first check. If your approval occurred on June 15, begin counting six-months on July 1, not June 15. Your first check, therefore, comes on January 1.

If you receive Social Security Disability and you’re under the age of 65, you receive automatic approval for Medicare. However, you must wait two years before coverage begins.  You do not need to enroll at the end of the two-year waiting period. Social Security automatically sends you the card; however, you want to opt-out of Part B or D due to having other coverage to avoid paying premiums.

Social Security Disability

My Experience

     I submitted my husband’s application for disability once he could no longer use his hands. His previous job was a supervisor of a fabrication shop and carpenter. He could not walk, lift, or use his arms or hands for intricate work, tolerate extremes in temperature, drive a car, or work a full day, due to primary progressive multiple sclerosis.


Started Company

     After losing his job through a layoff, he started his own drafting company.  However, as his condition progressed, it became difficult for him to control the mouse or hit the correct keys. It was my opinion at that point that he was unable to perform his job or any similar job for which his training and experience might qualify him. Therefore, he should meet the definition of disabled under Medicare regulations.  


Application Denied

     However, Medicare denied his application on the basis that he could perform other similar work.


The Challenge Begins   

      I set out to prove them wrong. After looking up his job group, I wrote down the job duties associated with his work category. By looking at the work duties, I was able to address all the “similar functions in relation to his limitations.  I planned to use that information with his appeal.


Drafted Sample Letter for Doctor

     To help his doctor know specifically what information Medicare needed for the appeal, I drafted a sample letter for him to follow if he wished.  The letter addressed his limitation as related to the job performance requirements. His doctor appreciated my efforts to make his work easier and used most of what I provided to him.  He mailed in the document with all the appeal data complied.


Denied Again

     To our dismay, once again Lynn’s appeal was denied. We were given a few days to appeal the denial, which I promptly did.  I looked up the code for the denial and attached the rationale for the denial with evidence showing how they were wrong in their assumptions.  This time they granted us a hearing.


The Hearing     

     The day of the hearing, the minute we “rolled” into the courtroom, I knew the judge would rule in our favor. The judge watched me settle Lynn at our table and started to write.  Before I sat down, he began asking questions about how long he had been in the wheelchair and when he stopped being able to drive. It became apparent that the only question let in his mind centered around determining an effective date related to when he became disabled.  

Medicare Facts

  Two ways exist to become eligible for Medicare
1.      You qualify for Medicare if you are 65 years old or older and
  • You are a U.S. citizen or permanent legal resident who has lived in the U.S. for at least five years; and
  • You or your spouse paid into Social Security or railroad retirement benefits long enough to be eligible to receive benefits (about ten years); or
  • You or your spouse are a government employee or retiree who has paid Medicare payroll tax
2.     You are younger than 65 and one of the following applies:
  • You have received social security disability benefits for at least 24 months (doesn’t have to be consecutive), or
  • You receive a disability pension from the Railroad Retirement Board and meet certain conditions, or
  • You have Lou Gehrig’s Disease (amyotrophic lateral sclerosis/ALS) which qualifies you immediately; or
  • You have permanent kidney failure requiring regular dialysis or a kidney transplant—and you or your spouse paid S.S. taxes and met the age/S.S. contribution requirements.


Enroll at Age 65

      You enroll in Medicare when you turn 65. If you are getting close to age 65, you have three months before your birthday, the month of your birthday, and three months after it to enroll.  If you don’t enroll during that time, you must pay a late fee when you do.

Enrollment is Once/Yr Except for Special Life Events     

     Enrollment is once a year unless you have a significant life event that occurs, and then you have thirty days from that event to enroll.

Choose Your Plan   

     When enrolling, you have choices to make.  You should go to the Medicare website for additional information on Parts B and D to help you make those choices. I’ve included a summary of the choice options. Once you become approved for Medicare, you receive a book that explains your coverage.


Part A covers hospitalization and is premium-free if you worked enough years to qualify for social security benefits. If you didn’t, you might still be able to buy Part A coverage. Hospitalization covers the following:

  • Inpatient care in a hospital
  • Inpatient care in a skilled nursing facility (not custodial or long-term care)
  • Hospice care
  • Home health care
  • Inpatient care in a religious nonmedical health care institution

Part B provides medical insurance (i.e., doctor’s appointments). Participants pay a monthly premium and a copay with use at doctor’s appointments when they participate in part B.

If you don’t sign-up for Part B during the open enrollment period when you become eligible, there is a late penalty you must pay. Some exceptions apply, such as being covered by a spouse’s employer’s insurance. Part B covers medically necessary doctor’s services, outpatient care, home health services, durable medical equipment, and other medical services, including many preventive services.

Part C is an alternative to Medicare cover. Medicare-approved private insurance companies offer Medicare Advantage Plans that must follow the rules set by Medicare. Medicare Advantage Plans may offer extra coverage, like vision, hearing, dental, and other health, and wellness programs. Most plans include Medicare prescription drug coverage (Part D).

Part D – Medicare offers Prescription Drug Coverage to everyone with coverage through Medicare-approved private companies. There is a monthly premium for prescription drug coverage that is an additional cost to the premium associated with Part B and Part C if required.

Medicare Does Not Cover the Following

  • Long-term care (also called custodial care, nursing home placement)
  • Most dental care
  • Eye exams related to prescribing glasses
  • Dentures
  • Cosmetic surgery  
  • Acupuncture  
  • Hearing aids and exams for fitting them
  • Routine foot care

An Example of How Medicare Works for Long Term Conditions

     Medicare covers hospitalizations as long as the victim is making progress toward recovery.  Once progress stops occurring, custodial care applies, and Medicare coverage ceases. At that point, the patient becomes a self-pay patient unless they have other medical coverage.

Here’s a summary of your potential cost under Medicare’s Maximum Limits



Annual Deductible

$  1,408

Days 1-60: $0 coinsurance

$         0

Days 61-90: $352 coinsurance each day


Days 91 and Beyond (limited to 60): $704 coinsurance per day


Beyond day 151: full cost


Total (excluding beyond day 151)


     Most people do not realize the potential gap Medicare leaves in coverage until they have a significant illness or accident. Unfortunately, it’s a considerable coinsurance, and if you do not have gap coverage, you will undoubtedly feel the hit to your income. Therefore, when you sign up for Medicare, also look for a Medigap (Medicare Supplement) insurance too.


couple reviewing their medications to understand them better
Looking up prescription information on the internet

Medicaid Vs. Medicare

     If you get Medicare and Medicaid confused, you’re not alone. A lot of people do.


     Medicare is a federal program funded by tax dollars that provides health coverage if you are 65+ or under 65 and disabled or a dialysis patient, no matter your income provided you paid into Social Security as an employee paying Medicare payroll tax.  Patients pay part of costs through deductibles for hospital and other costs. Small monthly premiums are required for non-hospital coverage.


     Medicaid, on the other hand, receives federal aid, but is a State controlled program that provides health insurance to low income individuals of any age.  Each State operates Medicaid programs based on their guidelines and regulations; therefore, qualifications vary per State. Most States establish requirements based on applicant income and State resources.

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