A Basic Review of Medicare

Medicare is the nation’s health insurance program offered to senior Americans (65 years or older) receiving Social Security (typically, retired workers).  Recently, there have been many questions concerning the longevity of Medicare. While these concerns may represent ideological debates, understanding the continuation of Medicare requires some knowledge of the program’s structure.  First, Medicare covers medically necessary services such lab tests, surgeries, and doctor visits and supplies (e.g. wheelchairs and walkers).   Medicare operates through four parts:

• Hospital insurance Part A provides coverage of services such as hospital care, skilled nursing facility, nursing home care, hospice and home health services.
• Medical insurance, Part B offers medically necessary and preventive services. These include services needed to diagnose or treat a medical condition, and services such as mental health, ambulance, second opinions and clinical research.
• Private plans for Parts A and B, are also known as Medicare Advantage or Part C. These plans are offered by private companies that contract with t Medicare. They include Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), Private Fee-for-Service Plans, Special Needs Plans and Medicare Medical Savings Account Plans.  It is important to note that Medicare Advantage plans cover everything Medicare covers, but they do not have to cover every benefit in the same way.
• Prescription drug plan, Part D subsidizes the costs of prescription drugs  depending on the tier of a drug on a list of covered drugs for Medicare beneficiaries. Medication on a lower tier will generally cost less than a drug in a higher tier. Prescribers can ask for lower copayments in cases where a higher tier medication may be indicated over a similar drug on a lower tier. If the patient has complex health needs, they may be eligible to participate in a Medication Therapy Management program.

Of these four parts, Part A or the Medicare Hospital Insurance Trust Fund which is financed through payroll taxes from  current workers and employers and overseen by a board of trustees reporting  to congress is most sensitive to growth rates for health care service costs and taxable payroll. As such, the Medicare Hospital Insurance Trust Fund is subject to economic trends. Recent changes in legislation, most notably the Affordable Care Act, have extended the Trust Fund from 2017 to 2029.

Eligibility

Let us turn to who is eligible to receive Medicare. Most people 65 or older are entitled to Medicare Parts A and B if they are receiving Social Security or Railroad Retirement Benefits; worked long enough in a federal, state, or local government job to be insured for Medicare; or are entitled to Social Security benefits based on a spouse's (or divorced spouse's) work record, and that spouse is at least 62. Eligibility for Parts C and D are contingent upon receiving Parts A and B. That is, according to the Social Security Administration (SSA) anyone with Medicare Parts A and B can choose to receive all of their health care services through an approved provider organization under Part C and is eligible for prescription drug coverage (Part D). The LGBT Community and Medicare

The LGBT Community and Medicare

Given that Medicare was established to care for retired workers, participation in the workforce is required. This requirement poses a challenge for those who have been marginalized from the traditional work force. Among these people are members of the LGBT community.  Challenges faced by lesbian, bisexual, gay, transgender and gender nonconforming individuals include significant barriers in securing employment, a necessary criteria for later qualification for Medicare benefits.

For example, according to the Transgender Legal Defense & Education Fund, securing gender-appropriate identity documents may be a daunting task involving interactions with courts. Additionally employment, when it is secured, may be fragile due to on-the-job harassment because of gender identity and expression (e.g., gendered dress codes or accessing sex-segregated restrooms).  As a result many transgender people face chronic underemployment, unemployment, and poverty.

Eligibility is not completely limited to work force involvement though, as someone may pay a premium to buy Part A.  According to the National Council on Aging, for individuals who work between 7.5 and 10 years the premium  is $254 per month and $461 per month for those who worked  less than 7.5 years.  However, for the reasons mentioned above, this presents a significant challenge to individuals facing poverty. However, some states assist individuals in paying for Part A, and/or Part B. Further, certain individuals may qualify for Extra Help to pay for their Medicare prescription drug coverage.

Legal Relationship Status and Eligibility

While many gays, lesbians and bisexual men and women actively participate in the labor force, both openly and closeted, their partners still face discrimination with regards to Medicare eligibility. For most Americans entering retirement, based on their work history their spouses, divorced spouses, widow or widower are eligible for hospital insurance upon turning 65.  Spouses under 65 and children who are disabled may be eligible for Medicare, usually after a 24-month qualifying period. Therefore one’s marital status may alter their partner’s eligibility for Medicare benefits. As such same-sex couples were not afforded these rights because their marriages were not recognized.

Effective June 26^th 2013, however, the U.S. Supreme Court struck down the section of the Defense of Marriage Act (DOMA) which previously barred same-sex couples from qualifying for each other’s federal benefits (e.g., Social Security survivor benefits, federal tax benefits and employee health and retirement benefits). In light of the Court’s actions, a legally-recognized spouse can receive up to half of a living spouse's benefit, if it's larger than his or her own. Similarly, widows or widowers are now able to receive up to 100 percent of a deceased spouse's benefit or his/her own benefit. However this is only a partial gain. These benefits are conferred to only same-sex couples who are legally married and questions remain about what benefits can be accessed when the married couple resides in a state that does not recognize same-sex marriage. Presently there are thirteen states where same-sex couples may legally wed -- California, Connecticut, Delaware, Iowa, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New York, Rhode Island, Vermont, and Washington, the District of Columbia, and five Native American tribes  have legalized the issuing of same-sex marriage licenses. There are also some states where marriages are recognized but not conferred, though there are still some questions about whether couples may access federal benefits if they reside in those states. For further questions on marriage recognition as it relates to federal benefits, please refer to LGBT legal experts Lambda Legal.

Enrolling in Medicare

Members of the community must continue to advocate for improved and equal treatment for themselves, their partners, and the community at large. Despite these inequities, many members of the LGBT community are still eligible for some benefits.

Medicare.gov offers the following suggestions to determine if your needs are covered:  discuss your medical needs with a medical provider to identify if Medicare covers the services. Next, for some individual who are not automatically enrolled at age 65, they may apply online, visit a local Social Security Office or call Social Security at 1-800-772-1213.