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Medically Reviewed By:
Dr. Patricia Sullivan MD MPH on 8/6/2021
Written By: Annalise Baare
What is Medicare?
Medicare is a federal health insurance program. To qualify for this program, you must either be sixty-five years of age or older, have a qualifying disability, or have a diagnosis for End-Stage Renal Disease (ESRD).
Obtaining Medicare is an important step to continue medical coverage once an individual has surpassed the age bracket for prior insurance coverage.
Some individuals are automatically enrolled in Medicare when they have surpassed the age bracket for their particular insurance plan. Others will have to sign up for Medicare if the individual is sixty-five years old and not receiving Social Security benefits.
During the year, there are specific times to enroll in Medicare for insurance coverage or change the coverage an individual may already be receiving, signing up for Medicare Part B when first eligible may avoid certain penalties later on in coverage.
Individuals who sign up for Medicare choose how Medicare coverage is received and might even receive assistance with Medicare costs and premiums. There is also a program called Medicare Advantage, which is a bundling of multiple parts of Medicare.
Parts of Medicare
Medicare comes in several parts, but not all need to be utilized to receive coverage.
Medicare Part A is hospital insurance. This part provides coverage for care that requires hospital admission, care inside a nursing facility, hospice care, and some home health care options.
Medicare Part B is medical insurance. This part provides coverage for specific doctors, care that does not require admission to a medical facility, medical supplies such as oxygen tanks, and preventative services such as wellness checks and screenings.
Medicare Part D is prescription drug coverage that helps individuals pay for the cost of their prescription medication and vaccinations and doctor-recommended shots.
Primarily, Medicare Part A does not require the individual to pay a premium. If the individual applying for coverage has paid into Medicare taxes for a specified amount of time, which is most common. This is sometimes referred to as, “premium-free Part A.”
Everyone under Part B is responsible for paying a monthly premium. There is a standard monthly premium that most people pay. For the year 2020, that premium amount is $144.60. This is important to remember when making decisions about coverage, as most individuals aged sixty-five or older are under strict financial limitations.
The Elderly Can Be a Vulnerable Group
Individuals aged sixty-five or older are in an elderly and vulnerable group. Many elderly individuals have retired, become disabled, lost a spouse, or survived entirely on Social Security benefits. These factors are life-altering as isolated incidents, whereas many elderly individuals have dealt with more than one factor in their lifetime.
According to the Centers for Disease Control and Prevention (CDC), the most common drug types that are used among individuals aged sixty to seventy-nine are cholesterol control, diabetes control, and beta-blocking medicines in the United States. In a study conducted by the CDC, results had shown that just over eighty-three percent of the population in the United States aged sixty to seventy-nine were taking some prescription medication.
High cholesterol and cholesterol medication came out on top as the highest prescription medication use for citizens aged sixty and older. This is aside from any antidepressants, antianxiety, anticonvulsant, or mental health medications that are heavily prescribed and bring long-term patients considerable health risks.
Prescription Use Can Lead to a Substance Abuse (Addiction) Disorder
Long-term prescription medication use can lead to serious dependency, addiction, misuse, or even accidental overdoses. Prescription medication misuse has been the cause of an alarming amount of overdose deaths annually amid the drug epidemics.
Over time, patients can build a bodily tolerance to certain prescription medications. According to the National Association of Addiction Treatment Providers, tolerance is a sign of substance use disorder. This leads patients to seek higher and higher doses from their doctors and physicians—the higher the dose, risk of overdose and misuse increases.
Individuals with pre-existing conditions are at an even greater risk of health or mental complications.
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, substance use disorder is an addiction to drugs or alcohol.
Since drugs are defined as prescription medication and illicit substances, such as heroin or cocaine, drug addiction can happen to anyone.
Several medications are prescribed for pain management or relief, stimulants and sedatives. Long-term use or a mixture of medications can cause accidental overdoses, severe illness, or in some cases, coma or death. If an elderly individual is suffering from poor vision, a mistake in daily dose can cause serious distress and physical or mental damage.
There are warning signals that will help to identify when an individual may be struggling with substance use disorder.
If an individual takes more medicine or doses than their doctor recommended to get the desired effect, it is a strong warning sign that something is not right. Cravings for a substance, interacting less with work or social situations and ignoring responsibilities or relationships are other signs or indications that substance use disorder develops in an individual.
If caught early on, signs of dependency can be intervened before substance addiction becomes a serious problem.
Inpatient versus outpatient care
The Centers for Medicare & Medicaid Services (CMS) offers services that can help an individual recover from substance use disorder. Still, there is not a specific category or service that is targeted for substance use disorder.
When reasonable and necessary, determined by a qualifying practitioner, inpatient treatment is available and covered under Medicare. Medication that is provided during inpatient stay would be part of the inpatient payment and not paid separately.
There are many practitioners who would be authorized to determine whether an individual’s case was inpatient qualified. Physicians such as a medical doctor or a doctor of osteopathy, clinical psychologists, clinical social workers, nurse practitioners, clinical nurse specialists, physician assistants, and certified nurse-midwives are all authorized to decide. These inpatient services would all be a part of Medicare Part A.
Outpatient services fall under the Medicare Part B category. These services are on a case-by-case basis or as needed. Certain doctor visits and treatment is covered under this part of the coverage. Medicare Part B also covers medical supplies such as oxygen tanks, Continuous Positive Airway Pressure (CPAP) machines, canes, crutches, and body monitors. The medical supplies list made available under Medicare Part B coverage continues and is an enormous part of Medicare Part B utilization.
Outpatient services can also include psychologist or psychiatrist counseling, a powerful tool that is vastly underrated. Counseling is an efficient avenue for those who recognize substance use disorder in themselves. Counseling can begin to identify the origin of the individual’s substance use disorder.
Whether an individual chooses Medicare Part A, Medicare Part B, or both, cost efficiency is likely to play a role in deciding. Medicare Part A will help an individual who experiences frequent hospital visits or is prone to hospital admission. At the same time, Medicare Part B will aid individuals who are heavily reliant on medical supplies to survive.
When in doubt, contacting Medicare directly will answer any questions that may arise to give individuals information to make an educated decision.
Medicare and Substance Use Disorder
Elderly individuals can have an incredibly stressful experience in making medical decisions, especially if they are struggling with or are susceptible to substance use disorder. Although Medicare does not have a specified program for elderly individuals with substance use disorder, there are available options that are semi-customizable to fit the needs of the individual.
Treatment options are available, whether for inpatient care, outpatient care, or both. Elders do not need to be afraid of the cost of treatment, as Medicare has various plans that will fit even low-income budgets.
Whether an individual is automatically enrolled or is signing up for Medicare coverage, it is important to weigh the options to fit the patient’s needs.
If the individual is aware of a substance use disorder, speaking directly to a Medicare representative can help tailor a plan to treat the disorder with as little out of pocket as possible while still obtaining the necessary treatment.
Medicare is federal health insurance specifically for individuals sixty-five or older, for younger people who have specific disabilities, and for individuals who have permanent kidney failure that requires dialysis called End-Stage Renal Disease (ESRD). Medicare can automatically register and enroll some individuals, and some need to sign themselves up for coverage.
Medicare comes in multiple parts to expand coverage over specific frequencies such as doctor visits versus hospital stays. Medicare Part A is hospital insurance that covers inpatient stays to hospitals, nursing facilities or homes, hospice care, and even some home health care.
Medicare Part B is medical insurance that covers outpatient care such as certain doctor visits and medical supplies such as oxygen tanks, blood sugar monitors, canes, crutches, and CPAP machines. Medicare Part B also provides coverage for preventative services like lab tests and screenings. Medicare Part D is prescription insurance for pharmaceutical needs. This can help pay for monthly prescriptions and refills or pay for the prescription entirely.
Long-term use of certain prescription medications can cause dependency, addiction, or other serious health risks. These factors are especially difficult for people sixty-five and older to recover from due to the length of use. Elderly individuals are vulnerable to substance use disorders due to age, physical body limitations, and brain function. This makes dependency and addiction easier to develop and harder to wean off of.
Outpatient services and procedures are doctor visits, counseling sessions, and other medical appointments that allow the individual to return home or leave the building once complete. Inpatient services and procedures are hospital stays, nursing facility admissions, rehabilitation facilities, and other admissions that require overnight stays.
Medicare is an efficient insurance program that can offer treatment services to elderly individuals struggling with substance use disorder.