You have been paying into this system your entire working life.
This page exists because the moment most Americans begin using their senior healthcare benefits is also the moment they discover how little they were ever told about them. Not because they were careless. Because the information was never put in one place and explained in plain language.
What follows is that explanation — the history of what you built, how the system works, what changed along the way, and what to pay attention to as you start using it. No acronyms without explanation. No assumptions about what you already know.
Project Salus was built because the senior care system in the United States is genuinely difficult to navigate — and much of that difficulty is not inevitable. Federal coverage rules, state Medicaid programs, insurance plan structures, and provider networks are all matters of public record. The information exists. What has been missing is a single place where it is organized, translated into plain language, and kept current as things change.
The healthcare system that serves seniors — Medicare, Medicaid, home health, equipment suppliers, hospice, rehabilitation — has been quietly reshaped over decades by regulatory changes most beneficiaries never heard about. The entities with resources to engage in that process have shaped it accordingly. Project Salus exists to give individual beneficiaries the same information those entities have always had.
This is not a political project. It is an information project. You paid into this system. You deserve to understand it fully.
Who this is for
This page covers the federal Medicare and Medicaid programs — the coverage most Americans transition into at 65. Some people arrive at senior care through a different path. If you have coverage through the Department of Veterans Affairs, a Federal Employee Health Benefits plan, a government pension plan, or union retiree coverage, much of what follows still applies to you — but some of the enrollment decisions, coordination rules, and coverage priorities are different from what is described here. A dedicated guide for each of those situations is in development.
What you have been paying into
Medicare did not arrive fully formed. It was built over six decades through legislation, amendment, regulatory change, and budget negotiation — some of it designed to expand access, some of it designed to control costs. Understanding the history is not an academic exercise. It explains why the program works the way it does, and why some of what you expected is different from what you found.
What this coverage actually is
Medicare is not a single program. It is a set of parts — each covering a different category of care — that were created at different times and work together only if you understand how to combine them. Most people enter Medicare without a clear picture of what each part covers, which ones require a separate enrollment step, and which ones carry a permanent financial penalty if ignored.
Tap any card for a plain-language explanation of that coverage type. No prior knowledge assumed.
Medicaid eligibility, managed care structures, and the programs available to supplement Medicare vary enormously by state. What is available in one state can be completely different in another.
Select your state to see what applies where you live →What makes this different from what you had
For most people, healthcare has meant one thing for 30 or 40 years — a plan through an employer, an insurance card in a wallet, a copay at a front desk. That system built a set of assumptions about how healthcare works. Most of those assumptions do not carry over to Medicare. Understanding which ones no longer apply — before a situation makes it urgent — is one of the most valuable things this page can give you.
These differences apply whether you are coming from employer coverage, a spouse's plan, a union plan, or an individual market plan. The structure of Medicare is simply different from all of them.
None of these differences are your fault for not knowing. They are the result of a system that was designed separately from the one you spent your career in, built over six decades of legislation, and never consolidated into a plain-language transition guide for the people entering it. That is what this page is attempting to be.
What is actively changing and why it matters
Medicare is not a fixed program. It is being actively reshaped — through legislation, through regulatory guidance issued by the Centers for Medicare and Medicaid Services, through coverage determinations that establish what is and is not a covered benefit, and through reimbursement changes that affect which providers can afford to serve Medicare patients. Most of these changes receive little or no direct communication to the people they most affect.
Congress passes legislation that sets the broad parameters of the Medicare program — eligibility, benefit categories, funding mechanisms. Within those parameters, the Centers for Medicare and Medicaid Services, or CMS, issues regulations, coverage determinations, and reimbursement schedules that define in practical terms what is covered, at what rate, and under what conditions.
These administrative rules carry the force of law but are not voted on by Congress. They are published in the Federal Register — a federal publication that most Americans have never read — and are subject to public comment periods that are rarely participated in by individual beneficiaries. The entities that consistently engage in these processes — insurance companies, hospital systems, large supplier networks, and the trade associations that represent them — have the resources and expertise to do so. Individual beneficiaries, as a rule, do not.
The result is a regulatory environment that has been shaped primarily by the perspectives and interests of the entities that most actively engage with it. That is not a conspiracy. It is how regulatory processes work when one side is organized and resourced and the other is not.
The Competitive Bidding Program for home medical equipment — first introduced as a concept in 1997 and implemented nationally over the following two decades — is one of the clearest examples of a regulatory change with significant consequences for patients that received almost no public attention when it happened.
The program requires home medical equipment suppliers to submit bids to serve Medicare beneficiaries in designated geographic areas. Only the lowest-bidding suppliers receive contracts. The intent was to reduce Medicare spending on equipment by harnessing market competition.
Prior authorization is the process by which an insurance company must approve a service, procedure, or piece of equipment before it is covered. It exists in Original Medicare but in a limited form. In Medicare Advantage plans — now covering more than half of all Medicare beneficiaries — prior authorization requirements have expanded significantly over the past decade.
A 2022 report by the Senate Finance Committee found that Medicare Advantage plans denied prior authorization requests at rates of 5 to 13 percent for medically necessary care. An independent audit by the Office of Inspector General found that 13 percent of prior authorization denials in Medicare Advantage were for care that met Medicare coverage criteria and should have been approved. These are not obscure findings. They are documented in public government reports. They describe a system where the insurance company's approval process is resulting in delayed or denied care for a meaningful percentage of beneficiaries who are entitled to it.
New federal rules require Medicare Advantage plans to report their prior authorization data more transparently and to make faster decisions. Whether enforcement will be consistent and meaningful is a function of regulatory priority — which changes with administrations.
Every coverage determination CMS issues is public record. Every Medicare Advantage plan's prior authorization denial rate is now required to be disclosed. Every state Medicaid program's coverage rules are published. The Competitive Bidding Program's impact on supplier networks is documented. None of this is hidden.
What has been missing is a single place where it is organized, translated into plain language, connected to the situations people actually find themselves in, and kept current as things change. That is what Project Salus is attempting to build.
This is not a complaint about the system. It is a decision to understand it — because understanding it is the most effective form of accountability available to an individual beneficiary. You paid into this. You have the right to know exactly what you built, how it works, and where to look when something is not working the way it should.
What catches people off guard
These are the moments that consistently surprise people as they move into and through the Medicare system — not because the information is unavailable, but because nobody explains it proactively. Each one shows what most people expect, what is actually true, and what to do about it.
A Medigap supplement plan — private insurance sold alongside Original Medicare — covers the 20 percent coinsurance and effectively restores an out-of-pocket cap. The best time to purchase one is during the six-month guaranteed issue window that opens when you first enroll in Medicare Part B. After that window closes, insurers can decline to sell you a plan or charge more based on your health history in most states.
Some Medicare Advantage plans include dental, vision, and hearing benefits as part of their supplemental offerings — this is one of the reasons many people choose Medicare Advantage over Original Medicare. Standalone dental and vision plans are also an option. Neither fully replaces the coverage most employer plans provided, but both are worth evaluating carefully before you need them.
Enroll in a Part D plan when you first become eligible — even if you currently take no prescription medications. The cheapest available plan typically costs $10 to $20 per month. The penalty you would accumulate by waiting a year or more is almost always more expensive than the plan itself. The clock starts at eligibility, not at the moment you first need medication.
Long-term care insurance — purchased before it is needed, which often means before 65 — is the primary private mechanism for covering custodial care costs. After assets are spent down to program eligibility levels, Medicaid can cover nursing home care and some home-based custodial services depending on your state. Planning ahead significantly changes what options are available.
Ask directly at any hospital admission: am I being admitted as an inpatient or placed under observation status? Medicare law requires the hospital to provide written notice if you are under observation for more than 24 hours — this notice is called the Medicare Outpatient Observation Notice, or MOON. If a skilled nursing facility stay is anticipated after discharge, observation status can directly affect whether Medicare will cover it.
When a provider tells you that something requires prior authorization, ask when the request was submitted and what the expected response timeline is. Most authorization delays are administrative rather than clinical — a documentation gap that needs to be resolved, not a judgment that the care is inappropriate. A denial can be appealed. Roughly 60 percent of appealed Medicare denials are overturned at the first or second review level when additional documentation is provided.
Before you go — things worth having in place
These are not administrative boxes to check. They are the things that consistently make the difference between a family that can navigate a difficult situation and one that cannot. None of them require a crisis to address. All of them become significantly harder to address once a crisis begins.
Where to go from here
This page is the foundation. Each path below goes deeper into a specific part of what you just read.
Not sure where to start? Start with your state.
Coverage rules, Medicaid programs, and provider availability vary by state. Select yours on the home page to see what applies where you live.