Medicare 101
What is Medicare?
Federally sponsored individual health coverage for medically necessary procedures and services.
Medicare coverage requires copays, coinsurance and deductible payments that are the responsibility of the beneficiary (or other secondary insurance).
Who is Eligible?
Anyone age 65 or older who has participated in Social Security, Railroad Retirement System or employees of Federal, State or Local Governments or whose spouse has participated.
Individuals under age 65 that have been awarded Social Security or Railroad Retirement Disability after 24 months.
Those disabled due to ALS (Lou Gehrig’s Disease).
Individuals with End Stage Renal Disease (ESRD).
What are the “Parts” of Medicare?
Medicare Part A(hospital insurance) covers:
Inpatient hospital care
Skilled nursing facility care
Hospice care
Home health care
Medicare Part B (medical insurance) covers:
Doctor visits and services from other providers
Outpatient hospital services
Many preventative services
Durable medical equipment
Part B drugs
Medicare Part D (prescription drug coverage):
Helps cover the cost of prescription drugs.
It is important to note that you do not obtain your Part D coverage through Medicare. The plans are offered by Medicare approved private insurance companies that in most cases charge a premium, deductible and co-pays.
It is important to join a Medicare Part D plan when you first become eligible for Medicare to avoid paying a late enrollment penalty.
You may be able to delay enrolling Part D coverage without a penalty if you have creditable coverage, like coverage through your job or your spouse's job.
Medicare Advantage Part C:
Health plan options approved by Medicare
Another way to get your Medicare coverage
Still part of the Medicare Program
Run by private companies
Medicare pays the plan a “per capita” amount for each member’s care
May have to use network doctors or hospitals - ALWAYS check with your healthcare providers
Types of plans available vary from county to county
Combines Parts A & B and usually D
When can you enroll?
Generally during the Initial Enrollment Period.
During the Annual Enrollment Period: Oct 15th – Dec 7th
Changes become effective Jan 1st
Sometimes during various Special Enrollment Periods
Move to a different county or state
Service Area Reductions
Qualify for Extra Help or Medicaid
What are some things NOT covered by “original Medicare”?
Dental
Vision
Hearing
Long term care
While these items are not covered by “original Medicare”, some of these items like dental, vision and hearing are often obtained via “stand alone” plans or through Medicare Part C also known as Medicare Advantage. These plans are usually quite affordable and cover such things as routine and major dental care and dentures, vision exams and eye wear and hearing exams and hearing aids. Contact us to find out what options we offer to help cover these services. Long term care is not covered by Medicare or Medicare supplement insurance plans. Long term care insurance may be purchased through private insurers. Individuals also may be eligible for long term care through Medicaid.
Am I eligible for Medicare?
Anyone who has contributed to the Medicare system through their payroll taxes for at least 10 years, or 40 quarters, is able to receive Medicare benefits. In most cases, a non-working spouse will most likely qualify under the working spouses benefit when they turn 65. Also people under the age of 65 who qualify for social security disability are eligible. However, these individuals will need to be on disability for 24 months before receiving Medicare benefits
What should I know about Medicare enrollment?
How do I enroll?
Medicare enrollment is handled by the Social Security Administration.
Can be completed online at www.ssa.gov
Call 1-800-772-1213
Appointments can be made at local offices through the above toll-free number
Will I be automatically enrolled in Medicare?
Beneficiary will receive Medicare card in the mail indicating automatic enrollment in Part A and Part B … IF
Collecting Social Security or Railroad Retirement Benefits prior to age 65.
Under 65 entitled to Social Security Disability Benefits.
Coverage starts 1st day of birth month unless birthday is the 1st in which case coverage begins 1st day of month before.
If a beneficiary or their spouse are “actively” working for an employer providing them with creditable group health insurance coverage, they may be able to delay enrolling into Medicare Part B without penalties.
What do I do when I am losing employer coverage?
Sign up for Part B and Part D as soon as you can
Part B – you have an 8-month SEP to enroll without penalty
The sooner you enroll in Part B the sooner your coverage will begin
Enrolling in Part B triggers a 6-month Medigap open enrollment period
Part D – you have 63 days to enroll in Part D plan without penalty
What should I know about Medicare Supplements?
Medicare Supplements are often referred to as “Medigap” plans.
They are standardized insurance plans designed to fill the “gaps” in Medicare Part A and Part B (deductibles, copayments, etc.).
Plans are designated by letter (A, B, C, D, F, G, K, L, M, N).
C and F are no longer offered to those entering Medicare after January 1st, 2020.
All plans cover a basic group of benefits, each covering a different group of “gaps”.
Coverage of “gaps” is the same from company to company, premiums are not.
You can enroll in a Medicare supplement plan during your "Open Enrollment Period".
This occurs on the first day you are 65 and enrolled in Medicare Part B and lasts 6 months.
During this time, insurance companies cannot refuse to sell you any plan they offer, cannot subject you to underwriting and cannot make you wait for your coverage start due to pre-existing conditions as long as you have had "creditable coverage".
Outside of your Medicare Supplement Open Enrollment period, you can make changes at any time of year. HOWEVER, your acceptance into another Medigap plan will typically be subject to passing health underwriting questions.
Medicare 101 Education video coming soon!