Understanding how Medicare works may be tricky for some people. The following list of frequently asked questions will give you a deeper understanding of Medicare, its eligibility requirements and how to sign up.
Medicare 101
Q: What is Medicare and how does it work?
A: Medicare is the U.S. federal health insurance program for people who are 65 or older, younger than 65 with certain disabilities and those with End-Stage Renal Disease (ESRD).
There are four parts of Medicare: Part A, Part B, Part C, and Part D — each part covering different services. Part A (hospital insurance) and Part B (medical insurance) components make up Original Medicare, sometimes referred to as “traditional” Medicare.
In most cases, if you’re covered under Original Medicare you can go to any doctor, health care provider, or hospital that accepts Medicare.
Q: Who manages Medicare?
A: Original Medicare (Part A and Part B) is managed by the federal government. More specifically, the Medicare program is managed by the Centers for Medicare and Medicaid Services (CMS), which is part of the Department of Health and Human Services.
Medicare Advantage (Part C) and prescription drug coverage (Part D) are administered by private insurance companies.
Q: Who do I contact about getting Medicare?
A: The Social Security Administration works with CMS by enrolling people in Medicare. It provides an abundance of Medicare information and services online to facilitate enrollment, but if you don’t want to apply for benefits online, or wish to speak to a Social Security Representative for any other reason, you can:
- Call toll-free at 1-800-772-1213 7AM-7PM, Monday through Friday
- Contact your local Social Security office.
Eligibility
Q: How do I know if I’m eligible for Medicare?
A: Generally, you become eligible to receive Medicare when you turn 65 years old. However, you may become eligible under 65 if you have certain disabilities or End-Stage Renal Disease.
If you’re younger than 65, you may be eligible to receive Medicare benefits if:
- You’ve been receiving Social Security or certain Railroad Retirement Board (RRB) disability benefits for 24 months
- You have End-Stage Renal Disease (ESRD)
- You’ve been diagnosed with Lou Gehrig’s Disease (ALS)
Q: Do I have to apply for Medicare or do I get it automatically?
A: If you’re already receiving Social Security or Railroad Retirement Board benefits (either for retirement or for a disability), you’ll be enrolled in both Part A and Part B automatically upon meeting eligibility requirements (either your 65th birthday, or the 25th month you receive disability benefits). ALS patients are automatically enrolled in Medicare coverage when their Social Security disability benefits begin, regardless of age.
If you’re not already collecting Social Security or Railroad Retirement Board benefits when you become eligible for Medicare, you will have to manually enroll.
Those with End Stage Renal Disease typically must manually enroll.
Enrollment
Q: If I’m not enrolled in Medicare automatically, how do I sign up?
A: If you’re eligible for Medicare but not automatic enrollment, you can apply online, over the phone, or in person at your local Social Security office. If you worked for a railroad, you’ll need to contact the Railroad Retirement Board to sign up.
Q: Are there other options for receiving health care benefits besides Original Medicare?
A: Yes. As a Medicare beneficiary, you have several choices for how you receive your health care benefits. Private insurers offer coverage options as an alternative to what the federal government provides through Original Medicare Part A and Part B, as well as options to supplement it.
- Medicare Advantage (Part C) is provided by private insurance companies as an alternative to Original Medicare. These plans include all of the same benefits as Original Medicare**, plus others in some cases. Additional benefits may include vision, hearing, and dental services, and Medicare Part D prescription drug coverage.
- Prescription Drug Plans (Part D) are sold by private insurance companies and offer coverage for prescription medications. PDPs can be used in conjunction with Original Medicare or Medicare Advantage plans that don’t offer drug coverage. You may be able to receive Part D coverage through a Medicare Advantage plan.
- Medicare Supplement Insurance (Medigap) plans provide additional coverage for out-of-pocket costs associated with Original Medicare, including deductibles, copayments, and coinsurance. You can enroll in Medigap once you’ve enrolled in Original Medicare. You may not have a Medicare Advantage plan and Medigap plan at the same time.
Q: When are the Medicare enrollment periods?
A: There are several Medicare enrollment periods.
If you are not eligible for automatic enrollment, there is a seven-month Initial Enrollment Period (IEP) based around your birthday month. You’ll have the opportunity to enroll in Medicare three months before your 65th birthday, during your birthday month, and three months after it. If you’d rather enroll in a Medicare Advantage plan, you may do so during this time.
If you’re still covered under you or your spouse’s current employer’s insurance when you become eligible for Medicare, you may qualify for a Special Enrollment Period (SEP). If so, you can sign up for Medicare Part B without having to wait for the GEP or pay a penalty for late enrollment. You must generally enroll within eight months of retiring or coverage loss to avoid late penalties. There may be other circumstances that make your eligible for special enrollment as well — talk to a licensed insurance agent to learn more.
If you don’t sign up for Part A and/or B during your IEP, and you don’t qualify for special enrollment, you can sign up each year during the General Enrollment Period (GEP) from January 1 to March 31. However, coverage won’t begin until July 1 and you may be subject to late enrollment penalties if you wait too long to sign up.
Choosing a plan
Q. How is Medicare Advantage different than Original Medicare?
A: If are eligible for Medicare, you have the option of receiving health care benefits through either a Medicare Advantage plan or Original Medicare — the two cannot be combined. Your Medicare Advantage plan may offer additional benefits that Original Medicare doesn’t offer — like vision, dental and prescription drug coverage. This chart provides more information about these differences.
Your Medicare Advantage plan may have different deductibles, copayments, coinsurance and other out-of-pocket costs than those that come with Original Medicare.
Q: What is a Medicare Supplement Insurance Plan (Medigap)?
A: Standardized by the federal government, but sold by private insurance companies, Medicare Supplement Insurance plans are designed to cover certain out-of-pocket expenses associated with Original Medicare. Rather than pay for gaps in coverage out of pocket, you can purchase a Medicare Supplement Insurance plan to pair with your Original Medicare insurance.
There are 10 standardized Medicare Supplement Insurance plans labeled A, B, C, D, F, G, K, L, M and N available in most states.*** Be careful not to confused the four parts of Medicare (Part A, Part B, Part C and Part D) with Medicare Supplement Insurance plans.
You cannot have Medicare Supplement Insurance and Medicare Advantage at the same time.
Q: How can I get Medicare prescription drug coverage?
A: There are two ways to get Part D prescription drug coverage.
If you have Original Medicare or a Medicare Advantage plan that doesn’t offer drug coverage, you can also enroll in a standalone Prescription Drug Plan (PDP). These are separate plans sold by private insurer companies. Plan cost and availability can vary by location.
If you’d prefer, you can buy a Medicare Advantage plan that includes Part D drug coverage.
Q: Can I switch from Medicare Advantage to Original Medicare?
A: Yes. You can switch from a Medicare Advantage plan back to Original Medicare (or vice versa) every fall. The Fall Medicare Open Enrollment Period (also called the Annual Election Period, or AEP) runs from October 15‒December 7, during which time you can switch from Medicare Advantage to Original Medicare, and from Original Medicare to a Medicare Advantage Plan. You can also join, switch or drop Medicare Advantage plans or Prescription Drug Plans.
There is also the Medicare Advantage Open Enrollment Period from January 1‒March 31. During this period, you can switch Medicare Advantage plans, or you can drop your Medicare Advantage plan to return to Original Medicare. If you return to Original Medicare during this period, you can also enroll in a Part D prescription drug plan.
Coverage and benefits
Q: What does Medicare Part A and Part B cover?
A: Part A (Hospital Insurance) covers inpatient hospital care, skilled nursing services, hospice. Part B (Medical Insurance) covers doctor’s visits, durable medical equipment, preventive services and more.
Costs and payments
Q: Do I have to pay for Medicare?
A: Most people get Medicare Part A without having to pay a monthly premium. You can receive Part A without having to pay a premium if you or your spouse paid Medicare taxes while working for at least 10 years.
Everyone has to pay a premium for Part B each month. The standard Part B premium amount is $135.50 in 2019****, but can be higher, depending on your income. If you get Social Security or railroad benefits, your Part B premium will automatically get deducted from your benefits check — otherwise, you’ll be billed for it.
Keep in mind that Medicare Advantage plans have different premiums and costs than Original Medicare.
Q: Does Medicare cover all of my health costs?
A: No. Medicare doesn’t cover everything. You will still have to pay some costs out of pocket — expenses like deductibles, copayments and coinsurance.
If you have Original Medicare, a Medicare Supplement Insurance plan may help pay for some of these costs. You can’t buy a Medicare Supplement Insurance plan with Medicare Advantage, but your Medicare Advantage plan may offer lower out-of-pocket costs than Original Medicare.
Q: If I have limited income, are there resources to help me pay for Medicare?
A: If you have limited income and resources, there are several options to help you pay for health care costs and save money. Based on your income and/or disability status, you may qualify for one or more financial assistance programs.
Every state has Medicare Savings Programs (MSP) that can help pay your Part B premium, along with some deductibles and copays. Medicaid is a joint federal and state program that helps pay for health care costs, some drugs, and provides additional benefits like nursing home and personal care services. You may also qualify for Extra Help, which helps pay for prescription drugs, deductibles, coinsurance, and copays.
To find out what resources are available in your state, which you qualify for, and how to apply, contact your state Medicaid program.
Q: Where can I buy a Medicare Advantage plan?
A: Contact a licensed insurance agent today to get started.
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