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Medicare is the federal health insurance program for people age 65 and older. Certain people younger than age 65 can qualify for Medicare, including those who receive Social Security Disability Income and those who have permanent kidney failure. Because Medicare is health insurance, you share the costs of your care.
Traditional Medicare is also called Original Medicare or “Fee-For-Service" Medicare. This federal program starts with Part A hospital insurance and Part B medical insurance. For most people, Original Medicare Part A and Part B is a starting point for assembling more complete coverage.
This helps pay for inpatient care in a hospital or skilled nursing facility (following a hospital stay), some home health care, and hospice care. Part A is premium-free for most people, but beneficiaries share costs through deductibles and co-insurance.
This helps pay for doctors' services and many outpatient medical services and supplies. Part B is technically optional because most beneficiaries must pay a monthly premium; it comes with an annual deductible, plus a 20 percent co-insurance. If you want a Medigap supplement or a Medicare Advantage plan to help pay your share of the cost, you must have both Parts A and B.
Instead of getting your Medicare benefits through the original federal government program, you can get them through a private insurance company's Medicare Advantage (MA) plan. These plans combine all your Medicare-covered Part A and Part B benefits in a single package and can include prescription drug coverage (Part D). You must have Parts A and B before you can enroll in a Medicare Advantage plan. Medicare Advantage plan members pay a premium for Part B, plus usually a premium for the Medicare Advantage plan, and co-pays or co-insurance for services. Medicare Advantage plans are not the same as Medicare supplements (Medigap), which work only with Original Medicare.
This Medicare coverage is offered through private companies – either as part of a Medicare Advantage plan or as a stand-alone prescription drug plan for those with Original Medicare. Having Part A, Part B, or both, makes you eligible for Part D. Part D plan members pay a monthly premium and pharmacy co-pays. Some plans also include a deductible. Some people can get Part D through their employer group plan. The Department of Veterans Affairs offers similar coverage.
Your initial enrollment period is the seven months surrounding your 65th birthday. In this period, you can enroll in Parts A, B, C, and D. Your seven months are:
If you receive Medicare due to Social Security disability, your Parts A and B automatically start in your 25th month of disability income. The initial enrollment for Parts C and D starts in the 21st month and ends in the 28th month.
Note: If your birthday falls on the first day of a month, you start Medicare a month early. Your enrollment period moves up a month, as well. Example: If your birthday is Jan. 1, you can start Medicare on Dec. 1. You can sign up as early as Sept. 1. See Medicare Deadlines.
If you receive your red, white, and blue Medicare card in the mail, you will be set up to start Parts A and B beginning the first of the month you turn 65. You must decide:
Note: Unless you qualify to delay enrollment in Parts B and D, you could face lifetime penalties later for not enrolling during the seven-month period surrounding your 65th birthday.
Some people who are actively working and have insurance (but not COBRA) can delay enrollment in Parts B and D without a penalty. However, if you don't qualify for a penalty-free delay, you will pay higher premiums for the rest of your life. Key points:
If you decide to delay enrollment in Part B, your Welcome to Medicare packet contains an explanation on how to do this. If you delay enrollment in Part B, Part D, or both, you have enrollment deadlines soon after your employer-provided coverage ends. Check the deadlines page for specific information.
It depends. If you or your spouse have a large group employer or union coverage based on active work, then you might qualify to put off taking Part B and paying its premium until you no longer have this insurance. See the previous question on employer coverage.
When your active work employer group coverage (not COBRA) ends, you will have an eight-month special enrollment period (SEP) in which you can sign up to have your Part B begin. It can start without a lapse in coverage or a penalty on your Part B premium. Again, be sure to confirm with Social Security now that you will qualify for the special enrollment period. Document the contact – keep a record of the date, time, name of the representative, and information.
If you delay Part B and do NOT qualify for a special enrollment period, you will be able to enroll only in the general enrollment period, which is every year from Jan. 1 to March 31. Coverage begins July 1 that year. In addition, you will be charged a 10 percent premium penalty for every year that you were eligible to have Part B, but did not have it. That penalty will be added to your Part B premium for as long as you have Medicare.
No. COBRA refers to a federal law that lets some people keep their employer coverage going temporarily after they lose their job. Being on COBRA doesn't count as actively working. To delay Part B enrollment without penalty, you or a spouse must be actively working and receiving coverage under a group health plan. If you are already on COBRA and then your Medicare starts, turning 65 will change your status. Your COBRA will end. You will not qualify to delay your Part B without penalty. If you are already on Medicare and then start COBRA, you will still need to have Part B.
There are two general routes for assembling your Medicare insurance if you don't have an employer group plan or Veterans Affairs (VA):
Here are some charts of your choices:
Which route is best for me?
The best Medicare insurance for you depends on such key factors as what your doctor accepts, your health and prescription drug needs, your budget, and whether you plan to travel a lot. A SHIBA counselor can help you understand your choices, call 800-722-4134 (toll-free).
If you have an individual/family plan (not group coverage) when you become Medicare-eligible, turning 65 will change your status and your coverage may end. You will be expected to enroll in Medicare. Many government assistance programs also require you to enroll in Medicare when you become eligible.
You can combine Medicare with some health insurances, such as group coverage through an employer or retiree coverage. In fact, you may have to enroll in Medicare to continue to have this medical coverage or to avoid expensive medical bills.
How employer coverage works with Medicare varies. The key is to contact your employer or benefits administrator to see what happens when you turn 65. Some examples of where to call:
Veterans: Contact your local veterans' service officer if you have questions about whether to enroll in Medicare. Contact SHIBA if you have questions about how Medicare works once you enroll, if you are not close to a veterans' medical facility. Visit the veterans' office locator website.
Medicare has rules for how different plans work together and which health plan pays primary. Learn more by reading Medicare and Other Health Benefits: Your Guide to Who Pays First . Benefits Coordination and Recovery Center (BCRC) at 1-855-798-2627 (TTY: 1-855-797-2627).
Medicare will send an Initial Enrollment Questionnaire, asking about other insurance so that it can set up your file and make sure your claims are paid correctly. If you don't receive this questionnaire before your Medicare starts, contact Medicare or fill out the form online through MyMedicare.gov.
Medicare covers a wide variety of services, screenings, and tests. To find out if something is covered, visit Medicare's website.
Medicare does not cover long-term custodial care, routine dental care, dentures, cosmetic surgery, acupuncture, naturopathy, hearing aids, routine eye exams, eyeglasses (except after cataract surgery), care outside the United States, or exams for fitting hearing aids. Medicare Advantage plans may cover some of these services (such as providing a limited benefit for routine vision or preventive dental care).
Original Medicare does not cover outpatient prescription drugs. However, if you have Medicare Part A, Part B, or both, you can enroll in a stand-alone Part D plan to help pay for prescription drugs. Most Medicare Advantage plans include Part D coverage.
There is no “season"; you can apply for a Medigap supplement policy at any time. However, insurance companies generally may increase your starting premium because of your medical history (underwrite) and refuse to issue a policy. You have “guaranteed issue" (they may neither deny nor underwrite) during your six-month Medigap open enrollment period. This period begins the day your Part B starts and lasts for six months. This is the best time to purchase this insurance if you want to try it.
Other situations, such as employer coverage ending, may open a 63-day guaranteed issue opportunity. The SHIBA publication, Oregon Guide to Medicare Insurance Plans, has information on Medigap carriers, premium comparisons, and a list of guaranteed issue situations.
This depends on what type of Medicare insurance package you assemble. For example, if you have Original Medicare (Parts A and B), you will use your Medicare card when you get hospital or medical services. You will also use a separate card if you have a supplement, and yet another card if you have a prescription drug plan. However, if you have a Medicare Advantage plan, you will use that plan's card.
Once in Medicare, most people can change Medicare Advantage and prescription drug plans once a year. The date is Oct. 15 through Dec. 7. Changes are effective Jan. 1 of the next year. If you have Medicare and Medicaid (“dual eligible"), you can enroll in a plan, disenroll, or change plans at any time. Other options are:
Changes involving a Medigap are different. If you want to switch from a Medicare Advantage plan, you may have to wait until an open enrollment period in order to leave the plan.
It depends on your insurance choices and your annual income. Most people get Part A at no cost, but Part B has a monthly premium. Most people entering Medicare in 2022 pay $170.10 monthly for Part B, but people with higher incomes pay more.
If you are receiving a monthly retirement or disability (Social Security) check, your Part B premiums will be deducted from your check. If you are not receiving Social Security, you have two options:
Medicare has savings programs that help some limited-income people pay the Part B premium and other Medicare medical costs, and with Part D prescription drug costs.
Medicaid is a state-run assistance program that provides varying levels of hospital and medical coverage for people with low income and resources. Some “dual eligible" people qualify for both Medicare and Medicaid. Beneficiaries who qualify for the Medicare Savings Program can receive help with Medicare medical and prescription drug costs. For Medicaid information, contact your local Oregon Department of Human Services (ODHS) office by calling 800-282-8096 (toll-free) or going to the ODHS website.
If you get incorrect enrollment information from federal officials (Social Security or Medicare) and you documented the conversation (date, time, name of person you spoke with, and the key information provided), you may get “equitable relief" from any resulting problems or penalties.
If you get information from any other sources – whether it is insurance agents, human resources benefits administrators, volunteer counselors, or news articles – you may not be able to fix the problem. Example: You missed the deadline to enroll in Part B because someone other than Social Security erroneously said you didn't need it. You probably will have a lapse in coverage and be stuck with the lifetime penalty.
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