Medicare FAQ

Medicare is health insurance for people 65 or older, people under the age of 65 with certain disabilities, and people of any age with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or kidney transplant).

Part A – Hospital insurance
Part B – Medical insurance
Part C – Medicare Advantage
Part D – Medicare prescription drug coverage

• Inpatient hospital care
• Skilled nursing facility care
• Hospice care
• Home health care

• Services from doctors and other health care providers
• Outpatient care
• Home health care
• Durable medical equipment
• Some preventive services, including certain vaccines and cancer screenings

• Includes all benefits under Parts A and B provided by Medicare-approved private insurance companies
• May include extra benefits and services at an extra cost
• Usually includes Medicare prescription drug coverage (Part D) as part of the plan
• Medicare Advantage plans are network-based plans. When you visit an in-network healthcare service provider, the amount you’d be responsible for paying is less than if you go to an out-of-network provider. Some Medicare Advantage plans will not allow you to go out-of-network except in the case of an emergency.

• Helps cover your prescription drug costs
• Run by Medicare-approved private insurance companies
• May help lower your prescription drug costs and help protect against higher costs in the future

Apply 3 months prior to turning 65, so that you can have everything set up prior to your 65th birthday.

Apply for Part A and Part B if you do not have any other health insurance coverage after you turn 65. If you will have group coverage and you are continuing to work and not retire at age 65, apply for Part A only.

You must have creditable prescription drug coverage, so Part D is also needed if you do not have creditable prescription drug coverage.

$0 for most people (because they or a spouse paid Medicare taxes long enough while working, generally at least 10 years). If you get Medicare earlier than age 65, you won’t pay a Part A premium. This is sometimes called “premium-free Part A.”

Part B (medical insurance) costs $165.90 each month (or higher, depending on your income). The amount typically changes in January of each year. You’ll pay the premium each month, even if you don’t get any Part B-covered services.

Medicare Part B usually pays 80% of allowable charges for a covered service after you meet your Part B deductible. Unlike Part A, you pay your Part B deductible just once each calendar year. After that, you generally pay 20% of the Medicare-approved amount for your care.

Original Medicare is sometimes called “traditional Medicare.” Original Medicare coverage is managed by the Federal Government. If you don’t choose a Medicare Advantage plan (such as Medicare HMO or PPO), you will have Original Medicare.

Medigap helps pay some of the costs that Original Medicare does not cover, such as copayments and deductibles. You need both Part A and Part B to purchase a Medigap or Medicare Supplement policy.

Legal residents must live in the U.S. for at least 5 years in a row, including the 5 years just before applying for Medicare. To be eligible for Medicare, you must be a U.S. citizen or legal resident AND you must meet one of these requirements:

• Age 65 or older
• Younger than 65 with a qualifying disability
• Any age with a diagnosis of end-stage renal disease or ALS

Initial Enrollment Period (IEP)

For those who become eligible due to age, your IEP includes your 65th birthday month, the 3 months before and the 3 months after. Your IEP begins and ends 1 month earlier if your birthday is on the first of the month. You have 6 months to be guaranteed coverage in a Medicare Supplement insurance plan (Medigap), starting the first month you are age 65 or older and enrolled in both Medicare Part A and Part B. You may apply at other times, but you could be denied coverage or charged a higher premium based on your health history. Some states may have additional open enrollment rights under state law.

Your 7-month IEP includes the month you receive your 25th disability check, the 3 months before and 3 months after.

During annual enrollment, you can add, drop, or switch your Medicare coverage between the dates of October 15 – December 7 of each year.

If you’re already a Medicare Advantage plan member, you may disenroll from your current plan and either switch to a different Medicare Advantage plan one time only, or go back to original Medicare during this period.

Depending on certain circumstances, you may be able to enroll in a Medicare plan outside of the initial enrollment or annual enrollment time frames. Some ways you may qualify for a Special Enrollment Period are if you:

• Retire and lose your employer coverage
• Move out of the plan’s service area
• Qualify for Extra Help
• Have been diagnosed with certain qualifying chronic health conditions

This is an additional amount charged by Medicare that will be added to your Part D premium if you didn’t enroll in prescription drug coverage when initially eligible for Medicare and didn’t have other creditable drug coverage to qualify for enrollment during a Special Enrollment Period, or you didn’t enroll in prescription drug coverage within 63 days of losing your creditable drug coverage.

Extra Help is a Medicare program to help people with limited income and resources to pay for Medicare drug coverage (Part D) premiums, deductibles, coinsurance, and other costs. You must qualify to receive Extra Help from the Federal Government.

This is a state program that helps pay for Medicare coinsurance, deductibles, and premiums for certain elderly and disabled people through a program called Medicare Savings Program. These individuals are designated as Qualified Medicare Beneficiaries (QMB), Specified Low-Income Medicare Beneficiaries (SLMB), Qualified Individuals (QI), or Qualified Disabled Working Individuals (QDWI), and must meet the following eligibility criteria to receive assistance with Medicare-related costs:

• Be entitled to Medicare
• Be low income
• Be 65 years of age or older, or younger than 65 years of age and entitled to Medicare
• Have few personal resources

PPO (preferred provider organization). These types of plans mean you can visit any in-network provider for covered services. You also have the option to seek care from out-of-network providers, but your out-of-pocket costs will be higher.

An HMO is a health maintenance organization. This plan means you need to see in-network providers for covered services because there are no out-of-network provider benefits that will be covered except in case of an emergency. Most plans require you to choose a primary care physician to coordinate care.