Get More From Medicare: Helpful Explanations for Your Next Enrollment
Key Takeaways
- Original Medicare (Parts A and B)Original Medicare is a fee-for-service health insurance program available to Americans aged 65 and older and some individuals with disabilities. Original Medicare is provided by the federal government and is made up of two parts: Part A (hospital insurance) and Part B (medical insurance). , Medicare AdvantageMedicare Advantage (Medicare Part C) is health insurance for Americans aged 65 and older that blends Medicare benefits with private health insurance. This typically includes a bundle of Original Medicare (Parts A and B) and Medicare Prescription Drug Plan (Part D). , Medicare Part DMedicare Part D is prescription drug coverage for people enrolled in Medicare. Part D is optional and is offered by private insurance companies. , and Medicare Supplement Insurance (Medigap)Medicare Supplement Insurance (Medigap) is designed to provide coverage that Original Medicare (Parts A and B) does not. Medigap policies are purchased in addition to Original Medicare and have their own monthly premiums you’ll need to pay. are all health insurance for Americans aged 65 and older.
- Most people must enroll in Medicare the year they turn 65; automatic enrollment is uncommon.
- There are significant differences between the different forms of Medicare, including cost, coverage and enrollment.
What is Medicare, and how does it work?
New to Medicare? Trying to make sense of what’s covered, what it costs, how to enroll — or all three? You’re not alone. Medicare is a complicated process, and mistakes can be costly. To help, here’s a list of some of the most common questions for our licensed insurance agents, and more importantly, here are the answers.
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Is Medicare the same as health insurance?
Medicare aims to provide the same basic care as the job-based or private health insurance you’ve had in the past — but it’s only for Americans aged 65 and older or someone who receives disability benefits.
What is Original Medicare?
Original Medicare has two parts: Part A (hospital insurance) and Part B (medical insurance). It’s only available to Americans aged 65 and older and some Americans younger than 65 with disabilities. It is administered by the Social Security Administration and managed by the Centers for Medicare and Medicaid Services (CMS). Patients with Original Medicare can see any healthcare provider that accepts Medicare.
What is Medicare Advantage?
Medicare Advantage (Part C) replaces Original Medicare (Part A & B), but offers the same Part A & B benefits or coverages as Original Medicare. Along with receiving Part A & B benefits, Medicare Part C often bundles your benefits with additional ones like dental, hearing, vision, and prescription drug coverage.
When you have Medicare Part C, your Part C benefits ID card replaces your Medicare ‘Red, White & Blue’ card at every visit.
What is Medicare Supplement Insurance (Medigap)?
Medigap is private health insurance that helps cover the out-of-pocket costs that Original Medicare doesn’t. They’re designed to be purchased alongside Original Medicare and have separate monthly premiums you’ll need to pay. Medigap plans do not cover prescription drugs so a recipient will need to enroll into a stand alone Prescription Drug Plan to receive coverage for medications.
What is the Medicare Prescription Drug Plan (Part D)
Medicare Prescription Drug Plan (Part D) is prescription drug coverage for people enrolled in Medicare. Part D is optional for Original Medicare, and most Medicare Advantage plans include Part D.
Is Medicaid the same as Medicare?
No. Medicaid helps low-income Americans with some of their medical bills, while Medicare is health insurance available to all Americans aged 65 and older. Medicaid and Medicare may work together in instances when a patient is considered dual eligible.
ENROLLMENT
Am I automatically enrolled in Medicare?
Probably not. Some people are automatically enrolled in Parts A and B if they’re drawing Social Security benefits before turning 65. Otherwise, you’ll need to enroll yourself during your seven-month Initial Enrollment Period around your birthday month.
Is It mandatory to go on Medicare when you turn 65?
No, you are not required to have health insurance of any kind. However, not enrolling in Medicare can result in stiff enrollment penalties if you decide to enroll later.
How long before you turn 65 do you need to sign up for Medicare?
Don’t wait for your birthday to enroll. The year you turn 65, a seven-month Initial Enrollment Period opens. During this period, you can enroll in Original Medicare, Medicare Advantage, Medicare Prescription Drug Plan (Part D), and Medicare Supplement Insurance (Medigap).
How do I enroll in Medicare?
- Original Medicare Parts A and B: You can enroll with the Social Security Administration online, over the phone (SSA’s Medicare phone number: 1-800-772-1213) or in-person at a nearby office.
- Medicare Advantage, Part D and Medigap: One way is to visit each of the different government sites to shop all the available plans in your area, and then examine how they stack up with your needs. Instead, many enrollees choose to contact a licensed agent, like those at GoHealth, for impartial guidance and advice. They’ll go through your options and make sure your new policy works for you.
Do you need a birth certificate to apply for Medicare?
You will need to be able to provide proof of your age and that you are a U.S. citizen if you are enrolling in Medicare, so a birth certificate is a helpful document, but isn’t the only one you can use. Other documents like a driver’s license or medical or school records can help establish your age.
Is my choice permanent?
No. You can enroll in or switch your Medicare Advantage plan and Part D plan each year during the Open Enrollment Period, also called the Annual Enrollment Period, from Oct. 15 to Dec. 7. Suppose you want to drop your Medicare Advantage plan and enroll in Original Medicare. In that case, you can do so during the Medicare Advantage Open Enrollment Period each year from Jan. 1 to March 31.
- Note: The decision to not purchase Medicare Supplement or Medigap during your Initial Enrollment Period can be permanent; if you miss your Medicare supplement initial enrollment, you may have to undergo medical underwriting. In this case, the health insurance company may be able to deny you coverage because of a pre-existing condition.
Is there a penalty for missing your Initial Enrollment Period?
Yes. Medicare Part A, Medicare Part B and Prescription Drug Plan (Part D) each have their enrollment penalties if you miss your Initial Enrollment Period.
- Part A: You’ll pay a two-year, 10% increase to your monthly premium for each year you weren’t enrolled in Part A.
- Part B: For every 12-month period you delay enrollment, your monthly premium goes up 10%. This is a lifetime penalty.
- Part D: If you go more than 63 days past your IEP without drug coverage, your Part D premium will increase 1% each month you’re not enrolled in a plan.
What if I’m still working when I turn 65?
If you have a job-based plan when you turn 65, it may be possible to delay your enrollment until you lose that coverage, voluntarily or involuntarily. You may be able to enroll when you’re ready, without penalty, if you can prove you had group health insurance that was considered creditable coverage during the time you didn’t enroll in Medicare.
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COSTS
Is Medicare free?
No. While the government partially funds Medicare, enrollees typically pay various costs for their coverage. Some charges are paid monthly, like premiums; others are paid per service, like copayments and coinsurance.
How much does Medicare cost?
How much your Medicare will cost each year depends on many things, including your needs, work history and even income. This is true of Original Medicare, Medicare Advantage, Medicare Prescription drug Plan (Part D) and Medicare Supplement Insurance (Medigap). Make sure to understand the typical health insurance cost terms you’ll need to know, as well as any standard payment amounts you should expect.
What if I can’t afford Medicare?
There are several resources designed to make Medicare more affordable. You may also qualify for Medicaid, or even dual eligibility in both Medicare and Medicaid if you have limited resources.
What is a Part D donut hole?
Part D, or Medicare Prescription Drug Plan, has a coverage gap called a “donut hole.” Once you receive a certain amount of benefits from your plan in a year, your payments may increase. Instead of paying a co-payment for your medications, you’ll pay as much as 25% of the reasonable drug price. You may also have other fees to pay once you enter the donut hole.
COVERAGE
What does Medicare actually cover?
Original Medicare is made up of Part A (hospital coverage) and Part B (medical coverage). You’ll need to purchase Medicare Prescription Drug Plan (Part D) if you need medications, which will be a separate policy with separate costs. And while Original Medicare will provide you with the essential benefits you need, it may leave you with high out-of-pocket costs when you receive treatment. To help, there may be Medigap or Supplement plans in your area that can help.
Medicare Advantage Part C plans bundle many of these services together through private insurance companies to offer fairly comprehensive coverage options. But as with Original Medicare, there will still be gaps. Neither plan, for example, covers long-term care. Also, all services must be approved, which means cosmetic surgeries may not be covered.
Does every doctor accept Medicare?
No. Make sure to verify your doctor’s office accepts Medicare when scheduling any appointments. It also pays to ask the office which costs you should expect to pay during your visit.
Does my Medicare cover my spouse?
No. Medicare is an individual form of health insurance. You and your spouse will each have a separate Medicare policy. Being married does affect your Medicare coverage. Your joint income determines costs such as your premiums for Medicare Part B and Part D. You or your spouse may also be able to delay enrollment if you’re on the other’s group policy when you turn 65.
Does Medicare use provider networks?
Medicare Advantage uses provider networks, but Original Medicare (Parts A and B) does not. This may affect your prescription drug coverage; if you have a Part D plan through your Medicare Advantage plan, you may be limited to a specific network.
Sources
- Your health plan options. Medicare.gov.
- Apply for Benefits. SSA.gov.
- Social Security Office Locator. SSA.gov.
- Get help paying costs. Medicare.gov.
- Costs in the coverage gap. Medicare.gov.
This website is operated by GoHealth, LLC., a licensed health insurance company. The website and its contents are for informational and educational purposes; helping people understand Medicare in a simple way. The purpose of this website is the solicitation of insurance. Contact will be made by a licensed insurance agent/producer or insurance company. Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. Our mission is to help every American get better health insurance and save money.
Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.