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Medicare Learning Center

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The Medicare Learning Center

Understanding Medicare is easy once you learn some basic concepts. When you’re informed, you can make smart decisions about your healthcare and what plan is best for you. Here is some basic information to help you better understand Medicare and how it works.

Original Medicare, or Medicare Part A and Medicare Part B, is designed to cover the basics of your health care – things like hospitals, outpatient doctor visits, tests and preventive care. With Original Medicare, you pay a set amount for your health care, called a deductible. Then, Medicare pays its share and you pay a percentage of the cost of the service, called coinsurance.

Medicare Part C plans are a private insurance alternative to the government program. With this option, you get all your Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) coverage through the insurance company instead of directly through the government. Medicare Advantage plans that include drug coverage can give you all your Medicare benefits in one policy; these are known as Medicare Advantage Prescription plans.

Prescription drug coverage is not included with Medicare. If you decide not to join a Medicare Prescription Drug Plan (Part D) when you’re first eligible, or if you decide not to join a Medicare Advantage Plan (Part C) (like an HMO or PPO) or other Medicare health plan that offers Medicare prescription drug coverage, you’ll likely pay a late enrollment penalty unless you have other creditable prescription drug coverage, or you get Extra Help.

Medicare Supplement Plans, also known as Medigap, is designed to fill “gaps” in original Medicare Parts A and B. Medicare Supplements generally cover the remaining balance left after Medicare has paid its share, depending on the level of coverage you select. To ensure more complete coverage (medical and prescription drug), it is recommended that you also enroll in a standalone Prescription Drug Plan. While there are many different levels of Medigap plans to choose from, the benefits are standardized by state. This means that within your state, the coverage of each plan offered by one insurance company will be the same as the coverage for the same plan offered by any other insurance provider. The difference among the Medigap plans within your state lies in the details of how much coverage is offered and which gaps will be filled. With Original Medicare, you pay a set amount for your health care, called a deductible. Then, Medicare pays its share and you pay a percentage of the cost of the service, called coinsurance.

Feeling a little confused?

All of the elements of Medicare can become overwhelming. Trying to navigate through it all by yourself is a risky proposition. Luckily, the licensed professionals at McGonigal Senior Benefits are here to help. If the time has come to explore your options for healthcare in the Medicare environment, contact us today.

Understanding Enrollment Periods

Initial Enrollment Period

When you turn 65, you will automatically be enrolled in Medicare Part A and Medicare Part B if you are receiving benefits from Social Security or the Railroad Retirement Board.

 

If you are 65 and not yet receiving Social Security or Railroad Retirement Board benefits (because you’re still working), Medicare enrollment may work differently. If you aren’t already getting retirement benefits when you turn 65, you won’t be automatically enrolled in Medicare Part B and will need to sign up during your Initial Enrollment Period. If you have coverage through active employment and choose to delay enrollment in Medicare Part B, you will be given a Special Enrollment Period that starts when you stop working or your employer-sponsored health insurance ends. If you don’t sign up during this time, you can do so during the General Enrollment Period, but may owe a late-enrollment penalty.

 

Medicare Part A enrollment if you’re still working at 65 will depend on if you have enough work history to get Part A without a premium. If you’ve worked at least 10 years (40 quarters) and qualify for premium-free Medicare Part A, you’ll be automatically enrolled in Part A when you turn 65 even if you’re still working at the time. However, if you don’t have enough work quarters to get Medicare Part A without a premium, you’ll also need to manually enroll in Part A.

Open Enrollment Period - January 1 through March 31

If you miss your Initial Enrollment Period, you can sign up between January 1 through March 31 each year. Your coverage will begin July 1. You may have to pay a higher premium for late enrollment.

Special Enrollment Period

If you or your spouse (or family member if you are disabled) is currently working and you are covered by a health insurance through an employer or union, you will have a Special Enrollment Period when your coverage ends. There is also a Special Enrollment Period for international volunteers if you are serving as a volunteer in a foreign country.

 

For example: If your 65th birthday is October 20, 2014 and you automatically qualify for Medicare, your Medicare effective date would be October 1, 2014. If your birthday is on the first day of the month, Medicare Part A and Part B will be effective on the first day of the prior month. So then, if your 65th birthday is October 1, 2014, your Medicare effective date would be September 1, 2014.

 

If you are under age 65 and receiving Social Security or Railroad Retirement Board disability benefits, you automatically get Part A and Part B after you get disability benefits from Social Security or certain benefits from the RRB for more than 24 months. You will get your Medicare card in the mail three months before your 65th birthday or your 25th month of disability.

 

If you have ALS (amyotrophic lateral sclerosis, also called Lou Gehrig’s disease), you automatically get Part A and Part B the month your disability benefits begin.

 

If you have end-stage renal disease (ESRD), different rules apply. You can contact the Social Security Administration to learn more about Medicare eligibility because of end-stage renal disease by calling 1-800-772-1213, Monday through Friday, from 7AM to 7PM.

Annual Enrollment Period - October 15 through December 7

The Annual Election Period, which is when you can change your Medicare health or prescription drug coverage, is October 15 through December 7. You coverage will begin January 1 of the following year, as long as the plan gets your enrollment request by December 7. In most cases, you must stay enrolled for the calendar year.