Improve your understanding of Medicare with these answers to some frequently asked questions.
You’re eligible for Medicare if you are 65 or older, a U.S. citizen or permanent resident, and if Medicare taxes were taken out of your or your spouse’s paycheck for at least 10 years. If you’re under 65, you may still qualify for Medicare if you have a disability or permanent kidney failure or ALS (Amyotrophic Lateral Sclerosis also known as Lou Gehrigs disease).
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In most cases, Medicare is a federal health insurance program for people 65 years old or over and for certain disabled people under 65 years of age. You are automatically enrolled in Medicare hospital insurance (Part A) when you apply for Social Security benefits – usually upon reaching 65 years of age. Part A covers inpatient care in a hospital or a limited stay in a skilled nursing facility. Part B covers physician and outpatient hospital services. The premium you pay for Part B is deducted from your Social Security benefits.
Medicare pays for many healthcare services and supplies, but it doesn't cover all of your healthcare costs. For example, you pay a deductible for each hospital stay and coinsurance anytime you use the services of a physician or surgeon. Also, drug coverage is limited. Because Medicare rarely pays the full cost of covered services, you may want to consider a Medicare Advantage or Medicare Supplement insurance plan.
A Medicare Supplement insurance plan helps cover the costs that are left unpaid after Medicare Parts A and B pay their portion of your healthcare expenses. Unlike a Medicare Advantage plan, which is an alternative to your Medicare Parts A and B benefits, a Medicare Supplement plan is purchased in addition to your Medicare Parts A and B benefits.
Medicare Supplement policies are standardized into 10 plans - labeled "A" through "N", each with its own set of benefits. Plan A covers the most basic benefits. These basic benefits are also covered in each of the remaining Medicare Supplement plans - B through N. Plans B through N provide additional coverage beyond the basics.
Medicare Supplement policies are sold by private insurance companies. While the costs of these policies may vary, individual insurance companies must provide the same standardized benefits. Some companies may offer innovative benefits. To purchase a policy, in general you must be enrolled in Medicare Part A and Part B. In addition to paying the monthly Medicare Part B premium to Medicare, you will have to pay a premium to the insurance company providing your coverage.
Medicare Advantage (MA) plans are available through private health insurance companies and replace Original Medicare. MA plans may or may not include a Medicare prescription drug benefit. Medicare Supplement plans supplement Original Medicare, providing secondary coverage for out-of-pocket costs. Only beneficiaries with Original Medicare may enroll in Medicare Supplement plans. Beneficiaries cannot enroll in an MA plan and a Medicare Supplement plan. However, beneficiaries can enroll in a Medicare Supplement plan and a Medicare prescription drug plan (PDP), also known as Medicare Part D.
If you're enrolled in Medicare Part A and Part B, you're probably eligible to buy a Medicare Supplement policy. During your Medicare Supplement Open Enrollment Period – for people 65 or older, that’s six months after you sign up for Medicare Part B – a company must allow you to buy any Medicare Supplement insurance plan offered. In some states these plans may be available to those under age 65.
Here are key enrollment dates: October 15 – December 7 (Annual Election Period) If you're eligible, you can enroll in Medicare health benefits, such as a Medicare Advantage plan, for the following year. During this period, you can also change plans or enroll in a separate prescription drug plan.
You can enroll in a Medicare Advantage (MA) or a prescription drug plan (PDP) during the Annual Election Period (AEP), Initial Enrollment Period (IEP), Initial Coverage Enrollment Period (ICEP) or Special Enrollment Period (SEP).
You may enroll anytime during the first three months immediately preceding the month your enrollment in Medicare Parts A and B becomes effective. This time is called your Initial Coverage Election Period. It generally coincides with the month you turn 65 years old; however, some people choose to delay Part B coverage for a while if they have other coverage through their employer. In that case, it would be the month that your Part B coverage goes into effect, assuming you already have Part A.
There are no specific enrollment dates for a Medicare Supplement insurance plan. The best time to buy an insurance policy is during your Medicare Supplement Open Enrollment Period which lasts six months. It starts on the first day of the month in which you are BOTH age 65 or older AND enrolled in Medicare Part B. In some states, these plans may be available to those under age 65. For those enrolling in a Medicare Supplement insurance plan prior to the age of 65, your Medicare Supplement Open Enrollment Period begins on the first day you're enrolled in Medicare Part B. Once your Medicare Supplement Open Enrollment Period starts it cannot be changed.
You can change your Medicare plan during the Annual Election Period (AEP) or Special Enrollment Period (SEP). Go to When to Enroll in Medicare Advantage or Prescription Drug Plans for more information.
You can enroll in a Medicare Advantage (MA) or a prescription drug plan (PDP) during the Annual Election Period (AEP), Initial Enrollment Period (IEP), Initial Coverage Enrollment Period (ICEP) or Special Enrollment Period (SEP). Go to When to Enroll in Medicare Advantage or Prescription Drug Plans for more information.
PFFS plans feature limits on out-of-pocket expenses, coverage for emergency and urgent care, and in some cases, a prescription drug benefit. If you select a PFFS plan, it is an alternative to your Medicare coverage. However, you can return to Medicare down the road if you wish.
In most cases, if you are enrolled in a Medicare Advantage HMO (Health Maintenance Organization) plan, your Primary Care Physician (PCP) decides which specialists he or she refers patients to. Generally, primary care physicians will have established relationships with certain specialists they prefer to work with. So you'll need to check with your PCP about the specialist you would like to see. Please remember, you can't see a specialist listed in the directory without a referral from your PCP except in the case of emergency, urgently needed care, or out-of-area kidney dialysis.
The answer depends on your personal preferences and budget. For many people, the main reasons for choosing a Medicare Advantage plan are: (1) the simplicity of dealing with one company and (2) additional benefits and services not available with Medicare Parts A and B. For others, the choice comes down to price. In some areas, the all-in-one plan is less expensive than prescription coverage alone.
Before you select a plan, carefully consider the following questions. Your answers will help guide you to the plan that's right for you.
Do you already have a doctor you like?
Are you choosing a new doctor?
Is freedom to choose doctors and hospitals very important to you?
Do you need a prescription drug plan?
Do you have health problems today or old problems that may recur?
What drugs does the plan cover?
Does your doctor feel comfortable with the plan's guidelines for your treatment?
You can still apply for a Medicare Supplement insurance plan after your Medicare Supplement Open Enrollment Period has expired. However, your application may be subject to medical underwriting (i.e., a review of your medical history and current health) unless you qualify under guaranteed issue rights.
You also may have the right to buy a Medicare Supplement policy outside of your Medicare Supplement Open Enrollment Period if you lose certain types of health coverage. In general, this right is for 63 days from the date coverage ends or from the date you receive notice that your coverage will end. Colorado residents receive a guaranteed right to purchase a Medicare Supplement insurance plan for six months if their current coverage is involuntarily terminated and 63 days if terminated voluntarily. You must provide proof of the loss of your previous coverage. Otherwise, applying after your guaranteed issue period has expired may subject your application to medical underwriting which will help determine if your application will be accepted. More details can be found at Medicare Supplement Enrollment and Eligibility.
Medicare prescription drug coverage is insurance that covers both brand-name and generic prescription drugs at participating pharmacies in your area.
A late enrollment penalty (LEP) is a monthly premium penalty calculated and assessed by the Centers for Medicare & Medicaid Services (CMS).
If you do not enroll in a Medicare prescription drug plan (PDP) by the end of your Medicare Initial Enrollment Period (IEP) for Part D and do not have creditable prescription drug coverage for any continuous period 63 days or longer, you may have to pay an LEP.
You may choose to continue your drug coverage in another plan and not enroll in a Medicare Part D plan without an LEP if the other coverage is at least as good as the Medicare drug benefit.
You can avoid a late enrollment penalty (LEP) by:
Enrolling in a Medicare prescription drug plan (PDP) before the end of your Medicare Initial Enrollment Period (IEP) for Part D
Continuing your drug coverage in another plan with coverage that is at least as good as the Medicare drug benefit
Other LEP exceptions may include:
Members with a low income subsidy (LIS)
Members affected by Hurricane Katrina
Members receiving assistance from a state pharmaceutical assistance program (SPAP)
A formulary is a list of prescription medications approved for coverage by a health plan.
Yes. The government pays the health plan to administer Medicare Advantage plans. In some areas, the amount we receive from the government covers the entire plan premium – so it's possible to get all-in-one medical and prescription drug coverage for less than drug coverage alone. If you enroll in a zero-premium plan, you're still responsible for out-of-pocket costs like doctor's office copayments, as well as your Medicare Part B premium.
Creditable coverage is prescription drug coverage that is at least as good as the Medicare drug benefit.
Prescription drug coverage is insurance. Prescription drug coverage is not drug samples, discount cards, free clinics or drug discount websites. A Health Insurance Portability & Accountability Act (HIPAA) Portability Creditable Coverage statement is not proof that prescription drug coverage is as good as Medicare’s drug benefit.
As long as you still qualify for TRICARE, Veterans Affairs (VA), or the Federal Employee Health Benefits (FEHB) Program, your drug coverage did not change with the introduction of the Medicare Part D plan. Contact your benefits administrator or your FEHB insurer before making any changes to your coverage. It will almost always be to your advantage to keep your current coverage without any changes.
If you lose your TRICARE, VA, or FEHB coverage and join a Medicare Part D plan, in most cases you won't have to pay a penalty as long as you join within 63 days of losing benefits.
Yes. The U.S. Food and Drug Administration (FDA) requires that all drugs be safe and effective. Generics use the same active ingredients and are shown to work the same way to cure, treat, or prevent your illness or health condition. So they have the same quality, strength, and purity as their brand-name counterparts.
You should definitely sign up for Medicare Part A, the part of Medicare that covers inpatient hospital costs. In fact, Part A may even cover some costs that aren’t covered by your group plan. But you don’t need to sign up for Part B, which is the part that covers doctor visits, outpatient care, and other medical services. Those benefits are probably already covered by your group plan. After you stop working, you’ll be able sign up for Part B. If you work for a small company (fewer than 20 people), you may want to talk to your human resources manager about what you need to do.
You can sign up for a Medicare Advantage or Prescription Drug plans during your initial enrollment period, which is the seven-month period that starts three months before you turn 65. You can also switch from your Original Medicare plan to a Medicare Advantage or Prescription Drug plan during open enrollment, which is October 15 to December 7 every year. You can also sign up for these plans during special circumstances — if you move from one state to another or you lose coverage through another insurance company.
Didn’t sign up for Medicare when you first became eligible? Then you may qualify for the Special Enrollment Period if you lost your job or your group health coverage — or your spouse did. If that’s the case, then you have eight months after your group coverage ends to sign up for both parts A and B.
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