+How Does Medicaid Help People with Low Incomes Pay Medical Bills?

Medicaid is a joint federal and state program that helps pay medical bills for low-income people and limited resources. Eligibility for Medicaid depends on income level and family size.

Medicaid coverage differs from state to state. In all states, Medicaid pays for basic home health care and medical equipment. Medicaid may pay for the homemaker, personal care, and other services not covered by Medicare. There are Medicaid programs that pay some or all of Medicare’s premiums and may also pay deductibles and coinsurance for certain people who qualify for Medicare and need financial assistance.

For more information about Medicaid coverage in your state and to see whether you qualify, call your state medical assistance office.

+How does Medicare Special Enrollment Periiod for the Working Aged Work?

If you qualify for Medicare, but you have health insurance through an employer’s group health plan, you may be able to delay enrollment in Medicare Part B. When your employer-based coverage ends, you may be eligible for a Special Enrollment Period (SEP) to enroll in Medicare Part B without facing a late-enrollment penalty.

Medicare Part B Special Enrollment Period: who qualifies?

If you’ve worked at least ten years (40 quarters) while paying Medicare taxes, you typically qualify for premium-free Medicare Part A. Since most Medicare beneficiaries pay a monthly Medicare Part B premium, some choose not to enroll in Part B or delay enrollment. Generally, you face a lifetime late-enrollment penalty for Part B if you sign up after you’re first eligible for Medicare.

However, Medicare has a Special Enrollment Period when you can enroll in Medicare Part B without a penalty. This is how your SEP works:

If all of these apply to you…

you are 65 or older you are still working, or your spouse is still working you are covered by a health plan based on current employment …you may qualify for a SEP to enroll in Medicare Part B at any of these times:

while you are still covered by an employer or union group health plan during the eight months following the month when the employer or union group health plan coverage ends, or when the employment ends, whichever comes first.

If you’re working and plan to keep your employer’s group health coverage, talk to your benefits administrator to help you decide when to enroll in Part B.

Suppose your employer-based group coverage ends, and you don’t enroll in Medicare Part B during the SEP. In that case, you have to wait until the General Enrollment Period to enroll, and you may pay a higher Part B premium as a late enrollment penalty.

If you’re interested in enrolling in a Medicare Supplement (Medigap) plan, be aware that when your Part B coverage starts, your six-month Medigap Open Enrollment Period begins. Once this period begins, in most cases, it cannot be changed or restarted.

Additionally, if you drop Part B because you or your spouse (or family member, if you’re disabled) returned to work and had group health coverage, you can sign up for Part B again during the SEP described above. B premium will not go up. Make sure your group coverage is active before you drop Part B. However, you generally will not get another Medigap Open Enrollment Period when you restart Part B.

+ Medicare Enrollment - When can I apply for Medicare Part B?

U.S. citizens and legal permanent residents of at least five continuous years may be eligible for Medicare coverage. You’ve usually enrolled in Medicare Part A and Part B automatically when you turn 65 or qualify by disability at any age, and you receive Social Security Administration (SSA) or Railroad Retirement Board (RRB) benefits. For details about how you qualify for automatic enrollment, see Medicare Enrollment.

You’re not automatically enrolled in Medicare Part B in all situations. Here are a few examples of when you may qualify for Part B, but you need to sign up manually:

If you live in Puerto Rico, you’re typically signed up for Medicare Part A automatically when you turn 65 if you’re collecting SSA or RRB benefits. However, you need to sign up for Part B manually.

If you have an end-stage renal disease (ESRD, a type of kidney failure), you may qualify for Medicare regardless of age, but you generally have to apply manually. If you’re not receiving SSA or RRB benefits when you turn 65, you need to sign up for it if you want to enroll in Medicare Part B.

You can sign up for Medicare Part B during the following enrollment periods:

The Initial Enrollment Period (IEP) for Part B when you’re first eligible for Medicare. Your IEP typically starts three months before you turn age 65, includes your birth month, and lasts for three months after your birth month. That’s a total of 7 months. If you’re under 65 and disabled, you generally qualify for Medicare after receiving Social Security (or certain disability benefits from the Railroad Retirement Board) for 24 months. In this case, your 7-month IEP goes from the start of your 22nd month until the end of your 28th month of receiving disability benefits. If you sign up for Medicare Part B during your IEP, you won’t face a Part B late-enrollment penalty.

The General Enrollment Period (GEP) which runs from January 1 to March 31 of each year. You may enroll in Medicare Part B coverage if you are eligible. If you enroll in Part B during a GEP, it will be effective July 1 of the year in which you apply. You may have to pay a late-enrollment penalty. Your Part B premium may go up 10 percent for each 12-month period that you could have had Medicare Part B but did not sign up it. Suppose you didn’t take Medicare Part B when you were first eligible because you or your spouse worked and had group health plan coverage through your employer or union. In that case, you could add Medicare Part B coverage during a Special Enrollment Period (SEP). You can sign up during the following periods under the Part B SEP:

While you’re still covered by the employer or union group health plan During the eight months following the month the employer or union group health plan coverage ends, or when the employment ends — whichever is first.

To add Medicare Part B, contact the Social Security Administration at 1-800-772- 1213 (TTY users 1-800-325-0778), 7 AM-7 PM, Monday to Friday. For additional information, contact Medicare at 1-800-MEDICARE (TTY users 1-877-486-2048), 24 hours a day, seven days a week

+Can I delay Medicare Enrollment Without Paying a Medicare Part B Penalty?

Yes, you can delay your Medicare Part B enrollment in certain situations without paying higher premiums (also known as a late-enrollment penalty). Suppose you didn’t enroll in Medicare Part B when you were first eligible because you or your spouse worked and had group coverage through an employer or union. In that case, you can choose to sign up for Medicare Part B during a Special Enrollment Period (SEP) without paying a late-enrollment penalty.

You can sign up for Medicare Part B when you have coverage through current or active employment. Or you can sign up for Medicare during the eight-month Special Enrollment Period that starts when your employer or union group coverage ends, or you stop working (whichever happens first). If you get COBRA or retiree benefits after you stop working, keep in mind that this doesn’t count as coverage based on current employment; make sure you don’t wait until your COBRA benefits end to enroll in Medicare Part B.

Remember that if you do not enroll in Medicare Part B during your Special Enrollment Period, you’ll have to wait until the next General Enrollment Period, which occurs from January 1 to March 31 each year. You may then have to pay a late-enrollment penalty for Medicare Part B because you could have had Part B and did not enroll. If you owe a late-enrollment penalty, you’ll pay a 10% higher premium for every 12 months that you were eligible for Medicare Part B but didn’t sign

up for it. You may have to pay this higher premium for as long as you’re enrolled in Medicare.

Medicare Part B enrollment – avoiding the Part B penalty

There are a few situations when you may be able to delay Medicare Part B without paying a late-enrollment penalty. For example, suppose you were volunteering overseas or living out of the country when you turned 65 and weren’t eligible for Social Security benefits. In that case, you may be eligible for a Special Enrollment Period when you return to the United States. The length of your SEP will depend on your situation. If you aren’t sure if you qualify for a Special Enrollment Period, call Medicare to confirm at 1-800-633-4227 (TTY users 1-877-486-2048), 24 hours a day, seven days a week

+ Do I have to get Medicare Part B? How to Get Part B if you need it:

You are not required to have Medicare Part B coverage if you have employer coverage. You can drop Medicare Part B coverage and re-enroll in it when you need it.

Maybe you’re 65 but enjoying your career and want to work a few more years. You’re eligible for Medicare, but you also have employer coverage. Do you have to be dually covered with Medicare Part B coverage and employer health insurance?

If you’re a Medicare beneficiary and want to drop Medicare Part B coverage while you’re working and covered by your employer’s group health insurance, you may do so. You also may choose to defer enrollment in Medicare Part B coverage if you are employed at age 65 or older and eligible for Medicare.

What is Medicare Part B coverage?

Medicare Part B coverage extends to things like:

Outpatient care Preventative treatments and screenings such as cardiovascular screenings, diabetes screenings, mammograms, and prostate cancer screenings Ambulance services Durable medical equipment Physical therapy and occupational therapy Outpatient mental health care Your employer coverage may also cover all of the above. What does Medicare Part B cost?

Medicare Part B coverage (medical insurance) comes with a monthly premium, so some beneficiaries prefer to delay or drop Part B enrollment when they have other coverage. (The standard Medicare Part B premium was $144.60 in 2020.) However, it makes sense to keep Medicare Part A if you get it premium-free as most people do after working a minimum number of quarters.

You should contact your employer or union benefits administrator before delaying Medicare Part B coverage. In some cases, your employer may require you to enroll in Medicare Part A and Part B to get your full coverage.

What if I decide I want Medicare Part B and employer coverage?

If you drop Part B coverage while covered by an employer’s plan, you can sign up for Part B again during your Special Enrollment Period (SEP). You can enroll in Part B anytime you’re working (or your spouse is working) and covered by the employer – or union-based health insurance plan.

Your SEP extends for eight months after you or your spouse stop working, or the group coverage based on current employment ends, whichever occurs first.

A SEP lets you enroll in Medicare Part B outside of your Initial Enrollment Period. As long as you enroll in Part B during your SEP, you typically won’t have to pay a Part

B late-enrollment penalty in the form of a higher premium.

+ How Much is the Medicare Late Enrollment Penalty?

The Medicare program may charge a late-enrollment penalty if you don’t enroll in certain Medicare programs or plans when you’re first eligible. Delaying enrollment could increase your out-of-pocket costs for your coverage. There are late-enrollment penalties for Medicare Part A, Medicare Part B, and Medicare Part D plans.

It’s important to understand the period when you’re first eligible for Medicare. This period is called your Medicare Initial Enrollment Period (IEP), and if you qualify for Medicare by age, it starts three months before you turn 65, includes the month you turn 65, and ends three months later. It lasts for a total of seven months.

Original Medicare refers to Medicare Part A (hospital insurance) and Part B (medical insurance). It is the government-sponsored health care program for those who qualify by age (usually 65 and over). You may also qualify for Medicare before age 65 if you receive Social Security disability benefits. Medicare Part D is optional prescription drug coverage available from private Medicare-approved insurance companies.

Note that another eligibility requirement for Medicare is U.S. citizenship or permanent legal residence for at least five years in a row.

Medicare enrollment penalty: Medicare Part A

Most Medicare beneficiaries get Medicare Part A premium-free. You wouldn’t be charged a premium for Part A if you or your spouse worked at least ten years (40 quarters) while paying Medicare taxes. And you’re automatically enrolled in Medicare Part A if you’re already collecting Social Security or Railroad Retirement benefits when you turn 65 or qualify through disability.

Suppose you don’t qualify for premium-free Medicare Part A, and you’re not automatically enrolled. In that case, you may be required to pay a 10% higher monthly premium if you do not enroll when you are first eligible. You will have to pay this higher premium for twice the number of years that you could have had Part A coverage but did not enroll. The Part A premium can be as high as $458 in 2020 (without the penalty).

For example, if you delayed enrollment in Medicare Part A for one year after your IEP was over, you could pay a 10% higher monthly premium for two years.

Medicare enrollment penalty: Medicare Part B

Medicare Part B may also have a late-enrollment penalty if you don’t sign up when first eligible, depending on your situation. Your monthly premium may go up 10% for each full 12-month period that you went without Part B coverage after your IEP ended. You may have to pay this enrollment penalty for the remainder of the time you are enrolled in Medicare.

For example, suppose your IEP ended August 6, 2017, and you delayed Medicare Part B enrollment until the Medicare General Enrollment Period (January 1-March 31) in 2020. This would only include one full 12-month period of delay, so in this case, you’d pay a 10% penalty on top of your Medicare Part B premium — but you’d pay this penalty for as long as you’re enrolled in Medicare Part B.

Some people choose to defer enrollment in Medicare Part B — such as those still working and covered by an employer’s group plan. This is an example of a situation that could qualify you for a special enrollment period for Part B, and you might not have to pay the late-enrollment penalty.

Medicare enrollment penalty: Medicare Part D

Medicare prescription drug coverage (Medicare Part D) is optional. If you decide to get this coverage:

You may have to pay a higher monthly premium for your Medicare Part D Prescription Drug Plan if you go 63 or more consecutive days without creditable prescription drug coverage after your Initial Enrollment Period (IEP). Creditable prescription drug coverage is expected to pay at least as much as standard Medicare prescription drug coverage, on average.

Medicare calculates the late-enrollment penalty by multiplying the 1% penalty rate of the “national base beneficiary premium” ($32.74 in 2020) by the number of full, uncovered months you were eligible to enroll in a Medicare Prescription Drug Plan but did not (assuming you didn’t have other creditable prescription drug coverage). The final amount is rounded to the nearest $0.10 and added to your monthly premium.

For example, suppose you signed up for a Medicare Part D Prescription Drug Plan in 2020, eight months after your IEP ended. One percent of $32.74 is $0.32 x 8 months = about $2.56. So, about $2.56 would be added to your monthly Medicare Part D premium.

The “national base beneficiary premium” may go up each year, so the penalty amount may also go up every year. In addition to your premium each month, you may have to pay this penalty for as long as you have a Medicare Prescription Drug Plan.

For more about late-enrollment penalties and other Medicare enrollment information, see When to Apply for Medicare – Late Enrollment Penalties.

+ Is Medicare Part D mandatory or optional?

Whether you qualify for Medicare by turning 65 years of age, through disability, or by having a condition like Lou Gehrig’s disease, you may have the option to enroll in Medicare Part A and/or Part B. You also need to be a U.S. citizen or permanent legal resident of at least five straight years to qualify for Medicare.

Depending on your work history and how you qualify, you may be automatically enrolled or need to enroll manually. People often wonder how they obtain Medicare Part D, which is prescription drug coverage, and doesn’t automatically come with Original Medicare.

Medicare Part D benefits are available from either a stand-alone Medicare Prescription Drug Plan or a Medicare Advantage Prescription Drug plan, which combines Original Medicare (Part A and Part B) benefits with prescription drug coverage. Private insurance companies administer both types of plans with a contract with Medicare, and specific benefits and prices vary depending on the service area you live in.

Is Medicare Part D Mandatory?

It is not mandatory to enroll in a Medicare Part D Prescription Drug Plan. However, if you go without creditable prescription drug coverage for 63 or more days in a row after you’re first eligible, you may have to pay a late-enrollment penalty if you enroll

into a Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan later.

Read below to find out more about what kinds of coverage can help you avoid this penalty when you can enroll in a Medicare Part D Prescription Drug Plan or Medicare Advantage Prescription Drug plan and other information regarding the late-enrollment penalty.

What is creditable prescription drug coverage?

If you have health insurance in addition to Medicare, this might include creditable prescription drug coverage. Each year, the plan must tell you whether or not the prescription drug coverage is creditable, meaning it covers at least as much, on average, as Medicare’s standard prescription drug coverage does. Some common examples of creditable coverage include (but are not limited to) health insurance from:

Employer group coverage or union plans United States Department of Veterans Affairs (VA) TRICARE Indian Health Service (IHS) You can continue to use this prescription drug coverage alongside your Medicare benefits without penalty, as long as it’s creditable.

When can you enroll in Medicare Part D?

To enroll in a Medicare Part D Prescription Drug Plan, you need to have either Medicare Part A or Part B, and you have to live in the service area of the plan you choose. If you’re eligible for Medicare because of age, your seven-month Initial Enrollment Period for Part D usually takes place at the same time as your Initial

Enrollment Period for Part B, starting three months before your 65th birthday, including your birthday month, and ending three months later. If you qualify for Medicare through disability, you’ll get a subsequent Initial Enrollment Period for Part D when you turn 65 years of age.

The Medicare Part D late-enrollment penalty may apply if you enroll any time after your Initial Enrollment Period for Part D and go without creditable prescription drug coverage for more than 63 days in a row. Suppose you don’t enroll in Medicare Part D when you’re first eligible. In that case, your next opportunity will be during the Annual Election Period that occurs from October 15 to December 7 of every year. During this time, you can enroll into a stand-alone Medicare Prescription Drug Plan if you have Original Medicare or get prescription drug coverage through a Medicare Advantage Prescription Drug plan. You can also use this period to switch plans or disenroll from your plan.

During the Medicare Advantage Open Enrollment Period (OEP), you may be able to make certain coverage changes. The OEP runs from January 1-March 31 each year.

You can generally switch from one Medicare Advantage plan to another, regardless of whether the plans include prescription drug benefits. You can drop your Medicare Advantage plan and return to Original Medicare. You can enroll in a stand-alone Medicare Part D prescription drug plan if you drop your Medicare Advantage prescription drug plan during the OEP. However, you can’t switch from one stand-alone Medicare Part D prescription drug plan to another during this time.

You cannot generally enroll in a Medicare Advantage plan for the first time during this period.

You also cannot disenroll from a Medical Savings Account plan during the Medicare Advantage OEP.

You can’t make changes to your Medicare Part D coverage outside of these periods unless you qualify for a Special Election Period. Certain situations allow you to make

changes outside of the regular periods may include but aren’t limited to moving out of your plan’s service area, losing Medicaid eligibility, or moving into a nursing home.

What is the Medicare Part D late-enrollment penalty?

Suppose you’ve gone 63 consecutive days without creditable prescription drug coverage, either because you didn’t enroll when you were first eligible or because you lost your creditable coverage and didn’t get new coverage in time. In that case, you may have to pay a late-enrollment penalty when you do enroll in Medicare Part D.

The Medicare Part D late-enrollment penalty is added to the premium of the Part D Prescription Drug Plan you enroll into. Your Medicare Prescription Drug Plan determines this penalty by first calculating the number of uncovered months you were eligible for Medicare Part D but didn’t enroll under Part D or have creditable coverage. Your Medicare Prescription Drug Plan will then ask you if you had creditable prescription drug coverage during this time. Suppose you didn’t have creditable prescription drug coverage for 63 or more days in a row after you were first eligible. In that case, the Medicare Prescription Drug Plan must report the number of uncovered months to Medicare.

For example, let’s say you disenrolled from your Medicare Prescription Drug Plan effective February 28, 2020, and then decided to enroll in another Medicare Prescription Drug Plan during the Annual Election Period, with an effective date of January 1, 2021. This means you didn’t have creditable prescription drug coverage from March 2020 through December 2020, which adds up to 10 uncovered months.

Currently, the late-enrollment penalty is calculated by multiplying 1% of the “national base beneficiary premium” ($32.74 in 2020) times the number of full,

uncovered months that you were eligible but didn’t join a Medicare prescription drug plan and went without other creditable prescription drug coverage. This number is then rounded to the nearest $.10 and added to your Medicare Prescription Drug Plan monthly premium cost. The “national base beneficiary premium” may increase each year, so the total of your late-enrollment penalty can also increase each year.

+ Should I apply for Medicare or keep my employer's health plan?

Medicare and employer coverage: do you have to apply for Medicare?

If you are turning 65 and still working, you might still be covered by your employer’s health insurance plan. Or, perhaps, you get benefits through a spouse’s employer coverage.

Before you apply for Medicare, be aware that you might have several insurance options. For example, you may be able to:

Drop your employer coverage and enroll in Original Medicare, Part A, and Part B. If you take this route, you might want to think about signing up for prescription drug coverage under Medicare Part D and/or buying a Medicare Supplement plan. Medicare Supplement insurance can help pay the out-of-pocket costs of Medicare Part A and Part B.

Alternatively, you may have the option to receive your Medicare benefits from a Medicare Advantage plan.

Have both Medicare and your employer coverage?. Medicare and employer coverage will need to coordinate benefits, which means that either Medicare or

the employer plan pays first for covered care. The other insurance is “secondary” and may also pay a portion of the costs. More on who pays first below. Stay with your employer coverage and apply for Medicare later. Keep in mind that being eligible for Medicare doesn’t mean you have to take it. However, you might want to enroll in Medicare Part A (hospital insurance) as soon as you’re eligible, especially if you qualify for premium-free Part A. You generally qualify for Part A without paying a premium if you’ve worked at least ten years (40 quarters) while paying Medicare taxes.

Later, when your employer coverage ends, you can apply for Medicare Part B. To avoid a late enrollment penalty for enrolling in Medicare, make sure you apply for Medicare during your Special Enrollment Period.

You must contact your employer-based health plan administrator to find out how the plan works with Medicare.

To get the best value and health insurance coverage for your situation, learn about your employer coverage costs and your costs if you apply for Medicare. You’ll need to do a little research to determine the best arrangement for you.

If you apply for Medicare and keep employer coverage, what are your out-of-pocket costs?

If you apply for Medicare, be aware that it’s not free. Most people pay a monthly premium for Medicare Part B (medical insurance). However, you may be eligible to receive premium-free Medicare Part A (hospital insurance), as explained above. You may want to apply for Medicare Part A if you want when you are first eligible and apply for Medicare Part B later when you lose your employer coverage. That might be a cost-conscious way to increase your insurance coverage if you decide to have both Medicare and employer coverage.

Medicare Part A and Part B have deductibles, copayments, and coinsurance costs. For example, you’ll typically pay 20% after you’ve met your annual Part B deductible for medical services and supplies covered under Part B.

What about the other “parts” of Medicare – Part C (Medicare Advantage) and Part D (prescription drug coverage)? These Medicare coverage options might charge monthly premiums. And you still need to keep paying your Part B premium as well – if you have Part B. You must be enrolled in Medicare Part A and Part B to qualify for a Medicare Advantage plan under Medicare Part C.

It’s usually simple to find out your employer coverage costs. You can probably see the deduction in your paycheck for your health plan premium. If you’re happy with the coverage and feel the costs are affordable, you may want to keep it.

Review the deductibles and coinsurance cost-sharing amounts of your employer coverage. Increasingly, employer coverage might also include deductibles and coinsurance or copayment amounts.

Deciding whether to apply for Medicare or keep employer coverage

You’ll probably want to consider what additional benefits if any, your employer coverage includes beyond coverage for doctor visits and hospital stays. For example, does it include routine dental, vision, and/or prescription drug coverage? You generally don’t get these benefits under Medicare Part A and Part B. Part A and Part B have limited coverage for prescription drugs but generally don’t cover medications you take at home.

Also, consider whether your cost for employer coverage includes coverage for your spouse. If it does, you’ll want to factor in the cost for your spouse to get coverage

elsewhere before you decide to drop your employer coverage for Medicare. Medicare coverage is for individuals, not married couples or families.

On the other hand, you may be able to get the benefits listed above – routine dental care and prescription drug coverage, for example – through a Medicare Advantage plan.

Medicare and employer coverage: coordination of benefits

Let’s say you’re going to keep your employer coverage and also apply for Medicare. Medicare coordinates benefits with your employer coverage. Which insurance pays first? That is – which is the primary payer?

The size of the employer helps determine who pays first.

If you work for a company that employs 20 employees or more, your employer coverage usually pays first. Medicare is the secondary payer, paying its portion for covered services your employer’s group health coverage did not pay. You might still have to pay a deductible and/or copayment or coinsurance amount. If you work for fewer than 20 employees, Medicare usually pays first, and your employer coverage is the secondary payer. Be mindful, however, of employer coverage that has a Health Savings Account (HSA) feature – you typically can only contribute to your HSA for the portion of the year when Medicare doesn’t cover you.

+ What if I don't sign up for Medicare Part D when I turn 65?

Medicare Part D is optional but can help cover your prescription drugs. There are certain times when you can sign up for it. If you delay signing up for Medicare Part D coverage at the Medicare age 65, you may face a late enrollment penalty.

When you enroll in Original Medicare (Medicare Part A and Part B), you may also want to decide if you want to sign up for prescription drug coverage under Medicare Part D. Since Original Medicare usually doesn’t cover medications you take at home, you have the option of signing up for Medicare Part D coverage.

Why should I sign up for Medicare Part D?

Medicare Part D is Medicare prescription drug coverage. It’s optional but may be worth it if you take prescription drugs.

Medicare gives you a choice of two different ways you can get Medicare Part D prescription drug coverage:

A stand-alone Medicare Part D prescription drug plan that works alongside your Medicare Part A and/or Part B coverage

A Medicare Advantage prescription drug plan, which includes Medicare Part A, Part B, and Part D benefits in an all-in-one plan

When can I sign up for Medicare Part D?

There are generally four different times when you can sign up for Medicare Part D.

You can sign up for Medicare Part D during your Medicare Initial Enrollment Period (IEP)

This is when you can first enroll in Original Medicare (Part A and Part B). Many people are automatically enrolled in Original Medicare during their IEP when their Medicare age is nearing 65. But you typically won’t be enrolled in a Medicare prescription drug plan at this time.

For most people, the seven-month IEP begins three months before the month you turn 65, includes your birthday month and ends three months after your birthday month.

Your IEP at your Medicare age of 65 is also when you’re first eligible to sign up for Part D.

You can sign up for Medicare Part D during Fall Open Enrollment. You can generally sign up for Medicare Part D and make other changes during this period. Sometimes called the Fall Annual Enrollment Period, it happens each year from October 15 to December 7. During this time, you can usually:

Sign up for a stand-alone Medicare Part D prescription drug plan Change from one stand-alone Medicare Part D prescription drug plan to another Sign up for a Medicare Advantage prescription drug plan

Change from one Medicare Advantage plan to another

You may be able to make other coverage changes during the AEP.

You can sign up for Medicare Part D during the Medicare Advantage Open Enrollment Period (OEP)

If you want to get your Medicare Part D coverage through a Medicare Advantage plan, you may be able to use this enrollment period. But be aware that not every Medicare Advantage plan covers prescription drugs.

You can switch from one Medicare Advantage plan to another during the Medicare Advantage Open Enrollment Period (OEP). For example, if you have a Medicare Advantage plan that doesn’t include prescription drug coverage, you can switch to a Medicare Advantage prescription drug plan.

The Medicare Advantage OEP runs January 1 – March 31 each year. You can:

Switch Medicare Advantage plans Drop your Medicare Advantage plan, return to Original Medicare, and sign up for a stand-alone Medicare Part D prescription drug plan But you can’t:

Sign up for a Medicare Advantage plan unless you’re already enrolled in one, and you want to switch Sign up for a stand-alone Medicare Part D prescription drug plan (unless you drop your Medicare Advantage plan during this OEP and return to Original Medicare You may be able to sign up for Medicare Part D during a Special Enrollment Period

You can also sign up for Medicare Part D during a special enrollment period if you qualify for one. You might have a special enrollment period if any of these events occur:

You lose your creditable drug coverage Your current Part D plan is ending its contract Your current Medicare Advantage plan with prescription drug coverage is ending its contract You move outside the service area for your current plan You are leaving an employer where you had prescription drug coverage If one of these events arise, you can usually enroll in a Medicare prescription drug plan promptly to avoid going without prescription drug coverage.

Penalty if you don’t sign up for Medicare Part D

Even if you don’t take medications now, if you’re at risk for health problems as you get older, you might need medications later. If you delay enrollment in Medicare Part D at the Medicare age of 65, you might have to pay a Part D late enrollment penalty.

If you go for 63 days or more without prescription drug coverage after your Initial Enrollment Period (IEP), that’s when you could face a Part D late enrollment penalty. Your penalty is added to your monthly premium amount.

Avoiding the Medicare Part D late enrollment penalty

One way to avoid the penalty is to sign up for Medicare Part D during your IEP. Another is to keep your creditable prescription drug coverage if you have it. Creditable coverage might come from a former employer, Veteran’s Affairs, TRICARE, or Indian Health Service, to name a few examples.

What else should I know about signing up for Medicare Part D?

Private insurance companies contract with Medicare to offer these plans. Your costs may vary from one plan to another. You can generally expect to pay a monthly premium, a yearly deductible, and a copayment or coinsurance amount for each medication. Some plans may have premiums as low as $0, and some plans may have no deductible pay. One thing you can always count on is that you’ll need to continue paying your Medicare Part B premium as well.

+ If I retire at 62, is that my medicare age to get benefits?

No, but in some cases, when one spouse turns 62, the other spouse may qualify for premium-free Medicare Part A even if he or she hasn’t worked.

What’s the usual Medicare eligibility age?

Medicare benefits start once you reach the age of 65 (unless you qualify by disability). You’re automatically enrolled at age 65 if you’re already receiving Social Security or Railroad Retirement Board benefits.

If you’ve worked at least ten years (40 quarters) while paying Medicare taxes, there is no monthly premium for your Medicare Part A (hospital insurance) benefits. But if you haven’t worked or worked less than ten years, you may qualify for premium-free Part A when your spouse turns 62, if she or he has worked at least ten years while paying Medicare taxes. However, to be eligible for Medicare, you need to be 65 years old. You also need to be an American citizen or legal permanent resident of at least five straight years.

So, to summarize with an example:

Bob is 65 years old. He’s on Medicare, but he pays a monthly premium for his Medicare Part A benefits. He only worked for seven years and no longer worked. His wife, Mary, has worked for over 30 years.

Mary turns 62. Now, Bob no longer has to pay a Medicare Part A monthly premium.

Mary still has to wait until age 65 to be eligible for Medicare (unless she qualifies by disability).

If you retire at age 62, you may be able to continue to get medical insurance coverage through your employer, or you can purchase coverage from a private insurance company until you turn 65. While waiting for Medicare enrollment eligibility, you may contact your State Health Insurance Assistance Program to discuss your options.

+ Can my spouse get Medicare at age 62?

In a nutshell:

When you get Medicare at age 65, that doesn’t include Medicare for your spouse. In this way, Medicare is not like employer group coverage. Your Medicare insurance doesn’t cover your spouse.

How Medicare works if your age 62 spouse is still working and you’re on Medicare

To qualify for Medicare, your spouse must be age 65 or older. If your spouse is age 62 (or any age under 65), he or she could only qualify for Medicare by disability.

When you’re eligible for Medicare at 65, you might be automatically enrolled in traditional Medicare, also called Original Medicare. That includes Part A, hospital insurance, and Part B, medical insurance. Medicare for your spouse will happen later when she or he turns 65.

If you’re aging into Medicare at age 65, you can still help with Medicare planning for your spouse.

Medicare at age 65 if your younger spouse is still working

Even if you can get Medicare at 65 before your younger spouse, you might be able to save money by delaying Medicare enrollment, as described below.

Here’s a key question: Do you have employer-based health insurance through your spouse? If so, you might want to delay enrollment in Medicare Part B when you’re age 65.

You generally pay a monthly premium for Medicare Part B. Most people don’t pay a Part A premium. So, if you’re covered under your working spouse’s plan at age 65, you might want to save money by delaying Part B enrollment.

Check with your spouse’s health plan to make sure it will cover you, and ask how it works with Medicare.

Medicare at age 65: help your spouse plan for Medicare

When you qualify for Medicare at age 65, you’d be wise to learn about Medicare so you can have the best possible coverage for you. Then, you can use that wisdom to help guide Medicare planning for your spouse. Read this article on planning and budgeting for Medicare.

You might already know that your Medicare at age 65 doesn’t have to stop at Medicare Part A and Part B coverage. You have other Medicare coverage choices, and you can compare plans. You and your spouse have to enroll in Medicare coverage separately.

So, when you get Medicare at age 65, get the coverage that works best for you. Then, when your spouse turns 65, together, you can figure out the best coverage for him or her.

+ Will my non-working spouse, who turns 65 before me, get Medicare at age 65?

How can I be eligible for Medicare at 65?

To be eligible for Medicare at age 65, you must be either:

An American citizen A permanent legal resident of at least five straight years. If you satisfy residency and age requirements, you could be: Single Married Divorced Widowed Separated And still, qualify for Medicare. Does my marital status affect my Medicare payments?

Whether you have worked and paid Medicare taxes, and for how long, can affect whether you’re automatically enrolled in Medicare and whether you pay a premium

for Medicare Part A. Generally, you don’t pay a monthly Medicare Part A premium if you’ve worked for 40 quarters (10 years) while paying Medicare taxes. You typically pay a monthly premium for Medicare Part B.

Can I get Medicare for my non-working spouse?

If you are at least 62 and have worked for at least ten years in Medicare-covered employment, your spouse can get Medicare, Part A premium-free when he or she is age 65 or older.

If you have worked at least ten years in Medicare-covered employment but are not yet age 62 when your spouse turns age 65, he or she will not be eligible for premium-free Medicare Part A. In this case, your spouse can still enroll in Part A but will have to pay a premium until you are 62.

Can I delay Medicare enrollment if my spouse’s job covers me?

Some beneficiaries choose to delay enrollment in Medicare Part B, but if your spouse doesn’t enroll when first eligible for Medicare, he or she might pay a late enrollment penalty. However, if you are still working and your spouse is covered under your group health plan, your spouse may be able to delay enrollment in Part B without a late-enrollment penalty. Check with your group health plan to see how it works with Medicare.

+ Do you automatically get Medicare with Social Security Disability Benefits?

It typically takes two years to receive Medicare benefits if you are under 65 and receiving Social Security disability benefits. However, certain health conditions such as Lou Gehrig’s disease and end-stage renal disease (ESRD) make you exempt from this waiting period.

In 2019, over 60 million people were enrolled in Medicare. About 52 million qualified by age and about 8 million by disability, according to the CMS, the Centers for Medicare and Medicaid Services. The key to getting Medicare under 65 is generally receiving Social Security disability benefits.

If I’m eligible for Social Security disability benefits, when does Medicare kick in?

You will typically be automatically enrolled in Original Medicare, Part A, and B after you’ve received Social Security disability benefits (or certain Railroad Retirement Board disability benefits) for two straight years. Your Medicare coverage will start 24 months from the month you qualified for disability benefits. In some cases, this could be earlier than the month when you received your first check. You must be either a U.S. citizen or a legal permanent resident of at least five straight years to be eligible for Medicare.

Note that certain conditions may qualify you for Medicare under age 65, but have different enrollment details than those described above.

Suppose you have Lou Gehrig’s disease (Amyotrophic Lateral Sclerosis, or ALS). In that case, you’ve enrolled in Medicare automatically the first month you receive disability benefits from Social Security or the Railroad Retirement Board. According to the ALS Association, the life expectancy of someone with ALS averages two to five years from the time of diagnosis. If you have ALS, you may not have time to wait two years on Social Security disability.

If you have an end-stage renal disease (ESRD), you might qualify for Medicare, but you’re not automatically enrolled. According to the Cleveland Clinic, end-stage renal disease means kidneys are functioning at 10 to 15 percent of their normal capacity. At that point, the choices are dialysis or a kidney transplant. If you’re on dialysis or you’ve had a kidney transplant, contact Social Security (information below).

You can get more information about Medicare and Social Security disability benefits from the Social Security Administration:

On the Social Security website, https://www.ssa.gov/.

Over the phone, at 1-800-772-1213 (TTY users can call 1-800-325-0778) from 7 AM to 7 PM Monday-Friday.

In-person by visiting a local Social Security office.

People who qualify for Medicare may be dual-eligible for Medicaid. There may be no waiting period for Medicaid coverage.

Medicare if You’re Disabled and Under 65 – How it Works

If you’re disabled and received Medicare Part A before age 65 but did not accept Part B at that time, you may be automatically enrolled in Medicare Part B when you reach your 65th birthday. You will receive a new Medicare card showing the Part A entitlement date based on disability and the Part B entitlement date based on aging into the program.

You will receive the card about three months before the month you turn age 65. You won’t have to pay a late-enrollment fee for Medicare Part B, but you will be responsible for paying the Part B monthly premium if you choose to keep that coverage. The package you receive before your 65th birthday will explain how you can decline Part B if you don’t want it.

Remember that you need to be enrolled in Medicare Part B to qualify for certain Medicare plan options, such as Medicare Advantage and Medicare Supplement (Medigap) insurance. If you delay Part B enrollment, you might face a late enrollment penalty when you enroll later.

Whether by age or disability, you must be an American citizen or permanent legal resident of at least five years in a row to qualify for Medicare.

Qualifying for Medicare under 65 if you have a disability

Suppose you’re under age 65 with a disability and receive disability benefits from the Social Security Administration (SSA) or the Railroad Retirement Board (RRB) for 24 straight months. In that case, you will automatically be enrolled in Original Medicare, Part A, and Part B.

There are some other situations where you may qualify for Medicare before age 65:

Suppose you have ALS (amyotrophic lateral sclerosis, also called Lou Gehrig’s disease). In that case, you will automatically get Medicare Part A and Part B on the month that your SSA or RRB disability benefits begin.

If you have an end-stage renal disease (ESRD), you may qualify for Medicare, but you’re not enrolled automatically. Contact the SSA (information below) to apply for Medicare.

Once you qualify for Original Medicare, Part A, and Part B, you may want to consider additional or alternative Medicare coverage. For example, you can receive your Medicare benefits through a Medicare Advantage plan from a private insurance company that contracts with Medicare. There are several types of Medicare Advantage plans. In addition to providing your Medicare Part A and Part B benefits, many plans offer additional benefits, such as prescription drug coverage. You continue paying your Part B premium, as well as any Medicare Advantage plan premium.

Not every Medicare Advantage plan accepts applicants with ESRD. Those with ESRD may be able to enroll in a Medicare Advantage Special Needs Plan tailored to that disease, provided one is available in your coverage area. There may be other exceptions, so call any plan you’re considering and ask if it would cover you.

If you need prescription drug coverage, and you’re not enrolled in a Medicare Advantage Prescription Drug Plan, you can sign up for a stand-alone Medicare Part

D Prescription Drug Plan once you have Medicare Part A and/or Part B and live in the plan’s coverage area.

+ Can I get a Medicare Advantage Plan and Medicare Prescription drug Plan at the Same Time?

First, a quick rundown on what Medicare Part C and Part D refer to.

Medicare Part C refers to Medicare Advantage, an option that provides an alternative way to get your Medicare benefits. Offered by private insurance companies approved by Medicare, Medicare Advantage plans must provide the same coverage that Original Medicare, Part A, and Part B cover — but many Medicare Advantage plans offer extra benefits (such as routine vision services).

Most Medicare Advantage plans include prescription drug coverage. These plans are known as Medicare Advantage Prescription Drug plans.

Medicare Part D refers to prescription drug coverage that’s available as a stand-alone plan. Because Original Medicare (Part A and Part B) doesn’t cover prescription drugs except in limited situations, you might consider enrolling in a stand-alone Medicare Part D Prescription Drug Plan to augment your Original Medicare coverage. These plans are available from private, Medicare-approved insurance companies.

Usually, if you have Medicare prescription drug coverage, you’re either enrolled in Original Medicare and a Medicare Part D Prescription Drug Plan or a Medicare Advantage Prescription Drug plan.

If your Medicare Advantage plan doesn’t have prescription drug coverage, you might be allowed to add a Medicare Prescription Drug Plan. But you may want to contact your Medicare Advantage plan before making any changes.

Bottom line: If your Medicare Advantage plan includes prescription drug coverage, you cannot be enrolled in a stand-alone Medicare Part D Prescription Drug Plan at the same time.

You might want to consider the following options if your Medicare Advantage plan does not include prescription drug coverage:

Change to a different Medicare Advantage plan that includes prescription drug coverage.

Drop your Medicare Advantage plan, go back to Original Medicare (Part A and Part B), and add a Medicare Part D Prescription Drug Plan.

You cannot add or drop Medicare plans anytime; you can do this only during certain periods. For more information, see Medicare Enrollment: How and When to Enroll in Medicare.

Do you have more questions? Connect with any of our licensed insurance agents to answer your Medicare questions or discuss a Medicare plan option that may be right for you.

+ What are employment Quarters?

Understanding what employment quarters are and how they are calculated is useful because it can determine whether you need to pay a premium for Medicare Part A. This part of Medicare covers many hospital services. It is typically premium-free for people over 65 years of age if they are also eligible for retirement benefits from Social Security or the Railroad Retirement Board.

Employment quarters are a period used as part of the calculation for your Social Security or Railroad Retirement Board benefits when you retire. In general, you may qualify for these benefits by earning credits when you work in a job and pay Social Security or Railroad Retirement Board taxes.

Most of the time, you are also paying Medicare taxes, so the same employment quarters or credits add to your contribution towards Medicare when you reach age 65. Medicare Part A is funded largely by payroll taxes paid by employees, employers, self-employed people, and Medicare Part A premiums.

What are the employment quarters for Social Security?

The Social Security Administration calls employment quarters by several names, such as “quarter of coverage” and “Social Security credits” or simply “credits.”

How credits for Social Security retirement benefits (and thus, Medicare benefits) have been calculated has changed over the years. Today, Social Security credits are

based on your total income during the year, and the year is divided into four employment quarters.

According to the Social Security Administration, the dollar amount needed to earn credits may go up slightly each year, as average earnings increase. For more information on the current earnings needed to earn Social Security or Medicare work credit, visit the Social Security website, https://www.ssa.gov/

There are special rules for certain types of jobs, such as domestic work, farm work, and work for a church or similar organization that does not collect Social Security and Medicare taxes. Employment of this sort may count towards your employment quarters for retirement and Medicare benefits, but you should contact the Social Security Administration to confirm. Conversely, some people may not qualify for Social Security retirement credits, such as federal employees hired before 1984, railroad employees with more than ten years of service, and employees of some state and local governments. Other factors may be used to determine their eligibility for premium-free Medicare Part A.

What are the employment quarters for the Railroad Retirement Board?

If you worked for a railroad, your retirement benefits are calculated by how many calendar months you worked. Beginning at age 60 and with a minimum of 360 months of railroad service, you may qualify for a retirement annuity.

How many employment quarters do you need to have worked to get premium-free Medicare Part A?

For the Social Security Administration, the number of employment quarters that qualify you for retirement and premium-free Medicare Part A depends on your date

of birth. If you were born in 1929 or later, you need 40 credits (equal to 10 years of work). If you were born in 1928, you need 39 credits, and the amount decreases as the date goes further back — those born in 1927 need 38 credits, etc.

If you were a railroad employee and qualify for the minimum railroad retirement annuity noted above, you’re likely to qualify for premium-free Medicare Part A. That length of service should provide equivalent employment quarters and Medicare taxes.

Qualifying for premium-free Medicare Part A through your spouse’s employment

If you have never worked or have not worked enough employment quarters to qualify for premium-free Part A and you’re married, you might gain this benefit through your spouse’s employment history. Suppose your spouse receives Social Security retirement benefits or Railroad Retirement Board benefits. In that case, you can apply to Medicare when you’re eligible, and you may get Part A without paying a premium.

While Part A often has no premium, Medicare Part B usually does, whether you apply based on your employment history or your spouse’s. Together, Part A and Part B make up Original Medicare. You can get these benefits through the federal program or through private insurance companies that offer Medicare Advantage plans, also called Medicare Part C. There is also Medicare Part D prescription drug coverage (Medicare Prescription Drug Plans) and Medicare Supplement insurance (Medigap) sold by private insurance companies. You can add these to your Original Medicare if you wish.

+ When is my Medicare Effective Date?

Your Medicare effective date depends on when you sign up for Medicare, determined by your initial enrollment period. When you’re first eligible for Medicare, you have a 7-month open enrollment period. It includes three months before your 65 birthday, your birthday month, and three months after your 65th birthday.

You know you are eligible for Medicare at age 65 or the 25th month of receiving disability benefits, but when exactly does your Medicare coverage start?

When Will my Medicare coverage start?

For Original Medicare, Part A, and Part B, a simple way to determine your exact Medicare effective date is to refer to the lower right corner of your Medicare card or refer to your letter from either the Social Security Administration or the Railroad Retirement Board.

If you have any questions about when your Medicare coverage starts, you can contact Social Security at 1-800-772-1213, Monday through Friday, from 7 AM to 7 PM. For TTY services, call 1-800-325-0778.

If you worked for a railroad, you could call the Railroad Retirement Board at 1-877- 772-5772, Monday through Friday, from 9 AM to 3:30 PM. For TTY services, call 1-800- 325-0778.

If you enroll in a Medicare Advantage or Medicare Prescription Drug Plan, the date your coverage starts can vary, depending on when you enroll and which election period you qualify for. For questions about your effective date on these types of Medicare plan options, you can contact the Medicare health or drug plan directly or refer to mail you may have received from them.

Can I start Medicare before my 65th birthday?

You will have a Medicare initial enrollment period. If you sign up for Medicare Part A and Part B during the first three months of your initial enrollment period, your coverage will start on the first day of the month you turn 65.

For example, say your birthday is August 31. Your initial enrollment period will begin three months before your birthday month, or in this case, May. If you sign up in May, June, or July, your coverage will start on August 1.

When does Medicare start?

When your Medicare coverage starts depends on when you sign up. You may be automatically signed up if you are already receiving Social Security benefits.

Notice that signing up after your 65 birthday month creates a delay in when your Medicare coverage starts.

If you sign up for Medicare Part A and/or Medicare Part B this month: Your coverage starts: 3, 2, or 1 month before you turn 65 The first day of your birthday month The month you turn 65 One month after you sign up One month after you turn 65 Two months after you sign up Two months after you turn 65 Three months after you sign up Three months after you turn 65 Three months after you sign up During the Jan 1-March 31 General enrollment period July 1

+ What Diabetic services does Medicare cover?

The first fact you need to know is that you must be enrolled in Medicare Part B for Medicare to cover your diabetic services or supplies. If you have a Medicare Advantage plan, you’re required to be enrolled in both Medicare Part A and Part B, so as long as you continue paying your Part B monthly premium, you should be covered as described below.

If you’re not sure whether you’re enrolled in Medicare Part B, look at your red, white, and blue Medicare card, or contact your current health insurance provider.

Medicare Part B covers the following diabetic services, generally requiring your Medicare-participating doctor’s order:

Diabetes screening: Medicare covers tests to check for diabetes if you’re considered at risk for the disease. These screenings may include tests such as a fasting plasma glucose test or other Medicare-approved tests your doctor may order for you. Medicare may cover these screenings up to twice a year, depending on your risk factors.

Diabetes self-management training: For qualified beneficiaries, Medicare offers a training program that teaches you how to manage your diabetes. It includes education about self-monitoring of blood glucose, diet, exercise, and prescription medications. If you meet certain conditions, Medicare may cover 10 hours of initial diabetes self-management training, complete within a year, and two hours of follow-up training each following year.

A portion of the training is individual, with just you and your health instructor, but most of the training occurs in a group setting. Some exceptions might qualify you for 10 hours of individual training: if you’re blind or deaf, have language limitations, or if no group classes have been available within two months of your doctor’s order for the training. If you live in a rural area where you might have difficulty finding diabetes management training, it’s possible that you could get this training at a Federally Qualified Health Center (FQHC). For more information, visit Medicare.gov or call 1- 800-MEDICARE (1-800-633-4227; TTY users call 1-877-486-2048) 24 hours a day, seven days a week.

Yearly eye exam: Medicare covers annual eye exams to screen for diabetic retinopathy once every 12 months. These exams must be done by an eye doctor who is legally allowed to provide this service in your state.

Glaucoma screening: Medicare covers glaucoma screening once every 12 months for people at high risk for glaucoma: those with diabetes or a family history of the disease; African Americans age 50 and older; and Hispanic Americans age 65 and older. The test must be given or supervised by an eye doctor authorized to administer the test in your state.

Medical nutrition therapy (MNT) services: Medicare covers medical nutrition therapy services if you have diabetes or renal disease. To be eligible for this service, your fasting blood glucose has to meet certain criteria, and your doctor must prescribe these services for you. These services can be given by a registered dietitian or Medicare-approved nutrition professional. They include a nutritional assessment and counseling to help you manage your diabetes or kidney disease. Medicare covers 3 hours of one-on-one medical nutrition therapy services the first year the service is provided, and 2 hours each year after that. You may qualify for additional MNT hours of service if your doctor determines a change in your diagnosis, medical condition, or treatment regimen related to diabetes or renal disease and orders additional MNT hours during that episode of care.

Foot exam: Medicare may cover a foot exam every six months for people with diabetic peripheral neuropathy and loss of protective sensations, as long as you haven’t seen a foot care professional for another reason between visits. Medicare may cover more frequent visits to a foot care specialist if you’ve had a non-traumatic (not because of an injury) amputation of all or part of your foot, or if your feet have changed in appearance, which may indicate serious foot disease. Hemoglobin A1c Tests: Your doctor might order a hemoglobin A1c lab test. This test measures how well your blood glucose has been controlled over the past three months. Medicare may cover this test for anyone with diabetes if it is ordered by his or her doctor.

About diabetes tests

Medicare covers diabetic screenings or tests if you have any of the following risk factors.

High blood pressure Dyslipidemia (history of abnormal cholesterol and triglyceride levels) Obesity (with certain conditions) High blood sugar Impaired glucose tolerance Based on these tests’ results, you may be eligible for up to two diabetes screenings every year.

You typically pay 20% of Medicare-approved amounts for outpatient facility charges or doctor services. You pay nothing for preventive diabetes screenings.

+ How does Medicare cover mental health care?

Original Medicare is made up of Part A (hospital insurance) and Part B (medical insurance). It includes certain coverage for mental health care when the care comes from a Medicare-assigned health-care provider. Learn more about this Medicare coverage below.

What are Medicare benefits for mental health care?

Medicare Part A covers hospital inpatient mental health care, including room, meals, nursing, and other related services and supplies. This care can be received in a general hospital or a psychiatric hospital.

Medicare has a lifetime limit of 190 days of inpatient care in a psychiatric hospital.

Medicare uses benefit periods for hospital coverage. A benefit period begins when you’re admitted as a hospital inpatient and ends when 60 days in a row have passed since you have received inpatient care.

Your Medicare Part A costs for mental health care are listed below. Please note that the deductible and coinsurance amounts may vary year to year. You pay:

The Medicare Part A deductible – $1,408 in 2020 (the full deductible amount is applied for each benefit period) No coinsurance ($0) for days 1-60 $352 coinsurance per day in 2020 for days 61-90 $704 coinsurance in 2020 per “lifetime reserve day” after the 90th day. Lifetime reserve days are days that you remain an inpatient beyond the 90-day hospital stay that Medicare covers. Medicare pays for your covered costs, charging you a daily coinsurance amount for up to 60 of these days in your lifetime. All costs after your lifetime reserve days are used up. In addition to Medicare Part A costs, you may have some costs associated with Medicare Part B even when you’re a hospital inpatient (for example, doctor services).

Medicare Part B covers mental health services usually given outside a hospital, including visits with health professionals such as doctors, clinical psychologists, and clinical social workers. Some of the other mental health services that Medicare Part B may cover include, but aren’t limited to:

Annual depression screenings Psychiatric evaluation Certain diagnostic tests your provider orders Partial hospitalization (a structured program of outpatient psychiatric services as an alternative to inpatient mental health care) Individual and group psychotherapy by licensed professionals permitted by the state where therapy takes place Medication management Family counseling as part of your treatment Your Medicare Part B costs for mental health care are listed below. Please note that the deductible and coinsurance amounts may vary year to year. The annual depression screenings are free if you get them from a Medicare-assigned health care provider. For other mental health services, you pay:

The Medicare Part B deductible – $198 in 2020 20% of the Medicare-approved amount of health-care provider services A possible additional copayment or coinsurance if you receive your services as a hospital outpatient. The amount you pay depends on the service provided but is generally 20%of the Medicare-approved amount.

If you’re enrolled in a Medicare Advantage plan, you still get the same coverage listed above, and your plan might include additional benefits, such as prescription drug coverage. Offered by private Medicare-approved insurance companies, Medicare Advantage plans must provide at least the same coverage as Medicare Part A and Part B (except for hospice care, which Medicare still covers). You continue paying your Medicare Part B premium along with any premium the Medicare Advantage plan may charge.

+ Am I covered by Medicare if I travel outside the United States?

If you are a beneficiary of Original Medicare, Part A, and Part B, then you are free to travel anywhere in the U.S. without fear of losing your Medicare coverage. However, if you travel outside of the country, your Part A and Part B coverage options are much more limited.

For example, in Canada, Medicare will provide emergency coverage if you are traveling a direct route, and without unreasonable delay, between Alaska and another U.S. state, and the closest hospital that can treat you is in Canada. Medicare will also cover you while on a cruise ship if you need to receive care while the ship is in U.S. waters or port (or within six hours of arrival or departure from a U.S. port).

While in a foreign country, such as Canada or Mexico, Medicare could potentially cover non-emergency inpatient services if foreign treatment is closer to your residence than the nearest U.S.-based hospital. Medicare may cover medically necessary ambulance services to reach the foreign hospital, but only if you are admitted for a medically necessary covered inpatient hospital service.

In these situations, you pay 20% of the Medicare-approved amount and also the Part B deductible.

Traveling with Medicare Advantage

Suppose you receive your Medicare coverage through a Medicare Advantage (MA) plan, instead of Original Medicare. In that case, you may be required to stay within the plan service network to receive routine care when traveling inside the U.S., or you could be subject to higher costs. If this is the case, you would still be covered for emergency and urgent care as needed. Some MA plans are more flexible than others and may let you see health care providers outside of your network to obtain routine care. Remember, depending on the particulars of your Medicare Advantage plan, however, you could have to pay a higher amount to receive non-emergency care.

Medigap coverage outside the U.S.

As another option for foreign travel coverage, you may want to purchase a Medicare Supplement insurance plan, also known as Medigap or MedSup, to receive coverage while traveling outside of the U.S. Specifically, Plans C, D, F, G, M, and N provide some degree of foreign travel coverage up to plan limits. Some Medicare Advantage plans provide coverage for travel abroad also. Please note that Medigap plans are designed to supplement Original Medicare benefits and cannot be used combined with a Medicare Advantage plan.

+ Why doesn't Medicare cover dental care, hearing aids, and eyeglasses?

Original Medicare, Part A, and Part B doesn’t cover everything. Routine dental care, hearing aids, and eyeglasses are statutorily excluded from Medicare coverage. It would take an act of Congress to include routine dental services, hearing aids, and eyeglasses in Medicare program coverage.

Medicare coverage of dental care

Medicare doesn’t cover routine dental care, such as oral exams, cleanings, fillings, bridges, or crowns. However, there are a few situations where you may be covered for dental services:

Dental services may be covered if they are an essential part of another Medicare-covered procedure. For example, if you hurt your jaw in an accident, Medicare may cover jaw reconstruction if it is medically necessary to treat your injury. Medicare may cover the extraction of teeth to prepare the jaw for radiation treatment for jaw-related neoplastic diseases.

Medicare may cover dental examinations before a complicated procedure (such as a kidney or heart transplant) requires an oral exam. You’ll be covered under Medicare Part A or Part B, depending on whether the oral exam is performed in an inpatient or outpatient setting.

Some Medicare Advantage plans may include benefits beyond what Original Medicare covers, including routine dental services. Medicare Advantage plans vary in terms of the benefits covered, so check with the specific plan if you’re interested in dental coverage.

Medicare coverage of hearing aids

Medicare doesn’t cover hearing aids or exams to get fitted for them. You’ll pay 100% of the cost if you have Original Medicare, Part A, and Part B.

You may be able to get coverage for hearing care (including hearing aids) through a Medicare Advantage plan. Since benefits vary, check with the individual Medicare Advantage plan.

Medicare coverage of eyeglasses

Medicare doesn’t typically cover eyeglasses or contact lenses. However, Medicare Part B may cover corrective lenses after having cataract surgery to implant an intraocular lens. You’ll be covered for either one set of glasses or contact lenses following your surgery if you get these items from a supplier that is enrolled in the Medicare program. If you upgrade your frames, you’ll pay any extra costs.

In most other situations, you’ll pay the full cost for eyeglasses and contact lenses. You may be able to get coverage for routine vision services (including glasses or contact lenses) through a Medicare Advantage plan.

+ What's the difference between home health care and nursing home care?

Medicare considers home health care to be skilled, in-home nursing care, or outpatient therapy services to treat an illness or injury. Nursing home care services are somewhat similar but delivered in a skilled nursing facility (SNF). Whether Medicare covers these services will depend on the type of nursing care you need and how long you need it.

Medicare home health care

Intermittent or short-term home health services (for example, if you’re recovering after a recent hospitalization) are covered under Medicare Part A and Part B. These services must be provided by a Medicare-certified home health agency that works with your doctor to manage your care.

To be eligible for Medicare coverage:

Your doctor must order it medically necessary to receive intermittent skilled nursing care or outpatient therapy services at home. Medicare defines “intermittent” care as care given less than seven days a week or less than eight hours a day, for no longer than 21 days. If you need more than intermittent nursing care, Medicare will generally not cover it except in special circumstances. Your doctor must determine that your condition will improve and that your need for home health services is temporary.

You must be homebound, meaning you can’t leave your home without assistance, or it might be dangerous to leave due to your health condition. Homebound doesn’t necessarily mean bed-bound. You’re still considered homebound if you occasionally leave your home for short periods, even for non-medical purposes like attending religious services.

Medicare covers your home health services over 60 days, after which the doctor must review your plan of care. However, there is no limit to the number of times your doctor can reorder this care for you, as long as it remains medically necessary to treat your condition.

Medicare-covered home health care may include:

Skilled nursing services are given by a registered nurse or licensed practical nurse Physical therapy, occupational therapy, or speech pathology services Home health aide services

Medical social services

Durable medical equipment (DME)

Other supplies needed as part of your home care

Medicare coverage for in-home nursing care doesn’t usually include meals, homemaker services, or round-the-clock nursing. Custodial care isn’t covered if this is the only kind of care you need. Custodial care refers to personal assistance with daily living activities, such as bathing or getting dressed. These tasks are usually performed by home health aides and don’t require a medically trained nursing or rehabilitation team.

If you have Original Medicare, Part A, and Part B, you pay nothing for the home health services and 20 percent of the Medicare-approved amount for any durable medical equipment (DME).

Medicare nursing home coverage

Medicare doesn’t generally pay for long-term nursing home care. Medicare Part A does cover medically necessary, short-term care in a skilled nursing facility under certain conditions. Part A covers a semi-private room, medical supplies used in the facility, meals, and other items; see What is Medicare Part A? for details.

To be eligible for nursing home coverage, Medicare requires you to meet criteria such as, but not limited to:

You have a qualifying inpatient hospital stay of at least three days before entering the SNF.

The SNF is Medicare-certified.

Your doctor orders this type of skilled daily care for you, indicating that it can only be delivered by a skilled nursing or rehabilitation staff (or under the staff’s supervision).

You’re enrolled in Medicare Part A, with days left in your benefit period. It would be best to treat a hospital-related medical condition or certain medical conditions you develop in the SNF.

If you live in a nursing home, Medicare still covers hospital and medical services under Part A and Part B. If you take medications, pharmacies contract with Medicare Part D Prescription Drug Plans to provide drug coverage for nursing home residents.

Although Original Medicare generally doesn’t cover long-term nursing home care, you may be able to get help with costs if you have limited income and qualify for Medicaid. Contact your state Medicaid office to find out if you’re eligible.

Also, some Medicare Advantage plans (offered by private Medicare-approved insurance companies) may include coverage for nursing home services. In most cases, long-term nursing home care is only covered if you live in a nursing home contracted with your plan. However, some Medicare Advantage plans have Special Needs Plans (SNPs) that may help you live in a nursing home or have certain conditions, such as congestive heart failure.

What kind of care do I need?

If you need short-term, skilled nursing care to recover from an illness or injury, Medicare Part A’s home health benefit might cover you. If you’re recovering from a hospital stay, Part A’s skilled nursing facility coverage might cover your needs. Your Medicare-assigned doctor can recommend the kind of care you need and help place you in the appropriate situation. However, if you need full-time or long-term care, Original Medicare coverage may not be sufficient.

Many beneficiaries will need long-term care at some point in their lives, whether that takes place at home, in an assisted living facility, or a nursing home. If you need such care, visit LongTermCare.gov for information on long-term care options.

+ What are the pros and cons of Medicare Advatage vs. original Medicare?

Medicare Advantage vs. Original Medicare. That’s a decision that around 10,000 people could face every day. The Centers for Medicare & Medicaid Services (CMS) reported in 2015 that about 10,000 people became eligible for Medicare each day.

Medicare Advantage vs. Original Medicare: the pros and cons, and the differences

Original Medicare, Part A, and Part B is the government health insurance program for those 65 and older and people who qualify by disability.

Some quick Medicare Part A facts:

Part A is hospital insurance – it covers your care as a hospital inpatient. You may not need to pay a monthly premium if you’ve worked at least ten years while paying Medicare taxes.

A deductible applies.

You also have to pay coinsurance or copayments once you have paid the deductible.

Some quick Medicare Part B facts:

Part B is medical insurance – it may cover preventive services, doctor visits, lab tests, medical equipment and supplies, and other medically necessary services. You typically have to pay a monthly premium.

An annual deductible applies to many services.

You typically pay a 20% coinsurance for most services, although some services are free.

Original Medicare comes directly from the government. But you can choose to get your Part A, and Part B benefits through the Medicare Advantage program instead.

The Medicare Advantage program (also called Medicare Part C) gives you a way to get these benefits through a private insurance company. These insurance companies contract with Medicare to deliver your Part A and Part B benefits.

Here’s a table to help you see – at a glance – the main differences between Original Medicare and Medicare Advantage.

Medicare Advantage vs. Original Medicare Benefit or Feature Medicare Advantage Original Medicare Medicare Part A and Part B Benefits Yes Yes Prescription drug coverage Yes, with many plans (but not all) Includes only limited prescription drug coverage. Original Medicare doesn’t cover most medications you take at home. Additional benefits beyond Part A and Part B, such as routine vision or hearing care Yes, with many plans(but not all). Extra benefits Generally, no Choice of any doctor who accepts Medicare assignment Not with every plan. Many plans require you to stay with the plan’s provider network. Yes Generally cover non-emergency care anywhere in the United States Usually, no. You must live within the plan’s service area, although plans typically cover emergency care when you’re away from home in the U.S. Generally, yes Maximum out-of-pocket spending limit. Yes. Once you’ve reached this limit within a calendar year, the plan may cover your medical costs for the rest of the year. This limit varies among plans and may change year to year. No

If you have a Medicare Advantage plan, you’re still in the Medicare program. You still need to pay your monthly Part B premium – plus the Medicare Advantage premium.

Medicare Advantage vs. Original Medicare: when do you have to choose?

There’s no hurry if you can’t make up your mind about Medicare Advantage vs. Original Medicare. In most cases, you’re automatically enrolled in Original Medicare as soon as you’re eligible if you’re receiving Social Security benefits. If you want a Medicare Advantage plan, you have to take steps to sign up. And you can’t just sign up anytime – it’s important to be aware of your Medicare Advantage enrollment periods.

If you know from the get-go that you want a Medicare Advantage plan, you can sign up when you’re first eligible for Medicare. Your Medicare Initial Enrollment Period goes for seven months for most people.

If you don’t enroll in Medicare Advantage during the Initial Enrollment Period, you may have other opportunities.

The Annual Election Period (AEP), also called Fall Open Enrollment, happens every year from October 16 to December 7. You can sign up for a Medicare Advantage during this period – or you can switch back to Original Medicare if you have a Medicare Advantage plan. You can also switch from one Medicare Advantage plan to another or make certain other coverage changes.

You might qualify for a Special Enrollment Period (SEP) to sign up for a Medicare Advantage plan in some cases. Several different circumstances may qualify you for a SEP. Many of these involve losing your coverage, like losing employment-based health insurance.

You can usually sign up for a Medicare Advantage plan if you’re enrolled in Medicare Part A and Part B and live in the plan’s service area. If you have an end-stage renal

disease (permanent kidney failure), you might not qualify for most types of Medicare Advantage plans – call the plan you want to enroll in, and ask. You can generally enroll in a Special Needs Plan, a specific type of Medicare Advantage plan.

To enroll in a Medicare Advantage plan, you can contact the plan or click Browse Plans on this page to display plans in your area. From there, you can enroll online.

+ Are there $0 Monthly Premium Medicare Advantage Plans?

All Medicare Advantage plans offer, at minimum, the same coverage as Original Medicare, Part A and Part B. These plans are sold by private insurance companies with the ability to set their prices. The Centers must approve them for Medicare & Medicaid Services (CMS).

Costs of $0 monthly premium Medicare Advantage plans

However, although a Medicare Advantage plan may offer a monthly premium as low as $0, you should keep in mind that there may be other costs you could be responsible for. If you are enrolled in a Medicare Advantage plan, you will need to continue paying your Medicare Part B premium. Additional costs you may be responsible for include prescription drug costs, copayments, coinsurance, and annual deductibles. It is recommended that beneficiaries compare all of the different costs associated with Medicare Advantage plan coverage before enrolling in a plan in their service area.

+ Can a Medicare Advantage Plan be free?

“Free,” according to the Merriam Webster dictionary, means “not costing or charging anything.” Some people may refer to $0 premium Medicare Advantage plans as “free.” However, these plans are not free in the way that they could still cost you.

Are $0 premium Medicare Advantage plans free?

You might have been searching for Medicare Advantage plans available in your zip code and found a plan with a $0 monthly premium. This plan may appear to be “free” in the way that you don’t have to pay an additional monthly amount to be covered by the plan. You generally still have to pay your Medicare Part B premium, however.

Keep in mind that Medicare Advantage plans are offered by private insurance companies, which generally do business to make a profit. To offer $0 premium plans, they may charge in other ways, such as copayments/coinsurance. A copayment or coinsurance is an amount you pay whenever you receive a service (such as a doctor visit or an emergency room trip) or pick up a prescription drug. Plans with lower premiums or $0 premiums may have higher copayments/coinsurance.

Another way a $0 premium Medicare Advantage plan may cost you is with a deductible. A deductible is an amount, for example, $1,000, that you must pay out of pocket before your Medicare Advantage plan begins to pay your medical bills. Most Medicare Advantage plans have separate medical and prescription drug deductibles. You may have a $0 medical deductible, for example, but a $250 prescription drug deductible. Some Medicare Advantage plans have both $0 premiums and $0 deductibles.

Is there a way to get free Medicare coverage?

If you’re a low-income person eligible for Medicare, you also may be eligible for Medicaid. Being eligible for both Medicare and Medicaid is called being “dual eligible.” Unlike other Medicare coverage types, you may not have premiums, deductibles, or copayments/coinsurance if Medicaid covers you. Medicaid may also offer additional benefits that Medicare doesn’t, such as routine dental and routine vision services and hearing aids.

+ What's the difference between Medicare Advantage and Medicare Supplement Insurance Plans?

There are different ways that you can receive your Medicare coverage or add to that coverage. Medicare Advantage and Medicare Supplement insurance are options that may sound similar, but they’re quite different. They do have one main thing in common: they’re both offered by private insurance companies.

There are two options commonly used to replace or supplement Original Medicare. One option, called Medicare Advantage plans, is an alternative way to get Original Medicare. The other option, Medicare Supplement (or Medigap) insurance plans, work alongside your Original Medicare coverage. These plans have significant differences when it comes to costs, benefits, and how they work. It’s important to understand these differences as you review your Medicare coverage options.

Original Medicare, Part A, and Part B is a government health insurance program for those who qualify by age or disability. Part A is hospital insurance, and Part B is medical insurance. There are some out-of-pocket costs associated with Original Medicare, such as copayments, coinsurance, and deductibles. To help with those costs, if you’re enrolled in Original Medicare, you can purchase a Medicare Supplement (Medigap) insurance plan.

Medicare Advantage plans offer an alternative way to receive your Medicare benefits through a private, Medicare-approved insurance company. They must include all your Medicare Part A and Part B coverage (except hospice care covered under Medicare Part A). Still, They may offer additional benefits not included in Original Medicare.

You generally cannot enroll in both a Medicare Advantage plan and a Medigap plan at the same time.

Medicare Advantage plans

If you have a Medicare Advantage plan, you’re still enrolled in the Medicare program; in fact, you must sign up for Medicare Part A and Part B to be eligible for a Medicare Advantage plan. The Medicare Advantage plan administers your benefits to you. Depending on the plan, Medicare Advantage can offer additional benefits beyond your Part A and Part B benefits, such as routine dental, vision, hearing services, and even prescription drug coverage.

There are many different types of Medicare Advantage plans, described below:

Health Maintenance Organizations (HMOs) require you to use health-care providers in a designated plan network. They may require referrals from a primary care physician to see a specialist.

Preferred Provider Organizations (PPOs) recommend using “preferred” healthcare providers in an established network, and these plans are likely to cover more of your medical costs if you stay inside that network. You don’t need a referral to see a specialist.

Private Fee-for-Service (PFFS) plans to determine how much they will pay healthcare providers and how much the beneficiary is responsible for covering out-of-pocket. Medical Savings Account (MSA) plans deposit money into a “healthcare checking account” that you use to pay for healthcare costs before the deductible is met.

Special Needs Plans (SNP) are tailored health insurance plans designed for beneficiaries with certain health conditions.

If you decide to sign up for a Medicare Advantage plan, you may want to shop around because costs and coverage details are likely to vary.

Some of the costs associated with Medicare Advantage might include a monthly premium (not counting your Part B premium, which you must continue to pay as well), annual deductible, coinsurance, and copayments.

To be eligible to enroll in a Medicare Advantage plan, you must be enrolled in Original Medicare, reside in the plan’s service area, and (in most cases) not have an end-stage renal disease (ESRD).

Medicare Supplement insurance plans

Medicare Supplement insurance, also known as Medigap or MedSup, is also sold through private insurance companies, but it is not comprehensive medical coverage. Instead, Medigap functions as supplemental coverage to Original Medicare. Current Medigap plans don’t include prescription drug coverage.

Medigap plans may cover costs like Medicare coinsurance and copayments, deductibles, and emergency medical care while traveling outside of the United States. There are ten standardized plan types in 47 states, each given a lettered designation (Plan G, for example). Plans of the same letter offer the same benefits regardless of where you purchase your plan. Massachusetts, Minnesota, and Wisconsin offer their standardized Medigap plans.

The standardized Medigap plans each cover certain Medicare out-of-pocket costs to at least some degree. Every Medigap plan covers up to one year of Medicare Part A coinsurance and hospital costs after Medicare benefits are used up. For example, Medigap Plan G plans don’t cover your Medicare Part B deductible, while Medigap Plan C plans do. So, if you’d like to enroll in a Medicare Supplement insurance plan, you might want to compare the Medigap policies carefully.

While benefits are standardized, the costs are not, meaning they could fluctuate depending on the insurance company offering the plan and location. That is, while Medigap Plan G includes the same coverage no matter where you buy it, the premium for this plan can vary. Also, not every standardized lettered plan is offered in every state.

If you decide to sign up for a Medigap policy, a good time to do so is during the Medigap Open Enrollment Period, a six-month period that typically starts the month you turn 65 and have Medicare Part B. If you enroll in a Medigap plan during this period, you can’t be turned down or charged more because of any health conditions. But if you apply for a Medigap plan, later on, you may be subject to medical underwriting; your acceptance into a plan isn’t guaranteed.

Whether you enroll in a Medigap policy or a Medicare Advantage plan, you must continue paying your Part B premium.

+ What is a Medicare HMO? What are the differences between an HMO and PPO?

There are four main types of Medicare Advantage plans, but the Health Maintenance Organization (HMO) plans and Preferred Provider Organization (PPO) plans are the most common types. Here is a comparison of the two varieties:

HMO plans require that beneficiaries see health-care providers, doctors, and hospitals within the plan’s network except in urgent and emergencies. In some plans, known as HMO Point-of-Service (HMO-POS) plans, beneficiaries may be able to go out-of-network for certain services but may have to pay a higher cost.

PPO plans do not require that beneficiaries use in-network providers and do not require a referral to see a specialist.

HMO plans may require that beneficiaries choose a primary care physician. PPO plans do not require that beneficiaries choose a primary care physician. Both HMO and PPO plans generally include prescription drug coverage through a Medicare Advantage Prescription Drug plan (MAPD).

About Medicare HMOs

You will need to choose a primary care doctor upon enrolling in most HMO plans, and most of the time, this doctor will have to refer you to see a specialist. Some services, like yearly screening mammograms, do not require a referral.

Prescription drugs are covered under most HMO plans called Medicare Advantage Prescription Drug plans. Check with the plan you’re interested in first if you want it to include Medicare Part D prescription drug coverage.

If your physician leaves the plan’s network of providers, you will be notified of his or her departure. You can then select another doctor from within the plan’s network.

Another thing to remember is that you agree to receive coverage within that plan’s network if you use an HMO except in urgent and emergencies. You can still receive health care outside of the plan’s network, but be aware that the plan may not pay for these services.

About Medicare PPOs

Medicare Advantage PPO plans provide another managed-care option for beneficiaries who want greater provider flexibility. Your out-of-pocket costs will generally be lower with a PPO plan if you use doctors and hospitals in the plan’s preferred provider network. You may also choose to use out-of-network providers, but your copayment and coinsurance costs may be higher.

As mentioned, PPOs don’t require members to have primary care doctors, and referrals aren’t needed before seeing a specialist. Suppose you prefer the convenience of getting specialist care directly, without needing a referral from a primary care physician. In that case, this may be one factor to consider when choosing between an HMO or PPO plan.

Like HMOs, you can get Medicare prescription drug coverage through your PPO plan by enrolling in a Medicare Advantage Prescription Drug plan. Remember that not every PPO plan includes prescription drug benefits, and costs and benefits may vary by plan.

+ Why do I need to go through underwriting to get a medicare supplment insurance plan?

Medical underwriting involves a review of your medical history. Some health insurers use underwriting to determine whether they will provide coverage to a prospective beneficiary, what premium to charge, and whether to impose a waiting period before coverage starts.

Suppose you’re enrolled in Medicare, and you decide to add a Medicare Supplement (also known as Medigap or MedSup) insurance plan to your Original Medicare coverage. In that case, the private insurance company might require underwriting before selling you a Medigap policy.

You can avoid underwriting and enroll in any Medigap plan that’s available where you live if you sign up for the Medigap plan during your six-month Medigap Open Enrollment Period. This period begins on the first day of the month that you’re both 65 years old and enrolled in Medicare Part B. For example, if you turn 65 on July 14 and are enrolled in Medicare Part B, you have until December 31 to enroll in a Medigap plan.

If you apply for a Medigap plan during your Medigap Open Enrollment Period, your acceptance into the plan is guaranteed, and the plan can’t charge more if you have a health condition. As a prerequisite, you must be enrolled in Original Medicare, Part A, and Part B.

If you apply for Medigap coverage after your open enrollment period has passed, you may have to go through medical underwriting. The insurer may review your medical history and refuse to sell you a policy or sell you one at a higher cost if you do not meet its underwriting requirements.

Sometimes you can join a Medigap plan after the Medigap Open Enrollment Period without undergoing a medical underwriting review. For example, if you’re enrolled in a Medicare Advantage plan, and the plan leaves the Medicare program, you might have a “guaranteed-issue right” to a Medigap plan.

Medicare Supplement Explained – Understand Plan F vs. Plan G vs. Plan N

Medicare Supplement (or Medigap) insurance plans are standardized across the nation, except in Massachusetts, Minnesota, and Wisconsin. Each of the ten plans is denoted by a letter. The currently available plans are A, B, C, D, F, G, K, L, M, and N. These plans are provided through private insurance companies. Still, plan type with the same letter must offer the same set of basic benefits regardless of location.

Medicare Supplement Plan F

Medigap Plan F * is considered one of the most popular plans because it offers the most comprehensive coverage of certain health care costs, including:

Medicare Part A coinsurance and hospice care coinsurance

Medicare Part A deductible

Medicare Part B coinsurance or copayment

Medicare Part B deductible

Part B excess charges

First three pints of blood used in a procedure

Skilled nursing facility (SNF) care coinsurance

Coverage outside of the United States (up to plan limits)

Medicare Supplement Plan G

Medigap Plan G offers all of the same benefits as Plan F except for the Part B deductible.

Plan G will offer a high deductible option beginning January 1, 2020. Medicare Supplement Plan N

Medigap Plan N covers the same benefits as Plan F except for the Part B deductible and Part B excess charges. Also, it covers the Medicare Part A deductible at 50% versus 100%. Medigap Plan N pays for 100% of the Part B coinsurance, except for copayments of up to $20 for certain office visits and up to $50 for emergency room visits that do not result in an inpatient admission.

*As of January 1, 2020, people new to Medicare can’t buy plans covering the Medicare Part B deductible. This means that Medicare Supplement Plans C and F will no longer be available to new Medicare enrollees. However, if you already have a Plan C, Plan F, or high-deductible Plan F, you can keep it. If you were eligible for Medicare before January 1, 2020, you also might be able to buy Medicare Supplement Plan C, F, or high-deductible Plan F.

+What are Medicare Plan Star Ratings and How are they measured?

The Centers for Medicare & Medicaid Services (CMS) created a Star Rating system to help beneficiaries and their families compare plan performance and quality for Medicare Advantage plans, Medicare Prescription Drug Plans, and Medicare Cost plans.

Medicare plans are rated on a scale of 1 to 5, with a 5-star rating being the highest score a plan can receive. More stars indicate better performance and quality:

5-star rating: Excellent 4-star rating: Above Average 3-star rating: Average 2-star rating: Below Average 1-star rating: Poor Medicare plan star ratings: what do they measure?

For Medicare plans providing health coverage, such as Medicare Advantage or Medicare Cost plans, each plan is given an overall summary rating based on how it performs across five main categories:

Staying healthy: Plans are rated on whether members had access to preventive services to keep them healthy. This includes physical examinations, vaccinations like flu shots, and preventive screenings.

Chronic conditions management: Plans are rated for care coordination and how frequently members received services for long-term health conditions. Member experience: Plans are rated for overall satisfaction with the health plan. Member complaints: Plans are rated on how frequently members submitted complaints or left the plan, whether members had issues getting needed services, and whether plan performance improved from one year to the next. Customer service: Plans are rated for quality call center services (including TTY and interpreter services) and promptly processing appeals and new enrollments.

For Medicare Part D stand-alone Prescription Drug Plans and Medicare Advantage plans that include drug coverage, Medicare star ratings are also based on the following criteria:

Member experience Member complaints Customer service Drug safety and drug pricing accuracy The drug safety score is based on factors such as how accurate the plan’s pricing information is and how often members with certain medical conditions are prescribed drugs in a way that is safer and clinically recommended for their condition. Plans are also rated for whether drug pricing information on Medicare Part D Prescription Drug Plan and Medicare Advantage Prescription Drug plan websites is up-to-date and accurate. The percentage of plan members who got prescriptions for certain drugs with a high risk of serious side effects when there may have been a safer drug choice is also reviewed and scored.

The overall rating gives a quick summary of a plan’s performance, but you can also look up how the plan scored for individual areas within the above main categories.

For more information on the criteria, Medicare considers when rating its plans, visit https://www.medicare.gov/.

Keep in mind that plan ratings can change from year to year and are updated every fall. If you are enrolled in a Medicare plan, be sure to check the Medicare star ratings every fall so you can make an informed decision about whether to stay on the plan or switch to a different plan.

How to enroll in a Medicare 5-star rated plan

You can sign up for a 5-star rated Medicare Advantage, Medicare Prescription Drug Plan, or Medicare Cost Plan during the Annual Election Period.

If your Medicare plan doesn’t have a 5-star rating, you can switch to a Medicare 5- star rated plan within your service area one time during the 5-Star Special Election Period (SEP) from December 8 to November 30. If you have just switched Medicare Advantage plans during your AEP, this SEP is only available the following year.

If you decide to switch from your current Medicare Advantage plan to one with a 5- star rating, make sure you choose a plan with prescription drug coverage if you want this kind of coverage. Otherwise, you could pay a late-enrollment penalty if you add drug coverage at a later date.

+ When do I have to apply for Medicare if I'm still working?

This depends on your situation. If you’ve worked at least ten years (40 quarters) under Medicare-covered employment and paid Medicare taxes during that time, you qualify for premium-free Medicare Part A and will be automatically enrolled at age 65 even if you’re still working. If your spouse has enough employment quarters, you can also qualify for premium-free Medicare Part A based on their work history.

Another Medicare eligibility requirement is that you need to be an American citizen or permanent legal resident of at least five straight years.

Suppose you don’t have enough work history to get Medicare Part A without paying a premium. In that case, you can decide to delay enrollment if you already have health coverage through an employer or union (or through your work or your spouse’s employer). Medicare Part B always comes with a monthly premium, so you may similarly choose to delay your Part B enrollment if you or your spouse are still working and have employer-based group coverage.

Remember, if you don’t sign up for Medicare when you’re first eligible and don’t have other coverage based on current employment, you could have to pay a late enrollment penalty later when you do enroll. The late-enrollment penalty applies to Medicare Part B (and Part A, if you have to pay a premium for it).

Decide if you want Medicare while you’re still working

One factor to consider is that even if you have health coverage through your employer or union, Medicare may help pay for some of the costs not covered by your group health plan. For example, enrolling in Medicare may be useful if you work for a small company (less than 20 employees) because Medicare could be the primary payer before your group health insurance. You may want to consult with your employer or union benefits administrator for specifics on how your health coverage and costs may compare with Medicare.

Suppose you decide to wait until your group coverage ends in enrolling in Medicare Part A and/or Part B. In that case, you’ll have an 8-month Special Enrollment Period to sign up for Medicare that starts once you stop working or your group coverage ends (whichever happens first). You can also enroll in Medicare at any time that you are still working and have employer-based coverage.

If you choose COBRA after you stop working, do not wait until your COBRA coverage ends to sign up for Medicare. Suppose you delay enrolling in Medicare Part A and/or Part B after your Special Enrollment Period ends. In that case, you’ll have to wait until the next General Enrollment Period (January 1 to March 31 every year) to enroll, and you may have to pay a late-enrollment penalty.

+ How can I find out if my doctor accepts Medicare?

The Medicare.gov physician compare tool will help you find a Medicare doctor in your area. Seeing Medicare doctors generally makes your out of pocket costs less.

Maybe you’ve had a favorite primary care physician for years and hope to keep her when you have Medicare. Not every doctor accepts Medicare assignment (a payment agreement), although most do.

If your Medicare doctor accepts the assignment:

Your out of pocket costs may be less,

The doctor will submit a claim directly to Medicare and can’t charge you before submitting it, and

You generally only pay your deductible and coinsurance amounts.

If my doctor accepts Medicare, what does that mean?

Doctors who accept Medicare assignment can fall into any of the following categories:

Participating doctors accept Medicare assignment, meaning that they accept the Medicare-approved amount as payment for their services. These doctors charge

the Medicare program 80% and the beneficiary 20% of the cost of the benefit. Non-participating doctors can choose to either accept or not accept Medicare assignment. If the doctor does not accept Medicare assignment, you might have to pay a 15% additional charge above the service’s cost, known as a Medicare excess charge. You would then be responsible for up to 35% of the reduced Medicare-approved amount instead of 20%.

Doctors who have opted out of Medicare may charge you whatever they see fit for services and supplies. You would then be responsible for the full cost of the benefits.

To find a participating doctor in your area, you may use the Medicare.gov Physician Compare tool. This tool will help you find an approved Medicare doctor based on medical specialty, geographical area, or doctor’s name. In addition to finding Medicare-approved physicians, this tool provides information about each doctor, along with maps and directions to help you find the doctor’s office.

+ Medicare Renewal: Do I have to sign up for Medicare every year?

In general, once you’re enrolled in Medicare, you don’t need to take action to renew your coverage every year. This is true whether you are in Original Medicare, a Medicare Advantage plan, or a Medicare prescription drug plan. As long as you continue to pay any necessary premiums, your Medicare coverage should automatically renew every year with a few exceptions, as described below.

Medicare renewal – when might you have to renew your Medicare coverage?

There are some exceptions where you’ll need to take action to continue your coverage. Some situations where your Medicare Advantage or stand-alone Medicare Part D prescription drug plan coverage won’t be automatically renewed include, but aren’t limited to:

Your plan reduces its service area, and you now live outside of its coverage area. Your plan doesn’t renew its Medicare contract for the upcoming year. Your plan leaves the Medicare program in the middle of the year. Medicare terminates its contract with your plan.

Suppose your Medicare plan doesn’t renew its contract with Medicare for the coming year. In that case, your Special Election Period will run from December 8 to the last day of February of the following year. If you have Medicare Advantage and don’t enroll in a new plan by

the date that your current plan ends its contract with Medicare, you’ll be automatically returned to Original Medicare.

Keep in mind that your new coverage starts on the first day of the month after submitting your enrollment application, meaning if you apply on February 8, your new Medicare plan won’t begin until March 1.

You’ll also get a three-month Special Election Period if your Medicare Advantage or Medicare Part D Prescription Drug Plan terminates its contract with Medicare. This period starts two months before the contract ends and runs an additional month after the contract ends. If Medicare terminates your plan’s contract, you will have a Special Election Period that begins one month before the termination effective date and ends two months after the effective date of the termination.

While you may not need to renew your Medicare coverage, it’s still a good idea to review your coverage annually. Benefits, provider and pharmacy networks, drug formularies, and cost-sharing can all change from year to year and affect how much you pay out of pocket. Comparing plans annually is one way to ensure your coverage continues to meet your health needs and budget.

If you need help finding a plan that could work for you, you can type your zip code into the form on this page to see a list of Medicare plans in your vicinity.

+ How does Medicare card replacement work if my card is damaged, lost or stolen?

If your Medicare card is lost, stolen, or damaged, you can request a replacement Medicare card through the Social Security Administration in the following ways:

Online at www.ssa.gov.

By phone at 1-800-772-1213 (TTY users, dial 1-800-325-0778), Monday through Friday, from 7 AM to 7 PM.

In-person at your local Social Security office.

How soon will I get my replacement Medicare card?

Your new red, white, and blue card will be mailed to the address that Social Security has on file for you within 30 days. If you have moved and have not reported this information to Social Security, you will need to report your address change before they can process your request for a replacement card.

If you need proof that you have Medicare sooner than 30 days, you also can request a letter to use as temporary proof. This letter should be mailed to you in about ten days. If you need proof immediately for your doctor or a prescription, visit your nearest Social Security office.

If you signed up for Medicare through the Railroad Retirement Board (RRB), you’d need to request a replacement Medicare card through the RRB:

Visit www.rrb.gov.

Call 1-877-772-5772 (TTY users, dial 1-312-751-4701, Monday through Friday, from 9 AM to 3:30 PM.

Contact your local Railroad Retirement Board office.

+ What if my doctor isn't in my Medicare Plan Network?

To avoid paying higher costs, it’s a good idea to make sure your doctor is a participating Medicare doctor and, if applicable, in your Medicare plan’s network.

For Original Medicare, is there a Medicare network of providers?

If you have Original Medicare, Part A, and Part B, you can usually choose any doctor enrolled in Medicare. To find out if your doctor accepts Medicare assignment, you can do either of these:

Call the doctor and ask.

Use Medicare.gov’s Physician Compare tool. The finder tool lets you search through a list of physicians in your area to see which ones accept Medicare.

Medicare Advantage plans

Instead of receiving your benefits through Original Medicare, perhaps you opted for Medicare Advantage, also known as Medicare Part C. There are several different types of Medicare Advantage plans. Still, all of them are available from private, Medicare-approved insurance companies and cover your Medicare Part A and Part B benefits. Hospice care is the only exception; Medicare Part A still covers this care if enrolled in a Medicare Advantage plan. Many plans include additional benefits, such as prescription drug coverage and wellness programs. You still pay a

the monthly premium for Medicare Part B along with any premium the Medicare Advantage plan charges.

If you belong to a Medicare Advantage plan — for example, if it’s a Health Maintenance Organization (HMO) — the plan might have required you to choose a primary care physician from a list of doctors in the plan’s network. If you did this, you know the doctor is a participating Medicare provider within the plan’s service area. Your plan will notify you if the doctor leaves your plan. If you did not have to choose a primary care physician when you enrolled in your Medicare Advantage plan, for example, if you are in a Preferred Provider Organization (PPO), you can check with your plan provider to see if your doctor of choice is in the network.

In situations where your doctor is not in the plan’s network, you might need to change to a doctor in the network or change Medicare Advantage plans. There are certain times when you can sign up for, or switch, Medicare Advantage plans.

In any case, it’s always a good idea to check with your doctor before any appointment to make sure he or she is still in the Medicare Advantage plan. If he or she is not in the plan, you might have to pay for services.

Can I change my primary care provider?

In most cases, you can change primary care providers with Medicare Advantage coverage. You may want to make sure this is an option before enrolling in a plan and use your plan’s instructions for changing providers.