Helpful Information
What is Medicare?
Medicare is a federal health insurance program for:
People age 65 or older;
People with certain disabilities; or
People with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant.)
Medicare has Four Parts
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Helps cover inpatient care in a hospital or skilled nursing facility (following a hospital stay), home health care services, and hospice care services. Co-payments, coinsurance, and deductibles may apply for each service. You usually do not pay a monthly premium for Part A coverage if you or your spouse paid Medicare taxes while working.
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Helps cover doctors’ services, outpatient care, home health services, and other medical services. Part B also covers some preventive services. Copayments, coinsurance, and deductibles may apply for each service. You can find out if you have Part B by looking at your Medicare card. You pay the Part B premium each month. Part A and Part B are often referred to as “Original Medicare”.
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A health coverage option run by private insurance companies approved by and under contract with Medicare. Includes Part A, Part B, and, usually, other coverage like prescription drugs. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. In addition to your Part B premium, you usually pay one monthly premium for the services provided.
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A prescription drug option run by private companies approved by and under contract with Medicare. Helps cover the cost of prescription drugs, may help lower your prescription drug costs and help protect against higher costs in the future. Part D is available to everyone with Medicare.
Medicare Part A
Medicare A helps cover inpatient care in a hospital or skilled nursing facility (following a hospital stay), home health care services, and hospice care services. Co-payments, coinsurance, and deductibles may apply for each service. You usually do not pay a monthly premium for Part A coverage if you or your spouse paid Medicare taxes while working.
Medicare Part A Helps Cover:
Inpatient care in hospitals (such as critical access hospitals, inpatient rehabilitation facilities, and long-term care hospitals)
Inpatient care in a skilled nursing facility (not custodial or long-term care)
Hospice care services
Home health care services
Inpatient care in a religious non-medical health care institution (RNHCI).
You usually don’t pay a monthly premium for Part A coverage if you or your spouse paid Medicare taxes while working.
If you aren’t eligible for premium-free Part A, you may be able to buy Part A if you meet one of the following conditions:
You are age 65 or older, and you are entitled to (or enrolling in) Part B and meet the citizenship or residency requirements.
You are disabled and your premium-free Part A coverage ended because you returned to work.
Call Social Security at 1-800-772-1213 for more information about the Part A premium. TTY users should call 1-800-325-0778.
In most cases, if you choose to buy Part A, you must also have Part B and pay monthly premiums for both. If you have limited income and resources, your state may help you pay for Part A and/or Part B.
You can find out if you have Part A by looking at your Medicare card.
Note: Keep this card safe. If you have Original Medicare, you will use this card to get your Medicare-covered services. If you join a Medicare plan, you must use the card from the plan to get your Medicare-covered services.
Medicare Part B
Medicare Part B helps cover medically necessary services like doctors’ services, outpatient care, home health services, and other medical services. Part B also covers some preventive services. You can find out if you have Part B by looking at your Medicare card.
How Do You Get Medicare Part B?
If you get benefits from Social Security or the Railroad Retirement Board (RRB), in most cases you will automatically get Part B starting the first day of the month you turn 65. If your birthday is on the first day of the month, your Part B will start the first day of the prior month.
If you are under 65 and disabled, you will automatically get Part B after you get disability benefits from Social Security or certain disability benefits from the RRB for 24 months. You will get your Medicare card in the mail about three months before your 65th birthday or your 25th month of disability.
If you do not want Part B, follow the instructions that come with the card, and send the card back. If you keep the card, you keep Part B and will pay Part B premiums.
If you have ALS (Amyotrophic Lateral Sclerosis, also called Lou Gehrig’s disease), you automatically get Part B the month your disability benefits begin.
When Can You Sign up for Part B?
If you didn’t sign up for Part B when you first became eligible, you may be able to sign up during one of these times:
General Enrollment Period — Between January 1–March 31 each year. Your coverage will begin on July 1. You may have to pay a late enrollment penalty.
Special Enrollment Period — If you wait to sign up for Part B because you or your spouse is currently working, and you are covered by a group health plan based on that work, or if you are disabled and you or a family member is working, and you are covered by a group health plan based on that work. You can sign up for Part B anytime while you have group health plan coverage based on current employment or during the 8-month period that begins the month after the employment ends, or the group health plan coverage ends, whichever happens first. If you have COBRA coverage, you must enroll during the 8-month period that begins the month after the employment ends. This Special Enrollment Period doesn’t apply to people with End-Stage Renal Disease (ESRD).
Special Enrollment Period for International Volunteers — If you waited to sign up for Part B because you had health insurance while volunteering outside of the U.S. for a tax-exempt organization for at least a year. You can sign up during the 6-month period that begins the first month that any one of the following happens:
You are no longer volunteering outside the U.S.
The sponsoring organization is no longer tax-exempt.
You no longer have health insurance coverage outside the U.S.
If you have Medicare because of End-Stage Renal Disease (ESRD), you can sign up for Part B when you sign up for Part A. If you delay signing up for Part B, you can only get it during the general enrollment period, and you may have to pay a late enrollment penalty.
If you live in Puerto Rico, and you want Part B, you will need to sign up for it. Contact your local Social Security office for more information.
If you aren’t getting Social Security or RRB benefits, and you want to get Part B, you will need to sign up for Part B during your initial enrollment period (the 7-month period that begins three months before the month you turn age 65, includes the month you turn age 65, and ends three months after the month you turn age 65).
Important Note:
If you do not sign up for Part B when you are first eligible, you may have to pay a late enrollment penalty for as long as you have Medicare. Your monthly premium for Part B may go up 10% for each full 12-month period that you could have had Part B, but didn’t sign up for it. Usually, you don’t pay a late enrollment penalty if you sign up for Part B during a special enrollment period.
Medicare Part C
A Medicare Advantage Plan (like an HMO or PPO) is a health coverage choice for Medicare beneficiaries. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare.
If you join a Medicare Advantage Plan, the plan will provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. In all plan types, you are always covered for emergency and urgent care. Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care. Original Medicare covers hospice care even if you are in a Medicare Advantage Plan.
Medicare Advantage Plans aren’t considered supplemental coverage. They may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage. In addition to your Part B premium, you usually pay one monthly premium for the services provided.
Who Can Enroll in Medicare Part C?
You can generally join a Medicare Advantage Plan if you meet these conditions:
You have Part A and Part B.
You live in the service area of the plan. Contact the plans you’re interested in to find out about the service area.
You don’t have End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant). A few exceptions apply for ESRD. For more information call TTY users should call 1-877-486-2048, 24 hours a day/7 days a week or visit WWW.MEDICARE.GOV.
You’re a U.S. citizen or lawfully present in the United States.
How Medicare Part C Plans Work
Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to only doctors, facilities, or suppliers that belong to the plan).
Types of Medicare Advantage Plans
Health Maintenance Organizations (HMO) – A type of Medicare Advantage Plan that is available in some areas of the country. Plans must cover all Medicare Part A and Part B health care. Some HMOs cover additional benefits, like extra days in the hospital. In most HMOs, you can only go to doctors, specialists, or hospitals on the plan’s list, except in an emergency, and are typically required to obtain a referral from your Primary Care Physician before seeing a specialist. Your costs may be lower than in Original Medicare.
Preferred Provider Organizations (PPO) – A type of Medicare Advantage Plan in which you pay less if you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost. Referrals are not necessary to see a specialist.
Private Fee-for-Service Plans (PFFS) – A type of Medicare Advantage Plan in which you may go to any Medicare-approved doctor or hospital that accepts the plan’s payment. The insurance plan, rather than the Medicare Program, decides how much it will pay and what you pay for the services you get. You may pay more or less for Medicare-covered benefits. You may have additional benefits Original Medicare doesn’t cover.
Medical Savings Accounts (MSA) – Medicare MSA Plans have two parts: a high deductible health plan and a bank account. Medicare gives the plan an amount each year for your health care, and the plan deposits a portion of this money into your account. The amount deposited is less than your deductible amount, so you will have to pay out-of-pocket before your coverage begins.
Point of Service (POS) Plans – An HMO option that lets you use doctors and hospitals outside the plan for an additional cost.
Provider Sponsored Organizations (PSO) – Plans run by a provider or group of providers. In a PSO, you usually get your health care from the providers who are part of the plan.
Special Needs Plans (SNP) – A special type of plan that provides more focused health care for specific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or who have certain chronic medical conditions.
Medicare Part D
Medicare offers prescription drug coverage (Part D) to everyone with Medicare. Medicare Part D plans are offered by private companies to help cover the cost of prescription drugs. Everyone with Medicare can get this optional coverage to help lower their prescription drug costs. Medicare Part D generally covers both brand-name and generic prescription drugs at participating pharmacies.
There are two ways to get Medicare prescription drug coverage:
Medicare Prescription Drug Plans. These stand-alone plans (sometimes called “PDPs”) add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.
Medicare Advantage Plans (like an HMO or PPO) or other Medicare health plans that offer Medicare prescription drug coverage. You get all of your Part A and Part B coverage, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PDs.”
Whatever plan you choose, Medicare drug coverage will help you by covering brand-name and generic drugs at pharmacies that are convenient for you. Each Part D plan has a formulary – a list of medications the plan will cover. This list may also be referred to as a drug list, prescription drug list (PDL), or a covered medications list (CML). Drug coverage varies from one plan to another, so if you are considering a Part D plan, you may wish to review the plan’s Prescription Drug List to be sure it will meet your needs.
Other Facts to Consider
Avoid the late-enrollment penalty. Join when you first become eligible.
The Cost of Medicare Prescription Drug Coverage
Like other insurance, if you join a Medicare Part D plan, generally, you will pay a monthly premium, which varies by plan, and a yearly deductible for most plans. You will also pay a part of the cost of your prescriptions, including a copayment or coinsurance. Costs will vary depending on the prescriptions you use and which drug plan you choose, whether you go to a pharmacy in your plan’s network, whether your drugs are on the plan’s formulary and whether you qualify for Extra Help paying your Part D costs. Some plans may offer more coverage and additional drugs for a higher monthly premium.
If you have limited income and resources, you may quality for the following:
Extra Help paying for your Part D premium and other prescription drug coverage costs.
For More Information:
Call 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048, 24 hours a day/7 days a week.
Visit www.medicare.gov/Pubs/pdf/10126.pdf to view the brochure, “Get Help With Your Medicare Costs: Getting Started.” You can learn more by reading Medicare & You, the official government handbook about Medicare. You will need the free Adobe® Reader® software to download the files.
The Medicare Prescription Drug Coverage Gap (the “Doughnut Hole”)
Most Medicare Part D plans have a coverage gap, sometimes called the “Doughnut Hole.” This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay 25% of the costs instead of a fixed co-pay during your initial coverage limit, up to a yearly limit. Your yearly deductible, coinsurance or copayments, and what you pay while in the coverage gap all count toward this out-of-pocket limit. The limit does not include the drug plan’s premium or what you pay for drugs that are not on your plan’s formulary or prescription drug list.
There are plans that offer some 250coverage during the gap, like for generic drugs. However, plans with gap coverage may charge a higher monthly premium. Check with the plan first to see if your drugs would be covered during the gap.
Once a person reaches the plan’s out-of-pocket limit during the coverage gap, “catastrophic coverage” automatically kicks in. Catastrophic coverage assures that once a person has spent up to the plan’s out-of-pocket limit for covered drugs, he or she will only pay a small coinsurance amount or a copayment for the rest of the year.
It is important to note that people who get Extra Help paying drug costs will not have a coverage gap and will pay a small or no copayment once they reach catastrophic coverage.