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Below, you can find some free information that I've compiled over the years, based on my clients' number one medicare concerns.
Who Is Eligible For Medicare?

To be eligible for Medicare Part A and Part B, you must be a U.S. citizen or a permanent legal resident for at least five continuous years. Generally, Medicare is available for people age 65 or older, younger people with disabilities and people with End Stage Renal Disease (permanent kidney failure requiring dialysis or transplant), have Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s disease. Medicare has two parts, Part A (Hospital Insurance) and Part B (Medicare Insurance). You are eligible for premium-free Part A if you are age 65 or older and you or your spouse worked and paid Medicare taxes for at least 10 years. The standard monthly premium for Medicare Part B enrollees will be $148.50 for 2021. The annual deductible for all Medicare Part B beneficiaries is $203.00 in 2021.

How Do I Enroll In Medicare?

If you do not receive Social Security benefits:

If you are not receiving Social Security retirement benefits or Railroad Retirement benefits you will need to actively enroll in Medicare by calling the Social Security Administration at 800-772-1213 or online at socialsecurity.gov/medicareonly/.

 

If you already receive benefits from Social Security:

If you already get benefits from Social Security or the Railroad Retirement Board, you are automatically entitled to Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) starting the first day of the month you turn age 65. You will not need to do anything to enroll. Your Medicare card will be mailed to you about 3 months before your 65th birthday. If your 65th birthday is February 20, 2010, your Medicare effective date would be February 1, 2010. (Note: if your birthday is on the 1st day of any month, Medicare Part A and Part B will be effective the 1st day of the prior month. For example, if your 65th birthday is February 1, 2010, your Medicare effective date would be January 1, 2010.)

 

If you are under age 65 and disabled:

If you are under age 65 and disabled, and have been entitled to disability benefits under Social Security or the Railroad Retirement Board for 24 months, you will be automatically entitled to Medicare Part A and Part B beginning the 25th month of disability benefit entitlement. You will not need to do anything to enroll in Medicare. Your Medicare card will be mailed to you about 3 months before your Medicare entitlement date. (Note: If you are under age 65 and have Lou Gehrig’s disease (ALS), you get your Medicare benefits the first month you get disability benefits from Social Security or the Railroad Retirement Board.) For more information about enrollment, call the Social Security Administration at 1-800-772-1213 or visit the Social Security website.

What does Part A (Hospital Insurance) of Medicare cover?

In general, Part A covers:

  • • Inpatient care in a hospital
  • • Skilled nursing facility care
  • • Nursing home care (inpatient care in a skilled nursing facility that’s not custodial or long-term care)
  • • Hospice care
  • • Home health care

When you are admitted to a hospital or skilled nursing facility, Medicare Part A hospital insurance will cover the following for a certain amount of time:

  • • A semi private room (two to four beds per room), or a private room if medically necessary
  • • All meals, including special, medically required diets
  • • Regular nursing services
  • • special care units, such as intensive care and coronary care
  • • Drugs, medical supplies, and appliances furnished by the facility, such as casts, splints, wheelchair; also, outpatient drugs and medical supplies if they permit you to leave the hospital sooner
  • • Hospital lab tests, X-rays, and radiation treatment billed by the hospital
  • • Operating and recovery room costs
  • • Blood transfusions (you pay for the first three pints of blood, unless you arrange to have them replaced by an outside donation of blood to the hospital), and
  • • Rehabilitation services, such as physical therapy, occupational therapy, and speech pathology, provided while you are in the hospital.


To find out if Medicare covers a service not on this list, visit www.medicare.gov/coverage, or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

What Are My Medicare Coverage Options?

The main coverage options include:

    • Original Medicare, which comprises: Medicare Part A – hospital insurance. Medicare Part B – outpatient coverage.

    • Medicare Advantage (Part C)  A Medicare Advantage Plan (like an HMO or PPO) is another Medicare health plan choice you may have as part of Medicare. 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. Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D).

  • Medicare Part D – prescription drug coverage.Medicare Part D is simply insurance for your medication needs. You pay a monthly premium to an insurance carrier for your Part D plan. In return, you use the insurance carrier’s network of pharmacies to purchase your prescription medications. … Your Part Dinsurance card will be separate from your Medigap plan.

Medigap – Medicare Supplement insurance. Medigap is extra health insurance that you buy from a private company to pay health care costs not covered by Original Medicare, such as co-payments, deductibles, and health care if you travel outside the U.S. Medigap policies don’t cover long-term care, dental care, vision care, hearing care, vision care, hearing aids, eyeglasses, and private -duty nursing.  Most plans do not cover prescription drugs.



WHAT DOES MEDICARE PART A (HOSPITAL) AND PART B (MEDICAL) COST?

Part A costs: What you pay in 2023:
Premium $0 for most people (because they or a spouse paid Medicare taxes long enough while working – generally at least 10 years). If you get Medicare earlier than age 65, you won’t pay a Part A premium. This is sometimes called “premium-free Part A.” If you don’t qualify for premium-free Part A: You might be able to buy it. You’ll pay either $278 or $506 each month for Part A, depending on how long you or your spouse worked and paid Medicare taxes. Remember:
Deductible $1,600 for each inpatient hospital
benefit period
, before
Original Medicare
starts to pay. There’s no limit to the number of benefit periods you can have in a year. This means you may pay the deductible more than once in a year. 
Inpatient stay
  • Days 1-60: $0 after you pay your Part A deductible.
  • Days 61-90: $400 copayment each day.
  • Days 91-150: $800 copayment each day while using your 60
    lifetime reserve days
    .
  • After day 150: You pay all costs.
Skilled nursing facility stay 
  • Days 1-20: $0 copayment.
  • Days 21-100: $200 copayment each day.
  • Days 101 and beyond: You pay all costs.
Home health care  $0 for covered home health care services. 20% of the
Medicare-approved amount
for durable medical equipment (like wheelchairs, walkers, hospital beds, and other equipment)
Hospice care  $0 for covered hospice care services. You may also pay:
A stethoscope representing a person getting a checkup from a health care provider

Part B (Medical Insurance) costs

Part B costs: What you pay in 2023:
Premium $164.90 each month (or higher depending on your income). The amount can change each year. You’ll pay the premium each month, even if you don’t get any Part B-covered services. You might pay a monthly penalty if you don’t sign up for Part B when you’re first eligible for Medicare (usually when you turn 65). You’ll pay the penalty for as long as you have Part B. The penalty goes up the longer you wait to sign up. Find out how the Part B penalty works and how to avoid it.
Deductible $226, before Original Medicare starts to pay. You pay this deductible once each year.
General costs for services (coinsurance) Usually 20% of the cost for each Medicare-covered service or item after you’ve paid your deductible (and as long as your doctor or health care provider accepts the
Medicare-approved amount
as full payment – called “accepting assignment”). Find out how assignment affects what you pay.
Clinical laboratory services $0 for covered clinical laboratory services.
Home health care
  • $0 for covered home health care services.
  • 20% of the
    Medicare-approved amount
    for durable medical equipment (like wheelchairs, walkers, hospital beds, and other equipment).
Inpatient hospital care 20% of the
Medicare-approved amount
for most doctor services while you’re a hospital inpatient.
Outpatient mental health care
  • $0 for your yearly depression screening.
  • 20% of the
    Medicare-approved amount
    for visits to your doctor or other health care provider to diagnose or treat your condition.
  • If you get your services in a hospital outpatient clinic or hospital outpatient department, you may have to pay an additional amount to the hospital.
Partial hospitalization mental health care After you meet the Part B deductible:
  • 20% of the
    Medicare-approved amount
    for each service you get from a doctor or certain other qualified mental health professional
  • Coinsurance for each day of partial hospitalization services you get in a hospital outpatient setting or community mental health center
Outpatient hospital care
  • Usually 20% of the
    Medicare-approved amount
    for doctor and other health care providers’ services.
  • You’ll also pay a copayment to the hospital for each service you get in a hospital outpatient setting (except for certain preventive services). In most cases, your copayment won’t be more than the Part A hospital stay deductible amount.
    This additional hospital copayment means you may pay more for an outpatient service you get in a hospital than you’d pay if you got the same service in a doctor’s office.
Compare outpatient procedure costs under Original Medicare.

What's Not Covered By Medicare Part A (Hospital) And Part B (Medical)?

Medicare doesn’t cover everything. Some of the items and services Medicare doesn’t cover include:

 

  • ✖ Long Term Care (also called custodial care)
  • ✖ Most dental care
  • ✖ Eye exams related to prescribing glasses
  • ✖ Dentures
  • ✖ Cosmetic surgery
  • ✖ Hearing aids and exams for fitting them
  • ✖ Routine foot care


    Medicare does not cover Custodial Care, also referred to as long-term care.  Part A coverage will help pay for short-term stays in skilled nursing facilities. As opposed to skilled nursing that is performed by licensed medical professionals, custodial care can be provided by non-licensed caregivers. Some Medicare Advantage Plans (Part C) offer extra benefits that Original Medicare doesn’t cover like limited custodial care.


    Original Medicare (Part A and Part B) does not cover routine Dental or Vision care.  There are certain circumstances under which Original Medicare may provide some coverage for dental or vision in case of an emergency setting or as part of surgery preparation.  Medicare doesn’t cover eye exams for eyeglasses or contact lenses.  Some Medica    re Advantage Plans (Part C) offer extra benefits that Original Medicare doesn’t cover like dental and vision care. Medicare doesn’t cover hearing aids or exams for fitting hearing aids. You pay 100% for hearing aids and exams. Some Medicare Advantage Plans (Part C) offer extra benefits that Original Medicare doesn’t cover – hearing and exams for fitting them.


    Medicare never covers Ambulette services. An Ambulette is a wheelchair-accessible van that provides non-emergency transportation.  Medicare may cover scheduled, regular trips if the ambulance supplier receives a written order from your doctor ahead of time stating that transport is medically necessary. Original Medicare (Part A and Part B) generally does not cover transportation to get routine health care. However, it may cover non-emergency ambulance transportation to and from a health-care provider. Some Medicare Advantage Plans (Part C) offer extra benefits that Original Medicare doesn’t cover like transportation. 


    Medicare usually does not cover medical care you receive when traveling outside the U.S. and its territories. In limited situations,  Medicare may pay for non-emergency inpatient services in a foreign hospital (and any connected provider and ambulance costs).      Some Medicare Advantage Plans (Part C) offer extra benefits that Original Medicare doesn’t cover like emergency foreign coverage.


To find out what Medicare covers click here. 

What Happens During The Medicare Annual Enrollment Period?

Medicare Annual Enrollment Period Explained:


The Medicare Annual Enrollment Period is a period of time (October 15 through December 7) when current Medicare users can choose to re-evaluate part of their Medicare coverage (their Medicare Advantage/Part C and/or Part D plan) and compare it against all the other plans on the market. After re-evaluating, there is a better fit plan, there’s an option to switch, drop or add a Medicare Advantage and/or Part D plan.

The Medicare Annual Enrollment Period cannot be used to enroll in Part A and/or Part B for the first time. 


During the Medicare Annual Enrollment Period (AEP) the following can occur:

  1. Anyone who has (or is signing up for) Medicare Parts A or B can join or drop a Part D prescription drug plan.
  2. Anyone with Original Medicare (Parts A & B) can switch to a Medicare Advantage plan.
  3. Anyone with Medicare Advantage can drop it and switch back to just Original Medicare (Parts A & B).
  4. Anyone with Medicare Advantage can switch to a new Medicare Advantage plan.
  5. Anyone with a Part D prescription drug plan can switch to a new Part D prescription drug plan.


Re-evaluating Medicare Coverage During The Medicare Annual Enrollment Period
Each year, insurance companies can make changes to Medicare plans that can impact how out-of-pocket costs — monthly premiums, deductibles, drug costs, and provider or pharmacy “networks.” A network is a list of doctors, hospitals, or pharmacies that negotiate prices with insurance companies. They can also make changes to plan’s “formulary” (list of covered drugs). Given these yearly changes, it is a good idea to re-evaluate your current Medicare plan each year to make sure it still meets needs.


Below are some additional benefits of re-evaluating coverage during Open Enrollment:

  1. Switching to better prescription drug coverage can reduce out-of-pocket costs and ensure drug plans still cover needed prescriptions.
  2. Save money and keep your doctor in-network by switching Medicare Advantage or Part D plans. Research shows that the average consumer can save $300 or more annually if they review their Part D coverage
  3. Find a higher quality plan. Plans with a 5-star rating are considered high quality. If you are enrolled in a plan that is less than 3, consider using the Medicare Enrollment Period to switch.

How Can I Find And Compare Medicare Plans?

To find and compare Medicare Plans from Top Carriers, click HERE and Enroll Today!
If you need help to find the right Medicare plan for you please CONTACT ME.

What does Part B (Medical Insurance) of Medicare cover?

Medicare Part B helps cover medically-necessary services like doctors’ services and tests, outpatient care, home health services, durable medical equipment, and other medical services. Part B also covers some preventive services. Look at your Medicare card to find out if you have Part B.

The basic medically-necessary services covered include:

  • • Abdominal Aortic Aneurysm Screening
  • • Ambulance Services
  • • Blood
  • • Bone Mass Measurement (Bone Density)
  • • Cardiac Rehabilitation
  • • Cardiovascular Screenings
  • • Chiropractic Services (limited)
  • • Clinical Laboratory Services
  • • Clinical Research Studies
  • • Colorectal Cancer Screenings
  • • Defibrillator (Implantable Automatic)
  • • Diabetes Screenings
  • • Diabetes Self-Management Training
  • • Diabetes Supplies
  • • Doctor Services
  • • Durable Medical Equipment (like walkers)
  • • EKG Screening
  • • Emergency Department Services
  • • Eyeglasses (limited)
  • • Federally-Qualified Health Center Services
  • • Flu shots
  • • Foot Exams and Treatment (Diabetes-related)
  • • Glaucoma Tests
  • • Hearing and Balance Exams
  • • Hepatitis B Shots
  • • HIV Screening
  • • Home Health Services
  • • Kidney Dialysis Services and Supplies
  • • Kidney Disease Education Services
  • • Mammograms (screening)
  • • Medical Nutrition Therapy Services
  • • Mental Health Care (outpatient)
  • • Non-doctor Services
  • • Occupational Therapy
  • • Outpatient Medical and Surgical Services and Supplies
  • • Pap Tests and Pelvic Exams (includes clinical breast exam)
  • • Physical Exams
  • • Physical Therapy
  • • Pneumococcal Shot
  • • Prescription Drugs (limited)
  • • Prostate Cancer Screenings
  • • Prosthetic/Orthotic Items
  • • Pulmonary Rehabilitation
  • • Rural Health Clinic Services
  • • Second Surgical Opinions
  • • Smoking Cessation (counseling to stop smoking)
  • • Speech-Language Pathology Services
  • • Surgical Dressing Services
  • • Telehealth
  • • Tests (other than lab tests)
  • • Transplants and Immunosuppressive Drugs


To find out if Medicare covers a service not on this list, visit medicare.gov/coverage, or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

What If I Miss Medicare Annual Open Enrollment?

If you have missed the Fall Medicare Open Enrollment period, there is a Medicare Advantage Open Enrollment Period, which lasts from January 1 to March 31 every year. During this other Medicare Open Enrollment period, you can switch from one Medicare Advantage plan to another, and you may go back to Original Medicare.

What If I Need Help After Open Enrollment?

I offer free and unbiased guidance year-round on issues related to Medicare. You can CONTACT ME.

Do I have to sign up for Medicare at 65?

Your coverage under Medicare kicks in at exactly 65, but you don’t need to wait until your 65th birthday to sign up. Rather, your initial enrollment window starts three months before the month you turn 65 and ends three months after the month in which you turn 65. You get a solid seven months to sign up.

Can I Have Both Employer Insurance And Medicare?

Medicare pays secondary if the insurance is from current work at a company with more than 20 employees. You will have a Special Enrollment Period to enroll in Medicare at any point while covered by the employer plan, or up to eight months after the first month you are without that employer coverage.

Should I Enroll In Medicare If I Have Employer insurance?

If you have health insurance through your employer and your company employs 20 or more individuals, then you don’t have to enroll in Medicare upon turning 65.  Now, because Medicare Part A is free for most people, it pays to enroll in it as soon as you’re eligible, even if you have existing coverage.

How Do I Enroll In Medicare Part B (Medical Insurance) Only?

If you are already enrolled in Medicare Part A and you want to enroll in Part B, please complete form CMS-40B, Application for Enrollment in Medicare – Part B (medical insurance). If you are applying for Medicare Part B due to a loss of employment or group health coverage, you will also need to complete form CMS-L564, Request for Employment Information.

You have three options to submit your enrollment request under the Special Enrollment Period.

You can do one of the following:

1. Go to “Apply Online for Medicare Part B During a Special Enrollment Period” and complete CMS-40B and CMS-L564. Then upload your evidence of Group Health Plan or Large Group Health Plan.

2. Fax your forms to 1-833-914-2016.

3. Mail your CMS-40B, CMS-L564, and evidence to your local Social Security field office.


Note: When completing the CMS-L564:

  • • State, “I want Part B coverage to begin (MM/YY)” in the remarks section of the CMS-40B form or online application.
  • • If your employer is unable to complete Section B, please complete that portion as best as you can on behalf of your employer without your employer’s signature.
  • • Also submit one of the following forms of secondary evidence:
    • ○ Income tax returns that show health insurance premiums paid.
    • ○ W-2s reflecting pre-tax medical contributions.
    • ○ Pay stubs that reflect health insurance premium deductions.
    • ○ Health insurance cards with a policy effective date.
    • ○ Explanations of benefits paid by the GHP or LGHP.
    • ○ Statements or receipts that reflect payment of health insurance premiums.


You’ll have Original Medicare (Part A and Part B) unless you make another choice. You can decide to add a drug plan (Part D) or buy a Medigap policy to help pay for costs that Original Medicare doesn’t cover. You can choose to join a Medicare Advantage Plan (Part C) and get all your Medicare coverage (including drugs and extra benefits like vision, hearing, dental, and more) bundled together in one plan.  


Please remember you have a Special Enrollment Period to enroll in Medicare Part B (Medical Insurance).  It is extremely important to understand the timeline.


Please CONTACT ME as soon as you enroll in Medicare Part B (Medical Insurance). I will help you find a plan that’s right for you.

When Can I Change My Medicare Coverage?

  • • January 1 to March 31 – General enrollment for Medicare Part B, for people who didn’t sign up when they were first eligible (this is also the general enrollment period for people who have to pay premiums for Medicare Part A and didn’t sign up when first eligible).
  • • January 1 to March 31 – Medicare Advantage open enrollment period: People who already have Medicare Advantage can switch to Original Medicare (plus a Part D prescription drug plan) or to a different Medicare Advantage plan.
  • • October 15 to December 7 – Open enrollment period for Medicare Advantage and Medicare Part D.
  • • December 8 to November 30 – Special enrollment for 5-star plans
  • • First year of Advantage coverage – One-time trial period during which it’s possible to switch from Medicare Advantage to Original Medicare, Medigap or Part D plan.
  • • Special Enrollment Periods (SEPs) are periods of time outside normal enrollment periods when you can enroll in health insurance. They are typically triggered by specific circumstances. For more information on Medicare Special Enrollment Periods click here.

Does Original Medicare Cover Part D (Prescriptions)?

Original Medicare does not cover prescription drug needs – a separate Part D plan is needed. In order to be eligible for Medicare Part D enrollment, you must: Have Medicare Part A and/or Part B

 

Medicare Part D provides prescription drug coverage, and is part of the government’s Medicare program, but is offered and managed through approved private insurers. You pay a monthly premium, deductibles, copays and coinsurance for your Medicare prescriptions drug coverage to an insurance carrier for your Part D plan. In return, you use the insurance carrier’s network of pharmacies to purchase your prescription medications.  In most cases if you use a Preferred Pharmacy in the network your out pocket cost will be less than getting your prescriptions from a Standard Pharmacy.  Some Part D insurers may offer you the option of Mail Order. That means you can order up to three months of your prescription drugs at a time and they’ll be delivered right to your house.  Most Medicare drug plans (Medicare Prescription Drug Plans and Medicare Advantage Plans with prescription drug coverage) have their own list of what drugs are covered, called a formulary. Plans include both brand-name prescription drugs and generic drug coverage.  Your cost sharing for the prescriptions in the formulary is based on the drugs tier. A Medicare drug plan can make some changes to its drug list during the year if it follows guidelines set by Medicare. Your plan may change its drug list during the year because drug therapies change, new drugs are released, or new medical information becomes available.


I strongly recommend reviewing your plan choices every year, especially when it comes to Part D Prescription coverage. Medicare Part D plans vary greatly in terms of monthly premiums, annual deductibles, drugs covered and prescription prices. It is important to review your Part D coverage every year because premiums, co-payments or the drugs covered can change from year-to-year, even within the same plan. Even a change in the medication you’re taking can affect if a plan is right for you.  Your current plan should have sent you an “Annual Notice of Change” in September which outlines any changes to your current plan for next year. If you choose not to make any changes to your current plan, you do not have to take any action. Your plan will simply remain in effect for the next calendar year.

How much does Part D (Prescriptions) cost?

Most people only pay their Part D premium. If you don’t sign up for Part D when you’re first eligible, you may have to pay a Part D late enrollment penalty.

If your modified adjusted gross income is above a certain amount, you may pay a Part D income-related monthly adjustment amount (Part D IRMAA). Medicare uses the modified adjusted gross income reported on your IRS tax return from 2 years ago (the most recent tax return information provided to Social Security by the IRS). You’ll pay the Part D IRMAA amount in addition to your monthly plan premium, and this extra amount is paid directly to Medicare, not to your plan. Most people have the extra amount taken from their Social Security Check.  The chart below lists the extra amount cost by income.

Social Security will contact you if you have to pay Part D IRMAA, based on your income. The amount you pay can change each year. If you have to pay a higher amount for your Part D premium and you disagree (for example, if your income goes down), use this form to contact Social Security [PDF, 125 KB].  If you have questions about your Medicare prescription drug coverage, contact your plan.

If Social Security notifies you about paying a higher amount for your Part D coverage, you’re required by law to pay the Part D-Income Related Monthly Adjustment Amount (Part D IRMAA).  If you don’t pay the Part D IRMAA, you’ll lose your Part D coverage.

Employer/Union coverage and Part D IRMAA

Note 

You pay your Part D IRMAA directly to Medicare, not to your plan or employer.

You’re required to pay the Part D IRMAA, even if your employer or a third party (like a teacher’s union or a retirement system) pays for your Part D plan premiums. If you don’t pay the Part D IRMAA and get disenrolled, you may also lose your retirement coverage and you may not be able to get it back.

Things to remember

  • Pay your Part D IRMAA bill to Medicare as soon as you get it. Find out how to pay your bill. Keep your address current with Social Security, even if you don’t get a Social Security check.

Part D premiums by income

The chart below shows your estimated prescription drug plan monthly premium based on your income as reported on your IRS tax return. If your income is above a certain limit, you’ll pay an income-related monthly adjustment amount in addition to your plan premium.

 

 2021

What Is The Medicare Part D (Prescriptions) Coverage Gap (Donut Hole)?

The Medicare Part D (RX) Coverage Gap, also called the Medicare Part D (RX) Donut Hole, is a temporary limit on how much insurers will pay for your prescriptions. Persons who receive Extra Help in paying for their Part D plan do not pay additional co pays, even for prescriptions filled in the doughnut hole.  

To find out if you qualify for Extra Help click here: ssa.gov/benefits/medicare/prescriptionhelp/

CMS has released the following 2021 parameters for the defined standard Medicare Part D prescription drug benefit:

  • Deductible: $445 
  • Initial coverage limit: $4,130 
  • Out-of-pocket threshold: $6,550 

Catastrophic coverage: Minimum cost-sharing under the catastrophic coverage portion of the benefit: $3.70 for generic/preferred multi-source drugs, and $9.20 for all other drugs, or 5% coinsurance

Once Enrolled In Medicare How Can I Save Money?

Using A Qualified Agent To Help Save Money On Medicare

Ok, a shameless plug, but it is worth mentioning. You can go on any website and select a Medicare plan. How do you know if it is right for you? Do you have the time to go through every plan available in your area and select the right one? The longer you wait, you might miss important enrollment deadlines. Having a qualified agent like myself work on your behalf, and with many carriers, can save money on your Medicare costs.  You can be certain a qualified agent will direct you to the right plan for your situation, discussing the advantages, disadvantages, and expectations. Sure, we get paid a commission. The commission is paid for our efforts and to provide future service for your Medicare needs. You have someone in your corner. Does that make you feel comfortable?

To Save Money On Medicare, You Need To Know Your Enrollment Periods

Many don’t, and this is a major mistake I see many Medicare beneficiaries make, yet it’s one of the keys to saving money on Medicare.  Three months before you turn 65, a 7 month window starts for your Original Medicare (A&B), Medicare Advantage (C), and Prescription Drugs (Part D). Moreover, if you have done your homework and wished to purchase a Medicare Supplement plan instead, that window begins the month you turn 65 and goes an additional 6 months. Why are these initial enrollments important? If you don’t sign up when first eligible for Medicare, you will pay a penalty.  The Part B penalty is 10% of the premium for every 12 months you should have been enrolled. It is a lifetime penalty, so getting it right the first time is important. Likewise, you will pay a penalty if you don’t sign up for Part D prescription drugs when first eligible. That penalty is different than the Part B penalty. So, it is important that you know these enrollment periods in order to save money on Medicare.


Knowing Your Plan Options Can Help Save Money On Medicare

You really have three common plan options when it comes to Medicare insurance plans (there are other plan options for specific needs individuals such as Medicaid beneficiaries these plans are outside the scope of this article). Which one you choose depends on your self-health assessment. That is why the self-assessment is important because it will save you money.

1. Stick with Original Medicare (Parts A&B) and a Part D Prescription Drug Plan.

You can simply enroll in Original Medicare A & B, and enroll in Part D. You will have to pay the Part B premium and a Part D premium.

2. Enroll in a Part C Medicare Advantage Plan. 

A Medicare Advantage plan is offered by private insurers. It combines parts A & B. You typically have to pay a monthly premium in addition to part B. Nearly all Medicare Advantage plans integrate with Part D, in which there is no separate premium. So, that is a good thing! These plans may also offer other benefits such as preventative dental coverage, vision, and hearing among some fitness discounts.  The downside: you still have out-of-pocket exposure, up to $6,700 in 2020. You still have to pay plan deductibles, co-pays, and coinsurance. Is that worth the out-of-pocket exposure?

3. Enroll in a Medicare Supplement Plan.

Medicare supplement plans work in tandem with Parts A, B, and D, which means you would have to purchase a separate Part D plan if you choose a Medicare Supplement Plan. A Medicare Supplement Plan generally pays for your out-of-pocket costs. Most Medicare beneficiaries have access to 10 different Medicare Supplement plans. Other residents have alternative Medicare Supplement plans, but they work the same way.

4. Take An Assessment to Save Money on Medicare

In order to truly save money on Medicare, you first need to perform a financial self-assessment on your health. Does this mean you have to be a doctor? No, all you need to do is look in the mirror of your current health. Answer these questions:
• What were your health expenses during the last couple of years, including premiums?
• How much did you spend on prescription drugs?
(Note these two are easily found on your health insurance carrier’s website whether it is Medicare or not.)
• Do you have a family history of any conditions or diseases?
• Are you comfortable with out-of-pocket exposure or do you want a plan which will cover nearly everything?

The answers to these questions will help determine the best Medicare plan for your situation. For example, if you had a lot of out-of-pocket costs, or have a long-term, costly chronic condition, a Medicare Supplement plan might be beneficial for you rather than a Medicare Advantage plan.

5. Understanding Programs that Can Help You Save Money On Medicare

4 Programs that Can Help You Pay Your Medical Expenses:
There are federal and state programs available for people with Medicare who have income and resources below certain limits. These programs may help you save on your health care and prescription drug costs. 

 

Medicaid 

Medicaid is a joint federal and state program that helps pay medical costs if you have limited income and/or resources and meet other requirements. Each state has different income and resource requirements, and decides who’s eligible, what services are covered, and the cost for services. Call your State Medical Assistance (Medicaid) office for more information and to see if you qualify. Visit Medicare.gov/contacts, or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

  • Medicare Savings Programs

If you have limited income and resources, you may be able to get help from your state to pay your Medicare costs if you meet certain conditions. There are 4 kinds of Medicare Savings Programs: 

Qualified Medicare Beneficiary (QMB) Program—If you’re eligible, the QMB Program helps pay for Medicare Part A (Hospital Insurance)and/or Medicare Part B (Medical Insurance) premiums. In addition, Medicare providers aren’t allowed to bill you for Medicare deductibles, coinsurance, and copayments when you get services and items Medicare covers, except outpatient prescription drugs. 

Specified Low-Income Medicare Beneficiary (SLMB) Program— Helps pay Part B premiums only. 

Qualifying Individual (QI) Program—Helps pay Part B premiums only. You must apply each year for QI benefits and the applications are granted on a first come first-served basis. 

Qualified Disabled and Working Individuals (QDWI) Program— Helps pay Part A premiums only. You may qualify for this program if you have a disability and are working. The names of these programs and how they work may vary by state. Medicare Savings Programs aren’t available in Puerto Rico and the U.S. Virgin Islands. Call or visit your State Medical Assistance (Medicaid) office, and ask for information on Medicare Savings Programs. To get the phone number for your state, visit Medicare.gov/contacts. You can also call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. 

  • Supplemental Security Income (SSI) Benefits 

SSI is a cash benefit paid by Social Security to people with limited income and resources who are blind, 65 or older, or have a disability. SSI benefits aren’t the same as Social Security retirement benefits. You can visit benefits.gov/ssa, and use the “Benefit Eligibility Screening Tool” to find out if you’re eligible for SSI or other benefits. Call Social Security at 1-800-772-1213 or contact your local Social Security office for more information. TTY users can call 1-800-325-0778. Note: People who live in Puerto Rico, the U.S. Virgin Islands, Guam, or American Samoa can’t get SSI.

  • Extra Help

If you have limited income and resources, you may qualify for Extra Help to pay for some or most of the out-of-pocket costs of Medicare prescription drug coverage. The amount of Extra Help you get is based on your income and resources. 

How to apply for Medicare Extra Help:

1. Applying online at www.socialsecurity.gov/extrahelp.
2. Calling Social Security at 1-800-772-1213 (TTY 1-800-325-0778) and requesting an application be mailed to you or applying over the phone.
3. Applying in person at your local Social Security office.

*If you qualify for Medicaid, one of the Medicare Savings Programs, or SSI, you automatically qualify for Extra Help paying the costs of Medicare prescription drug coverage. The income and resources level may change each year(EPIC).


In addition you can explore the State Pharmaceutical Assistance Programs (SPAPs) that are state-run programs that assist low-income seniors and adults with disabilities in paying for their prescription drugs.  In New York the program is called Elderly Pharmaceutical Insurance Coverage Program (EPIC).  If you’re enrolled in Medicare and are 65 years or older you can apply for EPIC by calling 1 800 332-3742 (TTY 1 800 290 9138).  For more information on EPIC visit health.ny.gov/health_care/epic/

What Circumstances Allow An Individual To Obtain Coverage Outside The Medicare Open Enrollment Period(SEP)?

Medicare may grant you a special enrollment period (SEP) based on certain special circumstances, allowing you to enroll or make changes to Medicare Advantage and Part D coverage. These SEPs require original Medicare enrollment. During special enrollment periods, you can enroll in Medicare Advantage or Part D.

  • • If you lose your coverage from work or a union group then you have two full months from the date that your employer or group-based coverage ends to sign up for Medicare Advantage or Medicare Part D.
  • • If you or your spouse loses coverage through your employer, a union group or the Veterans Administration, then you also have two full months from the date your coverage ends to sign up for MA or Part D coverage.
  • • Your special enrollment period starts on the earliest date that you lose coverage. So, for instance, if you lose an employer-sponsored plan on July 15 and VA coverage on October 1, then your special enrollment period would start on July 15 since that loss came first.


There are additional considerations for people with employer-sponsored coverage. For example, people with employer-sponsored coverage may have postponed signing up for Parts A or B (or both). You qualify for an SEP as long as there were more than 20 employees when you turned 65. You (or your spouse) also had to have been covered through the job or union.

The times to apply for this SEP are:

  • • Any time you or your spouse is still covered or
  • • During the 8 months following the month the coverage or employment ends (whichever is first).

Waiting too long to enroll (in Part B, specifically) may put you at risk for a penalty; however, if granted an SEP, it’s likely that you’ll be exempt.


Beneficiaries who are disabled and working can qualify for this SEP, provided their employer has more than 100 employees. This applies to enrollees with coverage from a working family member as well. But those with COBRA or retiree health plans don’t qualify for SEPs; these plans aren’t considered current employment. You’ll want to enroll in Medicare when first eligible to avoid paying higher premiums.

Medicare also grants special enrollment periods for other situations, such as:

Changing locations

  • • Moving outside of your plan’s service area: If you move to a new place that’s outside of your current service area, then you can switch to a Medicare Advantage or Part D plan. Tell your plan early to get a jump start on choosing a new policy. If you do, your enrollment period starts the month before the month that you move and runs for two full months after you move. If you tell your plan after the move, then you can’t switch plans until the month that you move. Your enrollment period lasts for two full months afterwards as well.
  • Note: If you have an MA plan, you can opt to switch to original Medicare if you move. Keep in mind, though, that if you don’t choose another MA plan when you move, you’ll be switched to original Medicare automatically once you get disenrolled from the MA plan.
  • • Moving to a new address in the same service area: You can switch to a new MA or Part D plan if you move to a new address within the same service area as long as there are new plan options where you move. The same time limitations apply in this scenario as they do if you were to move outside of your plan’s service area.
  • • Coming back to the U.S. after living abroad: If you’ve been living in another country and you return to the states, then you can enroll in an MA or Part D plan. Your enrollment period starts the month that you move back to the U.S. and lasts for two full months afterwards.
  • • Living in, moving to or leaving an institution: For people who are about to move into an institution, currently living in one or about to leave one, there’s a special enrollment period that lasts for the duration of your stay plus two full months after the month that you move out. An institution includes places like skilled nursing facilities or long-term care hospitals. During this enrollment period, you can:
  • Enroll in a Medicare Advantage or Part D drug plan
  • Switch to a new MA or drug plan from an existing MA or drug plan
  • Disenroll from Medicare Advantage and enroll in original Medicare
  • Drop your Part D coverage altogether
  • • Being released from jail: If you get released from jail, then you can enroll in Part D or Medicare Advantage starting the month after you get released. You’ll have two full months afterwards to enroll.


    Losing your current coverage

  • • No longer qualifying for Medicaid: It’s estimated that about 1.8 million Americans will qualify for a special enrollment period each year because they no longer qualify for Medicaid (a program for low-income individuals and families). If you lose Medicaid coverage, you can change your plan for two full months starting the month you learn that you no longer qualify for Medicaid. If you’ve lost coverage for the next year, then your SEP lasts from January 1 through March 31.

    During the SEP, you can:

  • • Enroll in a Medicare Advantage or Part D drug plan
  • • Switch to a new MA or drug plan from an existing MA or drug plan
  • • Disenroll from Medicare Advantage and enroll in original Medicare
  • • Drop your Part D coverage altogether
  • • Voluntarily dropping employer-sponsored coverage, union coverage, or COBRA:
    If you voluntarily drop an existing plan through work, a union or COBRA, then you can enroll in an MA or Part D plan starting the month that your coverage ends. The SEP lasts for two full months afterwards.
  • • Involuntarily losing creditable coverage (or coverage becoming uncreditable):
    Within Medicare, creditable coverage refers to a policy that has a similar actuarial value to what Medicare Part D covers. For instance, you might have prescription coverage through your employer or your spouse’s employer instead of Medicare. If you lose this coverage after your initial sign-up period for Medicare has passed, then you can sign up for a Medicare Part D drug plan or a Medicare Advantage plan with drug coverage. The SEP lasts for two full months after you lose creditable coverage or you receive a notice from the insurer that the coverage is no longer creditable, whichever comes later.
  • • Leaving a Medicare Cost Plan:
    If you drop your Medicare Cost Plan, then you can enroll in a Medicare prescription drug plan. The enrollment period lasts for two full months after you drop the Cost Plan.
  • • Dropping a PACE plan:
    A Program of All-inclusive Care for the Elderly (PACE) plan is a plan that combines features of Medicare and Medicaid into one expansive plan for specific populations of the elderly. If you decide to drop your PACE plan, then you have two full months after the month you drop your coverage to enroll in a Medicare Advantage or Part D plan instead.

 

Pursuing other coverage options

  • • Enrolling in employer-sponsored or union coverage:
    If you decide to enroll in your employer’s health plan or a union plan, then you can drop your Medicare Part D or Medicare Advantage coverage as soon as your employer or union allows you to make changes.
  • • Getting drug coverage that’s comparable to Medicare Part D:
    Certain types of coverage, like VA coverage or TRICARE, offer drug plans that are comparable to what Medicare offers. If you have or enroll in one of these plans, then you can drop your MA or Part D coverage at any time.
  • • Enrolling in a PACE plan:
    PACE covers prescription drugs, so if you enroll in a PACE plan, then you can drop Part D or MA coverage at any time.

    Medicare contract changes
  • • Official actions or sanctions taken by Medicare:
    If there’s a problem related to your current Medicare plan, then Medicare may take official action against it, including certain sanctions. If that happens, you can switch to a new MA or Part D drug plan. Enrollment is determined on an individual basis.
  • • Termination of a plan’s contract by Medicare:
  • • A plan’s contract not being renewed by Medicare:


Other special circumstances

  • • Qualifying for Extra Help:
    The Extra Help program enables seniors to receive federal assistance in paying for some or most of Part D coverage. If you’re eligible, then you can join, switch or drop Part D coverage at any time. Your coverage will start on the first day of the month after you qualify for Extra Help and ask to join.
  • • Enrolling in or losing SPAP coverage:
    The State Pharmaceutical Assistance Program (SPAP) a state-sponsored program designed to help offset the costs associated with prescription drug coverage. If you’re eligible for an SPAP and your state offers one, then you can join a Part D plan or a Medicare Advantage plan with drug coverage. If you lose your SPAP eligibility, you can also switch to a new Part D or MA plan with drug coverage. These changes can only be made once per calendar year.
  • • Dropping Medigap when you first sign up for Medicare Advantage:
    If you had a Medigap policy in place when you signed up for Medicare Advantage and you drop that Medigap policy voluntarily when you first sign up for the MA plan, then you’ll need to switch to original Medicare. You have 12 months from when you first signed up for an MA plan to switch to original Medicare. You’ll also be able to buy a new Medigap policy once you switch.
  • • Enrolling in a Medicare Chronic Care Special Needs Plan:
    For people with certain medical conditions, Medicare offers a type of Medicare Advantage plan called a Special Needs Plan. These plans cater to individuals with chronic problems, such as End-Stage Renal Disease. If you qualify for this type of coverage, then you can enroll at any time. However, you should note that once you enroll, you won’t be able to use the special enrollment period to make any further changes to your plan.
  • • Dropping a Special Needs Plan:
    If you lose eligibility for your Special Needs Plan, then you can switch to a Medicare Advantage plan with drug coverage or a Part D plan. The enrollment period for this scenario starts from when you lose your special needs status and ends three months after your plan’s grace period ends.
  • • Joining or not joining a plan based on federal employee error:
    Errors made by federal employees may impact your decision to enroll. For example, you may sign up for the wrong Part D plan because a federal employee got the names of the plans switched up. Errors do happen. This particular SEP is determined on an individual basis. If you’re granted an SEP for this situation, then you’ll receive a notice from Medicare about the error. You’ll have two months from the time you’re notified to make changes, during which time you can:
    • ○ Enroll in a Medicare Advantage or Part D drug plan
    • ○ Switch to a new MA or drug plan from an existing MA or drug plan
    • ○ Disenroll from Medicare Advantage and enroll in original Medicare
    • ○ Drop your Part D coverage altogether

• Lack of proper notice regarding losing creditable coverage:
Insurers are supposed to tell you if you lose creditable coverage, which is coverage that’s as good as what Medicare offers. If you’re enrolled in a private plan with creditable coverage and you lose that coverage without being properly notified, then you can switch to a Medicare Part D plan or a Medicare Advantage plan with drug coverage. You’ll have two full months from the month that you receive the notice of error from Medicare or your plan. You may also be exempt from late penalties if you can prove that you were unaware of the error before you signed up.

What is a Special Enrollment Period?

A Special Enrollment Period (SEP) is an enrollment period that takes place outside of the annual Medicare enrollment periods, such as the annual Open Enrollment Period. They are granted to people who were prevented from enrolling in Medicare during the regular enrollment period for several specific reasons.

Special Enrollment Periods exist for Original Medicare (Part A and Part B), as well as for Medicare Advantage (Medicare Part C) and prescription drug plans (Medicare Part D).

Click here to view a complete list of Medicare’s Special Enrollment Periods to see if one or more may apply to you. If you’re not sure if a Special Enrollment Period applies to you contact me. 

What is a Special Enrollment Period?

A Special Enrollment Period (SEP) is an enrollment period that takes place outside of the annual Medicare enrollment periods, such as the annual Open Enrollment Period. They are granted to people who were prevented from enrolling in Medicare during the regular enrollment period for several specific reasons.

Special Enrollment Periods exist for Original Medicare (Part A and Part B), as well as for Medicare Advantage (Medicare Part C) and prescription drug plans (Medicare Part D).

Click here to view a complete list of Medicare’s Special Enrollment Periods to see if one or more may apply to you. If you’re not sure if a Special Enrollment Period applies to you contact me. 

What is the difference between Medicare and Medicaid?

Medicare
Medicare is an insurance program. Medical bills are paid from trust funds which those covered have paid into. It serves people over 65 primarily, whatever their income; and serves younger disabled people and dialysis patients. Patients pay part of costs through deductibles for hospital and other costs. Small monthly premiums are required for non-hospital coverage. Medicare is a federal program. It is basically the same everywhere in the United States and is run by the Centers for Medicare & Medicaid Services, an agency of the federal government.

Medicaid
Medicaid is an assistance program. It serves low-income people of every age. Patients usually pay no part of costs for covered medical expenses. A small co-payment is sometimes required. Medicaid is a federal-state program. It varies from state to state. It is run by state and local governments within federal guidelines.

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We do not offer every plan available in your area. Currently we represent 10 organizations which offer 232 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.