Who is Eligible

Original Medicare

“Original Medicare” refers to Medicare parts A and B. The federal government manages these plans, and you can receive care from any doctor, other health care provider, hospital, or other facility that accepts Medicare patients. Except during emergencies, it is important to ask the provider if they accept Medicare assignment before you obtain a service from them. If the provider does not accept Medicare, you may need to pay a much higher amount to receive their care.

Medicare Part A

Medicare Part A helps pay for inpatient hospital care and some other care, such as home health, hospice, and skilled nursing facility care.  Most people age 65 and over who are U.S citizens or permanent legal residents are eligible for Medicare Part A.

Costs

Medicare Part A is free if you receive or are eligible to receive Social Security benefits. In other words, it is free if you or your spouse has worked and paid taxes for at least 40 quarters (10 years).

If you are not eligible for premium-free Part A (do not have 10 years of work) you will have to pay a monthly premium for Medicare Part A. Depending in your income and assets, you may pay up to $422 each month in 2018. The specific amount you pay will depend on your work history and financial situation.

When should I enroll in Medicare Part A?

You can enroll in Medicare Part A during your 7-month Initial Enrollment Period between the three months before you turn 65 and the three months following. If you do not buy Part A during your Initial Enrollment Period when you are first eligible at 65 years of age, your monthly premium may cost 10 percent more once you do enroll. You will have to pay the higher premium for twice the number of years you were eligible for Part A, but did not enroll. For example, if you were eligible for Part A for 2 years but were not enrolled, you will have to pay the higher premium for 4 years. If you meet certain conditions that allow you to sign up for Part A during a Special Enrollment Period, you may not face the penalty.

If you’re under 65, you can get premium-free Part A if:

  • You got Social Security or Railroad Retirement Board disability benefits for 24 months.
  • You have End-Stage Renal Disease (ESRD)and meet certain requirements.

 

Is enrollment in Medicare Part A automatic or do I need to enroll?

If you are receiving some form of Social Security (Social Security or benefits from the Railroad Retirement Board) when you become eligible for Medicare (age 65,) you will be automatically enrolled in Part A and Part B.  If you are not receiving Social Security when you turn 65, you must enroll in Medicare through the Social Security Administration.  The application can be done online here, by phone at 800-772-1213, or in person at your local Social Security office.  The Social Security Administration has created a check list of the information you need to apply which you can down load here.

Medicare Part B

Medicare Part B is general health insurance coverage. Medicare Part B helps cover physician visits, outpatient services, preventative services, medical equipment, and some home health visits. Part B covers both medically necessary services and preventative services that help prevent illness or detect it at an early stage when treatment is most likely to work best.

Part B covers things like:

  • Clinical research
  • Ambulance services
  • Durable medical equipment (DME)
  • Mental health
  • Inpatient
  • Outpatient
  • Partial hospitalization
  • Getting a second opinion before surgery
  • Limited outpatient prescription drugs

The Affordable Care Act recently expanded the range of preventative services that Medicare Part B covers, such as mammograms and colonoscopies, and patients can receive a “Welcome to Medicare” preventative visit and a yearly “Wellness” visit with their provider.

Medicare Parts B does not cover most prescription drugs, dental care, vision exams, hearing exams or aids, cosmetic surgery, acupuncture, or long-term care (also called custodial care).

Costs

Anyone who is eligible for Medicare Part A can also enroll in Medicare Part B. Most Part B benefits are subject to a yearly deductible ($183 in 2018), and out-of-pocket copayments, coinsurance and monthly premiums. The standard Part B premium for 2018 will be $134 (or higher depending on our income).

Some people who have income or resources higher than a set amount may need to pay higher Part B premiums as determined by Social Security. People with limited income and resources may be eligible to receive assistance with Part B payments through a variety of programs such as Medicaid.

If you have Original Medicare and you obtain a service to which the Part B deductible applies, you must pay the entire Medicare-approved amount for that service until your deductible is met. At that point, Medicare will pay about 80% of the cost of the service, and the coinsurance you will pay will be about 20%. If it applies to the specific service, you may also need to make a copayment.

When should I enroll in Medicare Part B?

Similar to Part A, Medicare Part B has a penalty associated with enrolling outside of the Initial Enrollment Period when you first become eligible (the 7 month period around your 65th birthday). If you do not sign up for Medicare Part B during your Initial Enrollment Period, you will be charged a monthly premium of 10% of the Part B premium for every full 12 months you were eligible but did not enroll.

If you have employer based insurance when you turn 65, you may keep your plan and then need to enroll in Medicare Part B within 8 months of losing your employer plan to avoid paying a penalty.

 When is Medicare Open Enrollment?

The Medicare Open Enrollment period is from October 15 until December 7 each year (the dates changed in 2011, but have been the same ever since, and should remain as-is for the foreseeable future.). For 2018 Medicare coverage, open enrollment ended on December 7, 2017. For 2019 coverage, open enrollment will run from October 15, 2018, to December 7, 2018.

During the annual enrollment period (AEP)  you can make changes to various aspects of your coverage.

  • You can switch from Original Medicare to Medicare Advantage, or vice versa.
  • You can also switch from one Medicare Advantage plan to another, or from one Medicare Part D (prescription drug) plan to another.
  • And if you didn’t enroll in a Medicare Part D plan when you were first eligible, you can do so during the general open enrollment, although a late enrollment penalty may apply.

If you want to enroll in a Medicare Advantage plan, you must meet some basic criteria.