Medicare Overview

Do I Qualify for Medicare?

Individuals generally qualify for Medicare if they are:

Aged 65 or older: Most people become eligible for Medicare at age 65, regardless of their income or health status.
Disabled: Individuals under age 65 may qualify for Medicare if they have been receiving Social Security Disability Insurance (SSDI) or Railroad Retirement Board (RRB) disability benefits for at least 24 months.
Diagnosed with End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS): Individuals with ESRD or ALS may be eligible for Medicare regardless of age.

How Medicare Works

Choosing a Medicare plan can be a daunting task, it is an important decision that can greatly impact your healthcare coverage and costs. Medicare offers a variety of plans to choose from, each with its own set of benefits, costs, and coverage rules. To make an informed decision about which plan is right for you, it’s important to understand the basics of Medicare and how each plan works. Here are some key things to know about Medicare to help you choose the right plan for your needs.

STEP 1:

Enrolling Into Medicare

Enrolling in Medicare during the 7-month window refers to the Initial Enrollment Period (IEP), which begins three months before your 65th birthday month and lasts for a total of seven months.

Hit “Next” for an explanation of how to enroll during this period…

TIMING

Your Initial Enrollment Period starts three months before the month of your 65th birthday and extends for three months after your birthday month. This gives you a total of seven months to enroll in Medicare.

Medicare Parts

Determine which parts of Medicare you want to enroll in – Part A (hospital insurance) and/or Part B (medical insurance). Most people are eligible for premium-free Part A, while Part B requires paying a monthly premium.

Gather Information

Collect the necessary information and documents needed for enrollment, such as your Social Security number, proof of citizenship or residency, and information about any other health insurance coverage you currently have.

Enrollment Options

There are several ways to enroll during your Initial Enrollment Period:

Online: Visit the Social Security Administration (SSA) website at www.ssa.gov and follow the instructions to complete the Medicare enrollment application online.
Phone: Contact the SSA at their toll-free number, 1-800-772-1213 (TTY: 1-800-325-0778), and speak with a representative who will assist you in enrolling over the phone.
In Person: Visit your local Social Security office and apply for Medicare in person. To find the nearest office, use the SSA’s office locator tool on their website.

Submitting the Application

Provide the required information on the application, including personal details and the Medicare coverage options you’ve chosen. Review the application carefully for accuracy before submitting it.

Confirmation and Follow-up

After submitting your application, you should receive a confirmation notice or reference number. Keep this information for your records. The SSA will process your application and send you a Medicare card once your enrollment is complete.

Please Note

It’s important to note that enrolling during the Initial Enrollment Period ensures that you avoid any late enrollment penalties and have coverage starting when you’re first eligible. If you miss the Initial Enrollment Period, you may have to wait for the General Enrollment Period and could face penalties for late enrollment.

Step 2

Understanding Original Medicare as a Stand Alone Insurance Option

Medicare Part A

The Part A deductible is $1,548 for each benefit period. A benefit period starts when you’re admitted to a hospital or skilled nursing facility and ends when you haven’t received inpatient care for 60 consecutive days. for days 61-90 of an inpatient hospital stay, you may have a daily copay of $387 (in 2023). For days 91 and beyond, there is a daily copay of $774 (in 2023).

To be eligible for premium-free Part A, you generally need to have earned 40 work credits during your working years. Most people earn these credits by paying Social Security or Medicare taxes while working.

Medicare Part B

Part B covers a wide range of medical services, including doctor visits, outpatient care, preventive services, and medical supplies.

The cost breakdown for Medicare Part B consists of premiums and coinsurance:

Premiums: Most Medicare Part B beneficiaries are required to pay a monthly premium. The premium amount is determined by the government and may change annually. However, it’s important to note that the premium can also be affected by income-related adjustments, known as the Income-Related Monthly Adjustment Amount (IRMAA). The standard premium for most beneficiaries in 2023 is $170.10 per month. However, higher-income individuals may have to pay higher premiums based on a sliding scale.
Deductible: Before Medicare Part B starts covering your medical expenses, you must meet an annual deductible. The deductible amount can change each year. In 2023, the Part B deductible is $233.
Coinsurance: Once you have met the deductible, you will typically be responsible for paying a coinsurance amount. Coinsurance is a percentage of the Medicare-approved amount for covered services. For most services, you will be responsible for paying 20% of the Medicare-approved amount, while Medicare Part B covers the remaining 80%.

Step 3:

Determine if You Need Additional Coverage

Once you’ve grasped the basics of Medicare (Parts A and B), the next step is to evaluate whether you need additional coverage to enhance your healthcare benefits. Two common options for bolstering your Medicare coverage are Medicare Advantage, Medicare Supplements (Medigap), and Medicare Prescription Drug Plans. Next, we’ll explain the key differences between these options and highlight their respective pros and cons:

Medicare Advantage:

Pros:

All-in-One Convenience: Medicare Advantage plans, often offered by private insurance companies, typically bundle hospital and medical coverage, and often include prescription drug coverage.
Additional Benefits: Many Medicare Advantage plans provide extra services like dental, vision, and hearing coverage, which aren’t included in Original Medicare.
Cost Control: These plans usually have out-of-pocket maximums, limiting your annual healthcare expenses.

Cons:

Network Restrictions: Medicare Advantage plans often come with networks of doctors and hospitals. You may need to use in-network providers or pay more for out-of-network care.
Plan Changes: These plans can change from year to year, affecting your coverage and costs.
Referrals: Some plans require referrals to see specialists.

Medicare Supplements (Medigap):

Pros:

Freedom of Choice: With a Medigap plan, you can see any doctor or specialist who accepts Medicare patients without worrying about network restrictions.
Predictable Costs: Medigap plans help you budget by covering most, if not all, of the out-of-pocket costs that Original Medicare doesn’t cover.
Stable Coverage: Medigap plans are standardized, so your benefits remain consistent, regardless of the insurance company offering the plan.