MEDICARE

Medicare is a federal health insurance for anyone age 65 and older, some people under 65 with certain disabilities or conditions and also people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).

Eligibility for Medicare

Be age 65 or older; Be a U.S. resident; AND. Be either a U.S. citizen, OR. Be an alien who has been lawfully admitted for permanent residence and has been residing in the United States for 5 continuous years prior to the month of filing an application for Medicare.

Medicare has different parts that help cover specific services:

Part A: Which covers Hospital Stays and Inpatient care, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also help cover hospice care and some home health care. Beneficiaries must meet certain conditions to get these benefits. Most people don't pay a premium for Part A because they or a spouse already paid for it through their payroll taxes while working.

Part B: Which covers Doctor visit and Outpatient care also covers some other medical services that Part A doesn't cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary. Most people pay a monthly premium for Part B.

Part C: also called Medicare Advantage (MA), are private insurance plans offered by Medicare-approved companies. These plans provide most of Part A (Hospital Insurance) and Part B (Medical Insurance) coverage and typically offer extra benefits such as vision, hearing and dental care.

Part D: Which covers most outpatient prescription drugs. Part D is offered through private companies either as a stand-alone plan, for those enrolled in Original Medicare, or as a set of benefits included with your Medicare Advantage Plan.

Enrollment periods and when coverage begins:

Individuals eligible for premium-free Part A, who are not automatically enrolled, can enroll in Part A at any time after they are first eligible for the coverage.

Individuals who want premium Part A, Part B or both may only enroll during certain enrollment periods that are outlined in law. The following enrollment periods apply to both premium Part A and Part B:

Initial Enrollment Period
General Enrollment Period
Special Enrollment Period

Initial Enrollment Period (IEP)

The IEP is a 7-month period that begins 3 months before the month a person turns 65, their birthday month and ends 3 months after the person turns 65 (or 25th disability check), you'll have a 7-month window of time when you can sign up for Medicare. It's called your Initial Enrollment Period or IEP for short. Your IEP includes your 65th birthday month, the 3 months before and the 3 months after.

For further details please refer to THIS PAGE on cms.gov website

Example: You turn 65 on June 7. Your IEP is March 1 – September 30.

If, however, your birthday is on the 1st of the month, then your IEP is determined as though you were born the month before.

Example: You turn 65 on June 1. Your IEP is February 1 – August 31.

General Enrollment Period (GEP)

The General Enrollment Period (GEP) is the time period every year from January 1 to March 31 when you can enroll in Medicare Part B for the first time if you missed your Initial Enrollment Period (IEP).

Special Enrollment Period (SEP)

This means you can make changes to your Medicare Advantage and Medicare prescription drug coverage when certain events happen in your life, like if you move or you lose other insurance coverage. The likeliness to make changes are called Special Enrollment Periods (SEPs). Rules about when you can make changes and the type of changes you can make are different for each SEP. Coverage will begin the month after a person enrolls during their

Termination of Enrollment

Individuals qualified to premium-free Part A cannot voluntarily terminate their Part A coverage. This is not authorized by law. Generally, premium-free Part A ends due to:

Loss of entitlement to Social Security or Railroad Retirement Board benefits; or
Death.

There are Significant rules for when premium-free Part A ends for people with ESRD.

Premium Part A and Part B coverage can be voluntarily terminated because premium payments are required. Premium Part A and

Part B coverage ends due to:

Voluntary disenrollment request (coverage ends prospectively);
Failure to pay premiums
For individuals under age 65 (disabled and ESRD), loss of Part A entitlement (Part B terminates at the same time as Part A); or
Death.

Late Enrollment Penalty (LEP) for Part B

If an individual did not sign up for Part B when first eligible, the individual may have to pay a late enrollment penalty for as long as the individual has Medicare. The individual’s monthly premium for Part B may go up 10% for each full 12-month period that the individual could have had Part B but did not sign up for it.

For individuals enrolling using the SEP for the Working Aged and Working Disabled, the Part B LEP is calculated by adding the months that have elapsed between the close of the individual’s IEP and the end of the month in which the individual enrolls. For enrollments after your IEP has ended, months where you had group health plan coverage are excluded from the LEP calculation.

Original Medicare versus Medicare Advantage

Medicare Advantage plans offer the flexibility to use doctors in and out of network through their PPO plans and individuals do not have to pay any additional premium. On the other hand, individuals who choose to stay with Original Medicare have the option to self-insure for the 20% or buy a supplement plan to cover the 20% as well as purchase a mandatory Drug plan which will both incur a monthly premium and and prove to be more costly than a Medicare Advantage plan.

Things to consider when choosing between original Medicare and a Medicare Advantage plan for your health coverage.

Original Medicare - The traditional program offered directly through the federal government Includes Part A (inpatient/hospital coverage) and Part B (outpatient/medical coverage) Most doctors in the country take this insurance, Medicare limits how much an individual can be charged when they visit participating or non-participating providers Beneficiary receives a red, white, and blue card to show to providers when receiving care.

Medicare Advantage - Private plans that contract with the federal government to provide Medicare benefits Must provide the same benefits offered by Original Medicare, but may apply different rules, costs, and restrictions. May also offer certain benefits that Original Medicare does not cover Some of the most common types of plans are Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Private Fee-For-Service (PFFS) plans. Beneficiary shows the membership card from their plan when receiving care. If you sign up for Original Medicare and later decide you would like to try a Medicare Advantage Plan–or vice versa–be aware that there are only certain enrollment periods when you are allowed to make changes.

Doctor and Hospital Choice:

Original Medicare- You can go to any doctor or hospital that takes Medicare, anywhere in the U.S., also in most cases you do not need a referral to see a specialist.

Medicare advantage- In most cases, you can only use doctors and other providers who are in the plan’s network and service area (for non-emergency care), also you may typically need a referral to see a specialist.

Cost:

Original Medicare- For Part B-covered services, you usually pay 20% of the Medicare-approved amount after you meet your deductible. This amount is called your coinsurance.

You pay a premium (monthly payment) for Part B. If you choose to join a Medicare drug plan, you’ll pay a separate premium for your Medicare drug coverage (Part D).

There’s no yearly limit on what you pay out-of-pocket, unless you have supplemental coverage, like Medicare Supplement Insurance (Medigap).

You can get Medigap to help pay your remaining out-of-pocket costs (like your 20% coinsurance). Or, you can use coverage from a former employer or union, or Medicaid.

Medicare Advantage- Out-of-pocket costs vary, plans may have lower or higher out-of-pocket costs for certain services.

You pay the monthly Part B premium and may also have to pay the plan’s premium. Some plans may have a $0 premium and may help pay all or part of your Part B premium. Most plans include Medicare drug coverage (Part D).

Plans have a yearly limit on what you pay out of pocket for services Medicare Part A and Part B cover. Once you reach your plan’s limit, you’ll pay nothing for services Part A and Part B covers for the rest of the year.

You can’t buy and don’t need Medigap.

Coverage:

Original Medicare- covers most medically necessary services and supplies in hospitals, doctor offices, and other health care facilities. Original Medicare doesn’t cover some benefits like eye exams, most dental care, and routine exams.

You can join a respective Medicare drug plan to get Medicare drug coverage (Part D).

In most cases, you don’t have to get a service or supply approved ahead of time for Original Medicare to cover it.

Medicare Advantage - Plans must cover all medically necessary services that Original Medicare covers. Plans may also offer some extra benefits that Original Medicare doesn't cover - like vision, hearing, and dental services.

Medicare drug coverage (Part D) is included in most plans. In most types of Medicare Advantage Plans, you can't join a separate Medicare drug plan.

In many cases, you have to get a service or supply approved ahead of time for the plan to cover it.

Other Benefits:

Original Medicare - Does not cover vision, hearing, or dental services.

Medicare Advantage - May cover additional services, including vision, hearing, and/or dental (additional benefits may increase your premium and/or other out-of-pocket costs).