Original Medicare covers many health care services and supplies, but there are many costs (“gaps”) it doesn’t cover. There are several health care coverage plans that can help you pay for certain services above and beyond Original Medicare. These health care plans work with the benefits you have from Original Medicare. In most of these plans, there are generally extra benefits and lower co-payments than in Original Medicare. However, a person may have to see doctors that belong to the plan or go to certain hospitals to get services. A person can switch plans each year in the fall, if desired.

What you choose will affect how much you pay, what benefits you have, which doctors you can see, and other things that may be important to you.

Your main options for getting extra coverage beyond Original Medicare are:

– Medicare Advantage Plans: Provided by private insurance companies as a replacement of Part A and Part B. Often provide additional benefits above and beyond Original Medicare and Prescription Drug coverage.
– Medicare Supplement Plans (also known as “Med Supp” or “Medigap”): Provided by private insurance companies as an addition to Part A and Part B. Fills the “gaps” in Original Medicare plan coverage. Do not include Prescription Drug Coverage.
– Medicare Prescription Drug Plans (Part D): Insurance that covers both brand-name and generic prescription drugs at participating pharmacies in your area. Provides protection for people who have very high drug costs or from unexpected prescription drug bills in the future.

What to Consider When Choosing or Changing Your Coverage

Coverage: When choosing between Original Medicare and a Medicare health plan, does the plan provide extra coverage you want that Original Medicare doesn’t cover?

Your other coverage: Do you have, or are you eligible for, other types of health or prescription drug coverage? If so, read the materials you get from your insurer or plan, or call them to find out how the coverage works with, or is affected by, Medicare. If you have coverage through a former or current employer or union, talk to your benefits administrator, insurer, or plan before making any changes to your coverage.

Cost: How much are your premiums and deductibles? How much do you pay for services like hospital stays or doctor visits? Your costs vary and may be different if you don’t follow the coverage rules.

Doctor and hospital choice: Do your doctors accept the coverage? Are they accepting new patients? If you are considering a Medicare health plan, do you have to choose your hospital and health care providers from a network? Do you need a referral to see a specialist?

Prescription drugs: What are your drug needs? Do you need to join a Medicare drug plan? What will your prescription drugs cost under each plan? Are your drugs covered under the plan’s formulary (drug list)? Formularies can change.

Quality of care: The quality of care and services given by plans and other health care providers can vary. Medicare has information to help you compare plans and providers.

Convenience: Where are the doctors’ offices? What are their hours? Which pharmacies can you use? Can you get your prescriptions by mail?

Travel: Do you spend part of each year in another state? Will the plan cover you there?

How to Decide Which Plans are Best for You

How do I Enroll in Medicare?

Enrollment in Original Medicare is automatic for a person who is turning 65 and who is already getting Social Security benefits, or who will start getting them at age 65. A Medicare card will be mailed out about three months before the 65th birthday. If a person isn’t getting Social Security benefits when he or she turns age 65, the person will have to sign up for Medicare.

Automatic enrollment includes Part A and Part B. If people don’t want Part B, they should follow the instructions that come with the card, and send the card back. If they keep the card, they keep Part B.

Enrollment is also automatic for a person who has been entitled to Social Security disability benefits for at least 24 months. A Medicare card is mailed out about 3 months before the 25th month of disability benefits.

A person with amyotrophic lateral sclerosis (also known as Lou Gehrig’s disease) will get a Medicare card about 4 weeks after qualifying for Medicare. A person with end-stage renal disease, or ESRD, does not need to be receiving Social Security disability benefits to qualify for Medicare, and may still be working.

The Centers for Medicare and Medicaid Services (CMS) administers Medicare, but the Social Security Administration (SSA) is responsible for enrolling most people in Medicare. The Railroad Retirement board is responsible for enrolling railroad retirees. For questions about Medicare enrollment, or to apply for Medicare benefits, call SSA at 1-800-772-1213, or go to http://www.ssa.gov to find out more.

The Medicare card looks like the red, white, and blue card shown here. Your Medicare card is your proof that you have Medicare insurance.

When to Enroll in Medicare:

Original Medicare
When should I apply?

If you are already getting Social Security retirement or disability benefits or railroad retirement checks, you will be contacted a few months before you become eligible for Medicare and given the information you need. You will be enrolled in Medicare Parts A and B automatically. However, because you must pay a premium for Part B coverage, you have the option of turning it down.

If you are not already getting retirement benefits, you should contact the Centers for Medicare & Medicaid Services (CMS). about three months before your 65th birthday to sign up for Medicare. You can sign up for Medicare even if you do not plan to retire at age 65.

Once you are enrolled in Medicare, you will receive a red, white and blue Medicare card showing whether you have Part A, Part B or both. Keep your card in a safe place so you will have it when you need it. If your card is ever lost or stolen, you can apply for a replacement card or call Social Security’s toll-free number. You will also receive a Medicare & You (Publication No. CMS-10050) handbook that describes your Medicare benefits and Medicare plan choices.

Special enrollment situations

You also should contact Social Security about applying for Medicare if:

– You are a disabled widow or widower between age 50 and age 65, but have not applied for disability benefits because you are already getting another kind of Social Security benefit;
– You are a government employee and became disabled before age 65;
– You, your spouse or your dependent child has permanent kidney failure;
– You had Medicare medical insurance in the past but dropped the coverage; or
– You turned down Medicare medical insurance when you became entitled to hospital insurance (Part A).

Initial enrollment period for Part B

When you first become eligible for hospital insurance (Part A), you have a seven-month period (your initial enrollment period) in which to sign up for medical insurance (Part B). A delay on your part will cause a delay in coverage and result in higher premiums. If you are eligible at age 65, your initial enrollment period begins three months before your 65th birthday, includes the month you turn age 65 and ends three months after that birthday. If you are eligible for Medicare based on disability or permanent kidney failure, your initial enrollment period depends on the date your disability or treatment began.

When does my enrollment in Part B become effective?

If you accept the automatic enrollment in Medicare Part B, or if you enroll in Medicare Part B during the first three months of your initial enrollment period, your medical insurance protection will start with the month you are first eligible. If you enroll during the last four months, your protection will start from one to three months after you enroll.

The following chart shows when your Medicare Part B becomes effective:

General enrollment period for Part B

If you do not enroll in Medicare Part B during your initial enrollment period, you have another chance each year to sign up during a “general enrollment period” from January 1 through March 31. Your coverage begins the following July. However, your monthly premium increases 10 percent for each 12-month period you were eligible for, but did not enroll in, Medicare Part B.

Special enrollment period for people covered under an employer group health plan

If you are 65 or older and are covered under a group health plan, either from your own or your spouse’s current employment, you have a “special enrollment period” in which to sign up for Medicare Part B. This means that you may delay enrolling in Medicare Part B without having to wait for a general enrollment period and paying the 10 percent premium surcharge for late enrollment. The rules allow you to:

– Enroll in Medicare Part B any time while you are covered under the group health plan based on current employment; or
– Enroll in Medicare Part B during the eight-month period that begins with the month your group health coverage ends, or the month employment ends-whichever comes first.
– Special enrollment period rules do not apply if employment or employer-provided group health plan coverage ends during your initial enrollment period.
– If you do not enroll by the end of the eight-month period, you will have to wait until the next general enrollment period, which begins January 1 of the next year. You also may have to pay a higher premium, as described in General enrollment period for Part B.

People who receive Social Security disability benefits and are covered under a group health plan from either their own or a family member’s current employment also have a special enrollment period and premium rights that are similar to those for workers age 65 or older.

Medicare Advantage Plans
You can join, switch, or drop a Medicare Advantage Plan at these times:

– When you first become eligible for Medicare (3 months before you turn age 65 to 3 months after the month you turn age 65).
– If you get Medicare due to a disability, you can join during the 3 months before to 3 months after your 25th month of disability.
– Between November 15-December 31 each year. Your coverage will begin on January 1 of the following year.
– Between January 1-March 31 of each year. However, you can’t join or switch to a plan with prescription drug coverage during this time unless you already have Medicare prescription drug coverage (Part D).
– You also can’t drop a plan with prescription drug coverage or join, switch, or drop a Medicare Medical Savings Account Plan during this period.

In most cases, you must stay enrolled for that calendar year starting the date your coverage begins. However, in certain situations, you may be able to join, switch, or drop a Medicare Advantage Plan at other times. Some of these situations include the following:

– If you move out of your plan’s service area
– If you have both Medicare and Medicaid
– If you qualify for “extra help”
– If you live in an institution

Medicare Prescription Drug Plans
You can join, switch, or drop a Medicare drug plan at these times:

– When you first become eligible for Medicare.
– Between November 15-December 31 each year. Your coverage will begin on January 1 of the following year.

In most cases, you must stay enrolled for that calendar year starting the date your coverage begins. However, in certain situations, you may be able to join, switch, or drop Medicare drug plans during a special enrollment period (like if you move out of the service area, lose other creditable prescription drug coverage, live in an institution, or qualify for “extra help”).

You will be charged a late enrollment penalty (an amount that is added to your Part D premium for as long as you have Medicare drug coverage) if all of the following are true:

– You don’t join a Medicare drug plan when you’re first eligible.
– You don’t have other creditable prescription drug coverage.
– You later decide to join a Medicare drug plan.

Medicare Supplement Plans
The best time to buy a Medicare Supplement policy is during the 6-month period that begins on the first day of the month in which you are both age 65 or older and enrolled in Part B. (Some states have additional open enrollment periods.) After this initial enrollment period, your option to buy a Medicare Supplement policy may be limited.

During the open enrollment period, an insurance company can’t use medical underwriting. This means the insurance company can’t do any of the following:

– Refuse to sell you any Medicare Supplement policy it sells
– Make you wait for coverage to start (except as explained below)
– Charge you more for a Medicare Supplement policy because of your health problems
While the insurance company can’t make you wait for your coverage to start, it may be able to make you wait for coverage of a pre-existing condition. A pre-existing condition is a health problem you have before the date a new insurance policy starts. In some cases, the Medicare Supplement insurance company can refuse to cover your out-of-pocket costs for these pre-existing health problems for up to 6 months. This is called a “pre-existing condition waiting period.” Coverage for a pre-existing condition can only be excluded in a Medicare Supplement policy if the condition was treated or diagnosed within 6 months before the date the coverage starts under the Medicare Supplement policy. (Remember, for Medicare-covered services, Original Medicare will still cover the condition, even if the Medicare Supplement policy won’t cover your out-of-pocket costs.)

Even if you have a pre-existing condition, if you buy a Medicare Supplement policy during your Medicare Supplement open enrollment period and if you recently had certain kinds of health coverage called “creditable coverage,” it is possible to avoid or shorten waiting periods for pre-existing conditions. Prior creditable coverage is generally any other health coverage you recently had before applying for a Medicare Supplement policy. If you have had at least 6 months of prior creditable coverage, the insurance company can’t make you wait before it covers your pre-existing conditions. There are many types of health care coverage that may count as creditable coverage for Medicare Supplement policies, but they will only count if you didn’t have a break in coverage for more than 63 days.

If there was any time that you had no health coverage of any kind and were without coverage for more than 63 days, you can only count creditable coverage you had after that break in coverage. Talk to your Medicare Supplement insurance company. It will be able to tell you if your previous coverage will count as creditable coverage for this purpose. If you buy a Medicare Supplement policy when you have a guaranteed issue right (also called “Medicare Supplement protection”), the insurance company can’t use a pre-existing condition waiting period at all.

Note: You can send in your application for a Medicare Supplement policy before your Medicare Supplement open enrollment period starts. This may be important if you currently have coverage that will end when you turn age 65. This will allow you to have continuous coverage

While we specialize in Medicare Supplements, you can CLICK HERE to explore options for dental coverage options.

Medicare Part A Gaps

Medicare Part A (also known as Hospital Insurance) covers inpatient hospital, inpatient skilled nursing facility, home health, and hospice services. The following is a partial list of gaps in coverage that are not reimbursed by Medicare:

– Hospital deductible per spell of illness ($1156 for 2012);
– Hospital coinsurance payments (Medicare covers the first 60 days in full after the deductible has been met; the daily coinsurance payment for days 61 to 90 is $289 per day in 2012 and for days 91 + over, $578);
– Hospital services beyond 150 days per spell of illness;
– Skilled nursing facility coinsurance payments (Medicare covers the first 20 days in full; the daily coinsurance payment for days 21 to 100 is $144.50 per day in 2012);
– Skilled nursing facility services beyond 100 days per spell of illness;
– Home health aide services that are provided on more than a part-time or intermittent basis;
– Home health nursing and aide services when there is no longer a skilled care component;

Medicare Part B Gaps

Medicare Part B (also known as Supplementary Medicare Insurance) provides coverage for a variety of outpatient and physician services. It also pays for durable medical equipment, prosthetic devices, supplies incident to physician’s services, and ambulance transportation. The following is a list of gaps in coverage that are not reimbursed by Medicare:

– Part B deductible (an annual deductible – $140 in 2012- must be met before Medicare will make payment for covered services);
– Part B 20% coinsurance payment (Medicare pays 80% of the approved charge for all Part B services and items, an amount that varies according to the services and items provided);
– Balance billing above the Medicare-approved charge (many physicians and providers charge more than the amount Medicare approves);

WHO NEEDS MEDICARE SUPPLEMENT INSURANCE

Medicare beneficiaries fill in Medicare’s coverage gaps in a number of different ways, including:

– Government Programs (Medicaid/QMB/SLMB);
– Group Retirement Policies (Non-Standardized);
– Non-Standardized Individual Medigap Policies (Issued Prior to July 31, 1992);
– Standardized Individual Medigap Policies (Issued After July 31, 1992).

You can find information on all Medicare Preventive Services by clicking HERE.

You can find Your Guide to Medicare’s Preventive Services by clicking HERE.