Table of Contents

Introduction to Medicare

Medicare has four parts:

  • Medicare Part A (hospital insurance) helps pay for inpatient care in a hospital or skilled nursing facility (following a hospital stay). Part A also pays for some home health care, and hospice care.

  • Medicare Part B (medical insurance) helps pay for services from doctors and other health care providers, outpatient care, home health care, durable medical equipment, and some preventive services.

  • Medicare Part C (Medicare Advantage plans) are available in many areas. People with Medicare Parts A and B can choose to receive all their health care services through a private insurance company approved by Medicare to provide this coverage.

  • Medicare Part D (Medicare prescription drug coverage) helps cover the cost of prescription drugs. You will need to sign up for a Part D plan in additional to Original Medicare (Parts A and B), or it may be included in the Part C (Medicare Advantage Plan) you choose. NOTE: Be sure to sign up for Part D as soon as you are eligible for Medicare. Signing up later could result in a penalty.

When do I need to sign up?

  • Initial enrollment period - 7 months long.
  • Starts 3 months before turning 65 and ends 3 months after turning 65.
  • NOTE: If missed, there is a penalty (higher premiums). Sign up even if you are still working and covered under a company insurance plan.

Can I change my coverage later?**

  • General enrollment period: Jan 1- Mar 31.
  • Medicare Advantage and Prescription Drug Plan Open Enrollment: October 15-December 7
  • Medicare Advantage Disenrollment Period: January 1 - February 14
  • Coverage starts in July if you didn't sign up when eligible.

What is included? What do I need to purchase?**

  • Select Original Medicare (Parts A and B) or a Medicare Advantage Plan (Part C)
  • Sign up for a Part D if you choose Original Medicare or if it’s not included in your Medicare Advantage Plan

What do I have to Pay?

Your Medicare costs will vary depending on a few different factors:

  • Years Worked (Less than or greater than 10 years)

    • Original Medicare * Part A: No premiums if you’ve worked more than 10 years contributing to Medicare taxes, but there are deductibles on each hospital stay. Monthly premium if you’ve worked less than 10 years. * Part B: Monthly premium * Co-Pays and Deductibles
      • Medicare Advantage Plan
        • Monthly premium (in addition to Part B premium)
          • Co-Pays and deductibles
      • Part D: Monthly premium
  • If you decide to purchase a Supplemental or Medigap Plan, there will be monthly premiums in addition to the Part B premiums

  • Premiums can be deducted from your Social Security checks or paid for out-of-pocket.

Link: Medicare Costs for 2017

Medicare 101 Videos:

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Part A and Part B (Original/Traditional Medicare):

When you become eligible to sign up for Medicare, the combination of Part A and Part B is considered “Original” or “Traditional” Medicare

Some people get Part A and Part B automatically:

  • If you’re already getting benefits from Social Security
  • If you’re already getting benefits from the Railroad Retirement Board (RRB)
  • If you’re under 65 and have a disability
  • If you have ALS (also called Lou Gehrig’s disease)
  • You live in Puerto Rico and get benefits from Social Security or the RRB - NOTE - you automatically get Part A but need to sign up for Part B
  • If you get Medicare automatically, you’ll get your red, white, and blue Medicare card 3 months before your 65th birthday or on your 25th month of disability

Some people need to sign up for Part A and Part B

  • If you are not getting Social Security benefits yet (i.e. you’re still working) NOTE - talk to a Medicare Advisor about how your current employer’s insurance works with Medicare. You will still want to sign up for Medicare when you become eligible to avoid higher premiums when you stop working.
  • If you qualify for Medicare because you have End-Stage Renal Disease (ESRD) prior to turning 65

Some situations can impact how and when you sign up

  • You have retiree coverage
  • You live outside the U.S.
  • You have coverage through the Health Insurance Marketplace
  • You have coverage through a Health Savings Account (HSA)
  • Go to Medicare.gov for detailed explanations regarding these special conditions.
  • Or, discuss these conditions with a licensed Medicare Advisor

How to sign up for Medicare:

  • Sign up online with Social Security
  • Visit your local Social Security Office
  • Call Social Security at 1-800-772-1213 (TTY: 1-800-325-0778)
  • If you worked for a railroad, call the RRB at 1-877-772-5772 *NOTE - You don’t need to sign up for Medicare each year. However, each year you’ll have a chance to review your coverage and change plans during the general enrollment period from January 1 to March 31.

If you want to drop Part B

  • If you were automatically enrolled in both Part A and Part B and sent a Medicare card, follow the instructions that come with the card, and send the card back. If you keep the card, you keep Part B and will pay Part B premiums.
  • If you signed up for Medicare through Social Security, contact Social Security
  • Learn more about whether you should get Part B
  • You must pay your Part B premium every month for as long as you have Part B (even if you don’t use it).
  • If your Medicare has started and you want to drop Part B, contact Social Security for instructions on how to submit a signed request. Your coverage will end the first day of the month after Social Security gets your request.
  • If you drop Part B, you generally won’t be able to enroll in Part B again until the next General Enrollment Period (January 1 – March 31st). Also, you may have to pay a late enrollment penalty.

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Part C (Medicare Advantage):

What is Part C or Medicare Advantage?

  • Medicare Part C combines Part A and Part B and sometimes includes Part D coverage. It works more like regular insurance and costs a monthly premium.
  • Unlike traditional Medicare, where you can see any physician who accepts Medicare, you stay within the Medicare Advantage Plan's network of doctors and hospitals (like regular insurance). You can't go to just ANY Medicare provider. You must go with ones that are within your plan's network.
  • Medicare Advantage plans require co-pays and deductibles that may be lower than traditional Part A/B Medicare. Some plans may also include extras like Vision and Dental, which are not covered by traditional Medicare.
  • NOTE - you will still pay a monthly premium to Medicare and a monthly premium to your Advantage Plan provider

What are the different types of Medicare Advantage Plans?

  • Health Maintenance Organization (HMO) Plans
    • In most HMO Plans, you can only go to doctors, other health care providers, or hospitals on the plan's list except in an emergency.
      • In most cases, prescription drugs are covered in HMO Plans. Ask the plan. If you want Medicare prescription drug coverage (Part D), you must join an HMO Plan that offers prescription drug coverage.
      • In most cases, you need to choose a primary care doctor in HMO Plans.
      • In most cases, you have to get a referral to see a specialist in HMO Plans. Certain services, like yearly mammogram screenings, don't require a referral.
      • If your doctor or other health care provider leaves the plan, your plan will notify you. You can choose another doctor in the plan.
      • If you receive care from a doctor or facility outside the plan's network, you may have to pay the full cost.
      • It's important that you follow the plan's rules, like getting prior approval for a certain service when needed.

Preferred Provider Organization (PPO) Plans

  • A Medicare PPO Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. In a PPO Plan, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan's network. You pay more if you use doctors, hospitals, and providers outside of the network.
  • In most cases, you can get your health care from any doctor, other health care provider, or hospital in PPO Plans. PPO Plans have network doctors, other health care providers, and hospitals.
  • Each plan gives you flexibility to go to doctors, specialists, or hospitals that aren't on the plan's list, but it will usually cost more.
  • In most cases, prescription drugs are covered in PPO Plans. Ask the plan. If you want Medicare drug coverage, you must join a PPO Plan that offers prescription drug coverage. Remember, if you join a PPO Plan that doesn't offer prescription drug coverage, you can't join a Medicare Prescription Drug Plan (Part D).
  • You don't need to choose a primary care doctor in PPO Plans.
  • In most cases, you don't have to get a referral to see a specialist in PPO Plans. If you use plan specialists, your costs for covered services will usually be lower than if you use non-plan specialists.
  • A PPO Plan isn't the same as Original Medicare or a Medicare Supplement Insurance (Medigap) policy.
  • PPO Plans usually offer extra benefits than Original Medicare, but you may have to pay extra for these benefits.

Private Fee-for-Service (PFFS) Plans

  • A Medicare PFFS Plan is a type of Medicare Advantage Plan (Part C) offered by a private insurance company. PFFS plans aren’t the same as Original Medicare or Medigap. The plan determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care.
  • In some cases, you get your health care from any doctor, other health care provider, or hospital in PFFS Plans.
  • You can go to any Medicare-approved doctor, other health care provider, or hospital that accepts the plan's payment terms and agrees to treat you. Not all providers will.
  • If you join a PFFS Plan that has a network, you can also see any of the network providers who have agreed to always treat plan members, even if you’ve never seen them before. You can also choose an out-of-network doctor, hospital, or other provider, who accepts the plan's terms, but you may pay more.
  • Prescription drugs may be covered in PFFS Plans. If your PFFS Plan doesn't offer drug coverage, you can join a Medicare Prescription Drug Plan to get coverage.
  • You don't need to choose a primary care doctor in PFFS Plans.
  • You don't have to get a referral to see a specialist in PFFS Plans.
  • Out-of-network doctors, hospitals, and other providers may decide not to treat you even if you’ve seen them before.
  • For each service you get, make sure your doctors, hospitals, and other providers agree to treat you under the plan, and accept the plan’s payment terms.
  • In an emergency: doctors, hospitals, and other providers must treat you.
  • Show your plan membership ID card each time you visit a health care provider. Your provider can choose at every visit whether to accept your plan’s terms and conditions of payment.
  • You can’t use your red, white, and blue Medicare card to get heath care because Original Medicare won’t pay for your health care while you’re in the Medicare PFFS Plan.
  • Keep your Medicare card in a safe place in case you return to Original Medicare in the future.
  • You only need to pay the copayment or coinsurance amount allowed by the plan for the type(s) of service you get at the time of service.

Special Needs Plans (SNPs)

  • Medicare SNPs are a type of Medicare Advantage Plan (like an HMO or PPO). Medicare SNPs limit membership to people with specific diseases or characteristics. Medicare SNPs tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve.
  • Generally, you must get your care and services from doctors or hospitals in the Medicare SNP network, except:
    • Emergency or urgent care, like care you get for a sudden illness or injury that needs medical care right away
      • If you have End-Stage Renal Disease (ESRD) and need out-of-area dialysis
  • Medicare SNPs typically have specialists in the diseases or conditions that affect their members.
  • All SNPs must provide Medicare prescription drug coverage.
  • In most cases, SNPs may require you to have a primary care doctor, or the plan may require you to have a care coordinator to help with your health care.
  • In most cases, you have to get a referral to see a specialist in SNPs. Certain services, like yearly screening mammograms or an in-network pap test and pelvic exam (covered at least every other year), don't require a referral.
  • A plan must limit membership to these groups: 1) people who live in certain institutions (like a nursing home) or who require nursing care at home, or 2) people who are eligible for both Medicare and Medicaid, or 3) people who have specific chronic or disabling conditions (like diabetes, End-Stage Renal Disease (ESRD), HIV/AIDS, chronic heart failure, or dementia). Plans may further limit membership. You can join a SNP at any time.
  • Plans should coordinate the services and providers you need to help you stay healthy and follow doctor’s or other health care provider’s orders.
  • If you have Medicare and Medicaid, your plan should make sure that all of the plan doctors or other health care providers you use accept Medicaid.
  • If you live in an institution, make sure that plan providers serve people where you live. Find out more about where SNPs are offered.

Who can join a Medicare SNP?

You can join a Medicare SNP if you meet these requirements:

  • You have Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance).

  • You live in the plan's service area.

  • You meet the plan's eligibility requirements, like one of these:

    • Chronic Condition SNP (C-SNP): You have one or more of these severe or disabling chronic conditions: * Chronic alcohol and other dependence * Autoimmune disorders * Cancer (excluding pre-cancer conditions) * Cardiovascular disorders * Chronic heart failure * Dementia * Diabetes mellitus * End-stage liver disease * End-Stage Renal Disease (ESRD) requiring dialysis (any mode of dialysis) * Severe hematologic disorders * HIV/AIDS * Chronic lung disorders * Chronic and disabling mental health conditions * Neurologic disorders * Stroke
      • Institutional SNP (I-SNP): You live in an institution (like a nursing home), or you require nursing care at home.
      • Dual Eligible SNP (D-SNP): You have both Medicare and Medicaid.
  • Each Medicare SNP limits its membership to people in one of these groups, or a subset of one of these groups. For example, a Medicare SNP may be designed to serve only people diagnosed with congestive heart failure might include access to a network of providers who specialize in treating congestive heart failure. It would also feature clinical case management programs designed to serve the special needs of people with this condition. The plan's drug formulary would be designed to cover the drugs usually used to treat congestive heart failure. People who join this plan would get benefits specially tailored to their condition, and have all their care coordinated through the Medicare SNP.

Are Prescription Drugs (Part D) Covered in Medicare Advantage Plans?

  • Health Maintenance Organization (HMO) Plans: In most cases, prescription drugs are covered in HMO Plans. Ask the plan. If you want Medicare prescription drug coverage (Part D), you must join an HMO Plan that offers prescription drug coverage.
  • Preferred Provider Organization (PPO) Plans: In most cases, prescription drugs are covered in PPO Plans. Ask the plan. If you want Medicare drug coverage, you must join a PPO Plan that offers prescription drug coverage. Remember, if you join a PPO Plan that doesn't offer prescription drug coverage, you can't join a Medicare Prescription Drug Plan (Part D). Double check this statement with an expert
  • Private Fee-for-Service (PFFS) Plans: Prescription drugs may be covered in PFFS Plans. If your PFFS Plan doesn't offer drug coverage, you can join a Medicare Prescription Drug Plan to get coverage.
  • Special Needs Plans (SNPs): All SNPs must provide Medicare prescription drug coverage.

Choosing Doctors and Getting Referrals for Specialists with Medicare Advantage

  • Health Maintenance Organization (HMO) Plans: In most cases, you need to choose a primary care doctor in HMO Plans. You also need to get a referral to see a specialist. Some services, like yearly mammogram screenings, don’t require a referral.
  • Preferred Provider Organization (PPO) Plans: You don’t need to choose a primary care doctor and, in most cases, do not need to get a referral to see a specialist. In plan specialists will be less expensive than non-plan specialists.
  • Private Fee-for-Service (PFFS) Plans: You don’t need to choose a primary care doctor or get a referral to see a specialist in PFFS Plans. Keep in mind, you’ll want to verify that the services you need will be paid for by the provider you choose.
  • Special Needs Plans (SNPs): In most cases, SNPs may require you to have a primary care doctor, or the plan may require you to have a care coordinator to help with your health care. You may also need to get a referral to see a specialist in SNPs. Certain services, like yearly screening mammograms or an in-network pap test and pelvic exam (covered at least every other year), don't require a referral.

Where can I find a Medicare Advantage Plan?

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Part D (Prescription Drug Coverage):

Do I need to get Part D?

  • Medicare Part D can help offset the costs of prescription medications. Even if you are not currently taking medication, you may need prescriptions at a later time.
  • Medicare offers prescription drug coverage to everyone with Medicare. If you decide not to get Medicare drug coverage when you're first eligible, you'll likely pay a late enrollment penalty unless one of these applies:
    • You have other creditable prescription drug coverage
      • You get Extra Help
        • If you meet certain income and resource limits, you may qualify for Extra Help from Medicare to pay the costs of Medicare prescription drug coverage.
          • Other people pay only a portion of their Medicare drug plan premiums and deductibles based on their income level.
          • If you don't qualify for Extra Help, your state may have programs that can help pay your prescription drug costs. Contact your Medicaid office or your State Health Insurance Assistance Program (SHIP) for more information. Remember, you can reapply for Extra Help at any time if your income and resources change.
          • You automatically qualify for Extra Help if you have Medicare and meet any of these conditions:
            • Have full Medicaid coverage
              • Get help from your state Medicaid program paying your Part B premiums (in a Medicare Savings Program)
              • Get Supplemental Security Income (SSI) benefits
          • Even if you automatically qualify this year, you may not qualify for Extra Help next year. Changes in your income or resources may cause you no longer to qualify for one of the programs listed above. You’ll get a “Loss of Deemed Status Notice” (on grey paper) by the end of September if you no longer automatically qualify. Even if you get this notice, you may still qualify, but you need to apply to find out.
          • If your co-payment amounts change for the upcoming year, you'll get a notice (on orange paper) in the mail in early October with the new amounts.
          • If you don't get a notice from Medicare, you'll get the same level of Extra Help that you got for last year.
          • Make sure you’re paying the right amount
            • If you’re not sure if you're paying the right amount, call your drug plan. Your plan may ask you to give information to help them check the level of Extra Help you should get.
              • If you paid for prescriptions since you qualified for Extra Help, and you aren't enrolled in a Medicare drug plan, you may be able to get some money back. Keep your receipts, and call your plan. Or, you can contact Medicare's Limited Income Newly Eligible Transition (NET) Program at 1-800-783-1307 for more information (TTY: 711).
          • To apply for Extra Help, go to the Medicare website.
  • To get Medicare drug coverage, you must join a plan run by an insurance company or other private company approved by Medicare. Each plan can vary in cost and drugs covered.
  • Other ways to save on prescription drug costs:

How do I get Part D?

  • Medicare Prescription Drug Plan (Part D). These plans (sometimes called "PDPs") add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.
  • Medicare Advantage Plan (Part C) (like an HMO or PPO) or other Medicare health plan that offers Medicare prescription drug coverage. You get all of your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PDs.” You must have Part A and Part B to join a Medicare Advantage Plan.
  • Once you choose a Medicare drug plan, here's how you may be able to join:
    • Enroll on the Medicare Plan Finder or on the plan's website.
      • Complete a paper enrollment form.
      • Call the plan.
      • Call 1-800-MEDICARE (1-800-633-4227).
  • When you join a Medicare drug plan, you'll give your Medicare number and the date your Part A and/or Part B coverage started. This information is on your Medicare card.
  • Find a Medicare drug plan.

What does Part D Cost?

  • You'll make these payments throughout the year in a Medicare drug plan:
    • Monthly Premium
      • Yearly deductible
      • Co-payments or coinsurance
      • Costs in the coverage gap
      • Costs if you get Extra Help
      • Costs if you pay a late enrollment penalty
  • Your actual drug plan costs will vary depending on:
    • The drugs you use
      • The plan you choose
      • Whether you go to a pharmacy in your plan's network
      • Whether the drugs you use are on your plan's formulary
      • Whether you get Extra Help paying your Medicare Part D costs
  • Look for specific Medicare drug plan costs at https://www.medicare.gov/find-a-plan/questions/home.aspx, and then call the plans you're interested in to get more details.
  • If you have limited income and resources, your state may help you pay for Part A and/or Part B. You may also qualify for Extra Help to pay for your Medicare prescription drug coverage. (See “Do I Need to Get Part D?”)

Can I change my drug plan later?

  • You can switch to a new Medicare Prescription Drug Plan (Part D) simply by joining another drug plan during the open enrollment period for Medicare Advantage and Prescription Drug Plans from October 15-December 7.
  • You don’t need to sign up for Medicare each year. However, each year you’ll have a chance to review your coverage and change plans if you need to
  • NOTE - You don't need to cancel your old Medicare drug plan. Your old Medicare drug plan coverage will end when your new drug plan begins.
  • If you want to join a plan or switch plans, do so as soon as possible so you’ll have your membership card when your coverage begins, and you can get your prescriptions filled without delay. You should get a letter from your new Medicare drug plan telling you when your coverage begins.
  • Don't give personal information to plans that call you unless you're already a member of the plan.

What if I want to drop my drug plan?

  • If you want to drop your Medicare Prescription Drug Plan (Part D) and you don't want to join a new plan, you can do so during the Open Enrollment Period. The Open Enrollment Period is between October 15–December 7 each year. The change goes into effect January 1 of the following year.
  • To disenroll from a Medicare Prescription Drug Plan during Open Enrollment, you can do one of the following:
    • Call 1-800-MEDICARE (1-800-633-4227).
      • Mail or fax a signed written notice to the plan telling them you want to disenroll.
      • Submit a request to the plan online, if they offer this option.
      • Call the plan and ask them to send you a disenrollment notice. You’ll have to complete, sign and send the notice back to the plan.
  • You can’t drop your Medicare drug plan outside the Open Enrollment Period unless you meet certain special circumstances, such as:
    • Changing where you live to an area where the plan’s coverage is different or no longer available; moving back to the U.S. after living out of the country, moving into or out of an institution (such as a skilled nursing facility or long-term-care hospital), or are released from jail.
      • Losing your current coverage due to leaving an employer or union, coverage no longer being creditable, leaving a Medicare Cost Plan, dropping coverage from an All-Inclusive Care for the Elderly (PACE) Plan, no longer being eligible for Medicaid.
      • Your plan changes its contract with Medicare
      • You’re eligible for Medicare and Medicaid
      • You Qualify for Extra Help (see “Do I need Part D?)
      • You have a severe or disabling condition, and there’s a Medicare Chronic Care Special Needs Plan (SNP) available that serves people with my condition.
      • You received improper advisement from a federal employee regarding your coverage or loss of coverage
      • NOTE - If you now get drug coverage from an employer/union or other group health plan, make sure your coverage is creditable prescription drug coverage. You’ll get a notice of creditable coverage each year letting you know whether or not your drug coverage is “creditable.” Also, you can call your employer and ask if your drug coverage is creditable. They’re required to tell you or send you a letter with the information.
      • NOTE - If you go 63 days or more in a row without other creditable prescription drug coverage and then want to rejoin a Medicare Prescription Drug Plan later on:
        • You’ll have to wait for an enrollment period to sign up for coverage. However, you have a Special Enrollment Period which lasts from when you have drug coverage from an employer/union or other group health plan coverage to up to 2 months after that coverage ends.
          • You may have to pay a late enrollment penalty.

What if I have a Medicare Advantage Plan?

  • Your Medicare Advantage Plan (Part C) will disenroll you and you'll go back to Original Medicare if both of these apply:
    • Your Medicare Advantage Plan includes prescription drug coverage.
      • You join a Medicare Prescription Drug Plan (Part D).
  • Always check with your Medicare Advantage Plan provider prior to signing up for Part D coverage.

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