Original Medicare
HEALTH INSURANCE FOR SENIORS AND THE DISABLED.
Medicare is oftentimes confused with Medicaid but they are very different. It was originally designed to provide coverage to people on Social Security. Medicare Parts A & B are included in Original Medicare, they provide coverage for inpatient & outpatient benefits, respectively.
Medicare Part A (Hospital Insurance) helps to pay for hospitals, hospice, home health care and skilled nursing facility.
Medicare Part B (Medical Insurance) helps to pay for physician, diagnostic, preventive & outpatient services.
Medicare Part C (Medicare Advantage) covers all services that Original Medicare covers and it stands in place of Original Medicare. These plans offer extra coverages like vision, dental and hearing.
Medicare Part D (Prescription Drug Coverage) are stand-alone or Medicare Advantage Prescription Drug plans sold by insurance carriers contracted with Medicare.
When To Enroll In Medicare
If you are already receiving benefits from the Social Security Administration (SSA) or the Railroad Retirement Board (RRB), you will automatically get Medicare Part A and Medicare Part B beginning the first day of the month you turn 65.
Enrolling in medicare at 65
If you are close to 65 and not yet receiving Social Security or Railroad Retirement Benefits you will have to enroll during your Medicare Initial Enrollment Period (IEP). You may contact Social Security during the 7-month window that includes your 65th birthday month, the 3 months before and the 3 months after. If you worked for a railroad remember to contact the RRB.
Missing The Initial Enrollment Period
If you don’t enroll in Medicare when first eligible, and you don’t qualify for a Special Enrollment Period (SEP), you can sign up during the General Enrollment Period (GEP). The General Enrollment Period is spans from January 1-March 31 each year. Your coverage will not start until July 1.
Choices for Medicare-eligible individuals
currently in a Employer group health plan
Medicare When Working Past Age 65
If you plan to keep working, you still have a 7-month Initial Enrollment Period (IEP) when you turn 65. If you qualify to delay both Medicare Parts A & B, you can do so without penalty as long as you enroll within 8-months of either losing your or your spouse’s employer group health coverage. Enroll during the 8-month Special Enrollment Period (SEP) and provide proof of creditable prescription drug coverage to avoid a Part D penalty.
Having Creditable Drug Coverage
Before you delay Medicare be sure that you have creditable prescription drug coverage. Your or your spouse’s employer group health coverage must be as good as the standard Medicare Part D plan coverage. If your employer’s drug coverage isn’t creditable, you will need to enroll in a plan during your Initial Enrollment Period (IEP) to avoid a Part D penalty.
Frequently Asked Questions (FAQ)
Original Medicare Coverage FAQ
What is Original Medicare?
Original Medicare consists of Medicare Part A (hospital coverage) and Medicare Part B (medical coverage). It’s a federal health insurance program for individuals 65 or older; under 65 who have a qualifying disability; and of any age with a diagnosis of End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS, also called Lou Gehrig’s disease).
What is Original Medicare Part A?
Original Medicare Part A is hospital coverage. It helps pay for hospital stays and inpatient care in hospitals.
What is Original Medicare Part B?
Original Medicare Part B is medical coverage. It helps pay for doctor visits and outpatient care.
Is Medicare the same as Medicaid?
No. Medicare and Medicaid are both government programs that help people pay for health care, but they are not the same thing.
Medicare is a federal program that provides health care coverage for people who are 65 or older or have certain qualifying disabilities.
Medicaid is a joint state and federal program that provides health care coverage for individuals and families with limited incomes. “Dual eligibility” means you qualify for both Medicare and Medicaid.
Can I get my prescription drugs covered under Original Medicare?
No. Original Medicare doesn’t cover prescription drugs. Part A may cover some drugs you get as an inpatient. Otherwise, prescription drug coverage, also known as Medicare Part D, is available separately through private insurance companies approved by Medicare. You can get prescription drug coverage either through a stand-alone Part D plan (PDP) or a Medicare Advantage plan (MAPD) that includes prescription drug benefits.
Does Original Medicare cover vision, dental, or hearing care?
Generally, no. Original Medicare doesn’t cover routine vision or dental care, eyeglasses, or hearing aids. Part B may cover some dental or vision services if you meet certain conditions and they are considered medically necessary, but you’ll have to check with your health care provider and Medicare first. Many Medicare Advantage (Part C) plans, however, do offer these benefits. Be sure to compare the benefits of all plan options to find the coverage that best fits your needs.
Does Original Medicare pay for a nursing home stay?
Original Medicare Part A pays for some skilled nursing services, but doesn’t cover long-term or custodial care (daily life activities like eating and bathing). You’d also still be responsible for a portion of the costs, such as deductibles, copays and coinsurance.
Medicare Advantage FAQ
What is a Medicare Advantage plan?
Medicare Advantage plans (Part C) can combine Parts A, B, and D in a single plan. All Medicare Advantage plans include:
- All the benefits and coverage of Medicare Part A
- All the benefits and coverage of Medicare Part B
Plus, Medicare Advantage plans can include:
- Prescription drug coverage (Part D)
- Routine vision, dental, and hearing coverage
- Fitness benefits and wellness programs
- And more
Not all plans are available in all locations. Find out which plans are available where you live.
What’s the difference between a Medicare Advantage plan and a Medicare Supplement plan?
Medicare Advantage and Medicare Supplement plans are very different, and you can’t have both at the same time.
A Medicare Advantage (Part C) plan combines Part A, Part B, and often Part D (prescription drug) coverage into one plan. These plans may also include additional benefits, such as hearing, vision, dental, and fitness. Medicare Advantage plans also have an annual limit on out-of-pocket costs on covered services.
A Medicare Supplement (Medigap) plan helps with some of the out-of-pocket costs that Original Medicare doesn’t pay, like coinsurance and copayments.
Do Medicare Advantage plans have vision (eye care) benefits?
Most Medicare Advantage (Part C) plans offer routine vision care, such as eye exams, eyeglasses, and corrective lenses. Original Medicare (Parts A and B) alone doesn’t cover routine vision care.
Do Medicare Advantage plans have dental care benefits?
Most Medicare Advantage (Part C) plans offer routine dental care, such as dental exams. Original Medicare (Parts A and B) alone doesn’t cover routine dental care.
Do Medicare Advantage plans have hearing benefits?
Most Medicare Advantage (Part C) plans offer hearing care, such as hearing tests and hearing aids. Original Medicare (Parts A and B) alone doesn’t cover routine hearing care.
Prescription Drug (Part D) FAQ
What is a Medicare Part D plan?
Medicare Part D is prescription drug coverage. Medicare Part D plans (PDP) help pay for medications prescribed by a doctor. Part D plans are offered by private insurance companies approved by Medicare. The types of drugs covered is decided by the U.S. government. Beyond that list, every Medicare Part D plan covers a different set of drugs. When choosing a Part D plan, you need to make sure it covers the drugs you take.
Most Medicare Advantage (Part C) plans already include Part D prescription drug coverage, combined into a single plan with hospital and medical. Another option is to have a separate Part D plan in addition to Original Medicare, a Medicare Supplement Insurance plan, or a Private Fee-For-Service plan.
How do I know if my drugs are covered by the Medicare Part D plan?
All Part D plans have a drug list—also called a formulary—that gives you the information you need about which drugs are covered. The formulary can change, but your plan will let you know ahead of time if it does. The formulary will also tell you if your drug has any special rules or limits. Your plan will send you your formulary and/or give you a way to get all of your drug list information online.
Medicare Supplement (Medigap) FAQ
What is Medicare Supplement insurance?
Medicare Supplement insurance plans, offered by private insurance companies, help pay some of the out-of-pocket costs that Original Medicare (which includes Part A and Part B) doesn’t pay. Medicare Supplement plans are also known as Medigap plans.
When can I apply for Medicare Supplement insurance?
Your acceptance into a Medicare Supplement insurance plan is guaranteed if you apply during the Medicare Supplement Open Enrollment Period. It starts on the first day of the month in which you’re both age 65 or older AND enrolled in Medicare Part B. You can apply for a Medicare Supplement insurance plan any time during the year, and some states have additional enrollment periods and guaranteed enrollment situations.
If you apply outside of this timeframe or another guaranteed issue period, you may be denied coverage or charged more based on your health history. This doesn’t apply if you live in Connecticut and New York, where guaranteed issue is ongoing and Medicare Supplement plans are guaranteed available.
When can I apply for a Medicare Supplement insurance plan?
The best time to enroll in a Medicare supplement plan is during your Medicare Supplement Open Enrollment period because your acceptance is guaranteed. It starts on the first day of the month in which you’re both age 65 or older and enrolled in Medicare Part B. Some states have additional Open Enrollment periods and Guaranteed Issue requirements.
If you apply outside of Open Enrollment or Guaranteed Issue periods, you may be denied coverage or charged more based on your health history. This does not apply to residents of Connecticut and New York where Open Enrollment and Guaranteed Issue is ongoing and Medicare supplement plans are guaranteed available.
How much Medicare Supplement insurance coverage do I need?
There are ten standardized Medicare Supplement insurance plans. All of them pay towards out-of-pocket costs for Medicare-approved services. Some plans pay most or all of your out-of-pocket costs, but have a higher monthly premium. Other plans pay fewer out-of-pocket costs, but have a lower monthly premium. Benefits and costs vary depending on the plan chosen. Plans C and F are only available to individuals who were eligible for Part A or who turned 65 before January 1, 2020.
Does a Medicare Supplement insurance plan replace Original Medicare Part A and Part B?
No. A Medicare Supplement insurance plan works with Original Medicare, which includes Part A and Part B. Medicare supplement insurance helps cover some of the out-of-pocket health care costs that Original Medicare doesn’t pay for. For instance, Medicare Part B generally covers about 80% of Part B expenses. You’re responsible for paying the rest. A Medicare Supplement insurance plan could help pay your share.
Medicare Eligibility FAQ
When am I eligible for Original Medicare?
You’re eligible for Original Medicare once you turn 65 and are a U.S. citizen or legal resident. If you’re a legal resident, you must have lived in the United States for at least five years in a row before you’re eligible for Original Medicare.
I’m not 65 yet. Could I still be eligible for Original Medicare?
Even if you haven’t turned 65, you may be eligible to get Original Medicare. You need to be a U.S. citizen or legal resident for at least 5 years in a row, and have one of the conditions below:
- Under 65 and have a qualifying disability
- Any age and have Amyotrophic Lateral Sclerosis (ALS, also called Lou Gehrig’s disease) or End-Stage Renal Disease (ESRD).
Am I eligible for a Medicare Advantage or Medicare prescription drug plan?
Yes—but you have to enroll in Medicare Part A and/or Part B.
For a Medicare Advantage (Part C) plan, you must have both Medicare Part A and Part B to apply.
For Medicare Part D prescription drug plans, you need to first enroll in either Medicare Part A or Part B. You cannot be denied enrollment in a Part D plan. You must enroll in a Part D plan during your Initial Enrollment Period to avoid the late enrollment penalty for Part D. The exception to this rule is if you qualify for a Special Enrollment Period.
Medicare and Working Past 65 FAQ
What if I’m 65, but I’m still working? Do I still need to sign up for Medicare?
If you’re still working when you turn 65, you still need to make some decisions around Original Medicare—even if you’re covered by your employer’s health plan. When you turn 65, you may want to enroll in Medicare Part A, which is premium free. If you have qualified insurance from your employer, you may be able to delay enrolling in Part B and Part D without penalty. Or you may need to enroll when you turn 65. Talk to your employer’s benefit administrator to help you learn more about your choices.
What if I get health insurance under my working spouse?
If you’re 65 or older and covered by your spouse’s employer health insurance plan, you may be able to delay enrolling in Medicare or you may need to enroll at age 65. Employers have certain rules for covered dependents of Medicare age, so talk with the employer’s benefits administrator to understand your options.
Medicare Enrollment FAQ
When do I need to enroll in Original Medicare?
If you’re turning 65 AND are already receiving Social Security or Railroad Retirement Board benefits, you’ll be automatically enrolled in Original Medicare Parts A and B. If you’re not already receiving these benefits when you turn 65, you’ll need to sign up during your Initial Enrollment Period.
How do I enroll in Original Medicare?
If you’re not enrolled in Original Medicare automatically, visit the ssa.gov/benefits/medicare website, or call or stop into your local Social Security office. If you’re eligible for Medicare due to disability or End-Stage Renal Disease (ESRD), check www.medicare.gov for details on how to enroll.
What is the Medicare Initial Enrollment Period?
The Medicare Initial Enrollment Period (IEP) is a seven-month period that includes your 65th birthday month, the three months before and the three months after. You can enroll in Medicare Part A, Part B, Part C, Part D and Medigap during this time.
What is a Medicare Special Enrollment Period?
Medicare grants a Special Enrollment Period (SEP) when you’re working past 65 with creditable employer coverage and for certain qualifying situations and life events.
With the SEP for working past 65, you are granted eight months to enroll in Medicare Part A and Part B. However, you only get the first two months of this time to get a Medicare Advantage (Part C) and Part D plan without penalty.
For people who already have Medicare coverage, there is a special 2-month SEP that Medicare offers for people who experience a qualified life event. For example, if you move to a different state and your Medicare Advantage plan is not offered there, you would qualify for this SEP. During this two-month period, you can change Medicare Advantage or Part D plans, or if you choose, you can also return to just Original Medicare.
What is the Medicare Advantage Open Enrollment Period?
The Medicare Advantage Open Enrollment Period (MA OEP) runs from January 1 to March 31 every year. During this period, you can make a one-time election to leave a Medicare Advantage plan, switch to a different Medicare Advantage plan, or leave a Medicare Advantage plan and go back to Original Medicare (Part A and Part B). If you do that, you can also then enroll in a stand-alone Part D plan.
What if I want to change plans?
The Medicare Annual Enrollment period (AEP) happens at the same time every year, from October 15 to December 7. During this time you can join, switch or drop a Medicare plan—including Medicare Advantage (Part C) and Medicare prescription drug coverage (Part D).
Medicare Costs FAQ
How much does Original Medicare Part A and Part B cost?
It’s important to understand the basics of Medicare costs. Most people pay no premium for Original Medicare Part A. The premium for Original Medicare Part B depends on your income and may change each year. For both Part A and Part B, there are also deductibles and coinsurance. You may also qualify for help paying for Medicare costs.
How much do I have to pay for Medicare Part D plans?
There are some costs associated with Medicare Part D plans. Stand-alone Part D plans offered through a private insurance company, like UnitedHealthcare, charge a monthly premium. You could also consider Medicare Advantage (Part C) that includes Part D coverage under a single plan. Some plans also require you to pay an annual deductible and coinsurance or copayment amounts.
Medicaid and the Extra Help program, if you qualify for them, can also help cover costs of prescription drugs.
What is Extra Help?
Extra Help is a Medicare financial assistance program for people with low incomes and limited assets. It helps pay prescription drug costs. It is also called Low Income Subsidy or LIS.
What is the Donut Hole?
The Donut Hole is also known as the Coverage Gap. This is one of four drug payment stages in Medicare Part D plans. In the Coverage Gap, you pay a percentage of the drug cost—instead of copay or coinsurance—until you reach your out-of-pocket limit.
For 2022, it begins when your total drug costs have reached $4,430. In the Coverage Gap (Donut Hole), you pay 25% of the cost for brand name drugs and 25% of the cost of generic drugs, until you reach $7,050 in out-of-pocket costs.
IF YOU HAVE MEDICARE AND MEDICAID YOU MAY BE ELIGIBLE FOR A DUAL SPECIAL NEEDS PLAN DESIGNED WITH EXTRA BENEFITS BEYOND ORIGINAL MEDICARE.