What you need to know about Medicare coverage, eligibility, enrollment and costsUpdated October 6, 2017
Eligibility.com's detailed guide on Medicare will answer many questions you may have about the program. You can also fill out our eligibility form to the right or call us at 1-866-527-3331 and one of our licensed insurance agents will assist you on a one-on-one basis.
For additional information directly from Medicare, you can:
- Call Medicare toll-free at 1-800-MEDICARE (1-800-633-4227) to speak to a live customer service representative 24 hours a day, 7 days a week -- if you are hard of hearing or deaf, call Medicare’s TTY number at 1-877-485-2048
- Or, visit www.Medicare.gov
What is Medicare?
Medicare is the federal health insurance program for people who are 65 or older and are citizens or permanent residents of the United States. Medicare benefits are also available for younger people with some types of disabilities, Amyotrophic Lateral Sclerosis (ALS), and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).
People can get Medicare benefits either through Original Medicare or through a Medicare Advantage Plan.
Medicare has four parts
Medicare Part A is hospital insurance that covers medically necessary inpatient hospital stays, care in skilled nursing facilities, hospice care and some home health care.
Medicare Part B is Medicare insurance that covers certain doctors’ services, durable medical equipment (i.e. wheelchairs), preventative care, outpatient services, lab tests and x-rays, and ambulance services.
Medicare Part C (Medicare Advantage) is a type of Medicare health plan that is offered by private insurance companies approved by Medicare to provide Part A (hospital insurance) and Part B (medical insurance) benefits under one plan.
Medicare Advantage plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS), Special Needs Plans (SNPs) and Medicare Medical Savings Account Plans (MSA). Some people choose to get Medicare coverage through a Medicare Advantage Plan instead of through Original Medicare. Medicare Advantage plans must offer the same level of coverage as Original Medicare Parts A and B.
Most Medicare Advantage plans offer prescription drug coverage and may also offer extra benefits such as routine dental, vision and wellness programs.
Individuals may be required to pay a monthly premium for a Medicare Advantage plan which is in addition to the monthly Part B premium.
Also, the SilverSneakers fitness program is typically covered by Medicare Advantage plans.
Medicare Part D (Prescription Drug Plans) provides stand-alone prescription drug coverage that works alongside Original Medicare (Parts A and B). It is offered through private insurance companies that have contracts with Medicare. Most Medicare Advantage Plans offer prescription drug coverage.
In addition to these options, you may be able to enroll in other types of Medicare health plans offered by private companies that contract with Medicare to provide Part A and Part B benefits if you’re eligible.
For example, Medicare Cost Plans (available in certain areas of the country) and Demonstration/Pilot Programs (also called “research studies”) are Medicare health plans. (All Medicare Advantage Plans are also considered Medicare health plans.) Programs of All-inclusive Care for the Elderly (PACE) provides comprehensive medical and social services to certain frail, community-dwelling elderly individuals, most of whom are dually eligible for Medicare and Medicaid benefits. Individuals must meet certain conditions to be eligible to enroll in PACE. Individuals can leave the program at any time.
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At what age am I eligible for Medicare?
Many people begin their search for Medicare eligibility information asking about Medicare age requirements.
At what age are you eligible for Medicare? The age for Medicare eligibility depends on a few factors. In broad terms, there are two groups of people who are eligible for Medicare:
- People age 65 or older who are American citizens or legal permanent residents of the United States for at least five continuous years.
- People under 65 years old with qualifying disabilities or medical conditions.
Each of these has certain criteria that must be met.
Additionally, there also may be other special situations that allow you to apply for Medicare before age 65. Please contact Medicare directly for more information at 1-800-MEDICARE (1-800-633-4227) to speak to a live customer service representative 24 hours a day, 7 days a week. If you are hard of hearing or deaf, call Medicare’s TTY number at 1-877-485-2048.
How and when to Enroll in Medicare
How and when to enroll in Medicare is an important aspect of coverage. The annual open Medicare enrollment period begins each year in October, but there are other timeframes that also work for certain qualifying Medicare applicants. Remember, it is to your advantage to pay attention to deadlines and Medicare enrollment periods for all parts and situations that affect you.
Here are some deadlines and situations that apply to enrolling in Medicare.
If you are already getting Social Security or railroad retirement benefits, you will be contacted about three months before your 65th birthday. If you live in one of the 50 states, Washington, D.C., the Northern Mariana Islands, American Samoa, Guam or the U.S. Virgin Islands, you will automatically be enrolled in Medicare Parts A and B. Because a premium is required for Part B coverage, you will be given the opportunity to opt out of that coverage.
If you are not already getting Social Security or railroad retirement benefits, you can enroll in Medicare during the Initial Coverage Election Period to avoid any penalties or a gap in your health care coverage. The Initial Coverage Election Period is a seven-month period beginning three months before the month you turn 65, and ending three months after your 65th birthday. The good news is that you can sign up and get Medicare coverage even if you don’t plan on retiring when you turn 65.
There are also special situations that allow you to apply for Medicare before age 65:
- You’re a disabled widow(er) between 50 and 65.
- You work for the government and became disabled before turning 65
- You or an immediate family have permanent kidney failure
- You had Medicare Part B coverage in the past but dropped coverage
- You turned down Medicare Part B coverage when you first got Medicare Part A coverage.
- You or your spouse worked for the railroad industry.
Don't Miss These Important Medicare Enrollment Periods
When to enroll in Medicare or make changes is an important aspect of coverage. It is to your advantage to pay attention to deadlines and Medicare enrollment periods for all parts and situations that affect you.
Here are some time periods that apply to enrolling in Medicare for the first time or making changes to your existing Medicare coverage:
- Initial Enrollment Period
- General Enrollment Period
- Special Enrollment Periods (Special Circumstances)
- Annual Election Period
- Medicare Disenrollment Period
If you don’t enroll in Medicare Part B during your initial enrollment period, you can still sign up during the General Enrollment Period January 1 through March 31, but you may need to pay a late enrollment penalty. Your coverage will begin on the following July 1 of the year in which you sign up.
If you are in a Medicare Advantage plan and want to switch back Original Medicare (Part A and Part B), you can do so during the Medicare Advantage Disenrollment Period January 1 through February 14. If you do so, you will also have until February 14 to enroll in a Medicare Prescription Drug plan as well. Your coverage begins the first day of the month after your enrollment form is received.
For more information on how and when to enroll, contact the Social Security Administration, or visit a local Social Security office. Those who have been receiving social security disability benefits for at least two years can qualify for Medicare automatically. You can also check your current and future Medicare enrollment and other Medicare-related information online through the Medicare.gov website.
How do I check my Medicare eligibility or calculate my premium?
A Medicare eligibility check can be conducted by speaking with a customer service representative when you call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week. Queries can also be made by calling Social Security at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778.
You can also check your Medicare eligibility by visiting the Medicare website. It has an online Eligibility & Premium Calculator that can be used to find out if you’re eligible for Medicare and to calculate your monthly premium for Medicare coverage. You can access it by going here.
What’s covered under Medicare?
Many times, coverage for tests, services and medical care items depends on where you live. However, some of these things are universally covered no matter where you live. Check the Medicare website for a list of those items. You can also talk to your healthcare provider to see why certain items are needed, and ask if they can be covered under Medicare.
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Medicare Part A
Medicare Part A is hospital insurance that provides coverage for inpatient hospital care, as well as coverage for critical access hospitals and skilled nursing facilities (though not custodial or long-term care). It also covers hospice care and home health care so long as certain conditions are met.
Part A Eligibility
You are eligible for Medicare Part A at no cost, if:
- You are 65 or older AND
- You currently receive or are eligible to receive Social Security benefits (See eligibility information below). OR
- You currently receive or you are eligible to receive railroad retirement benefits. OR
- Your spouse receives or is eligible to receive Social Security or railroad retirement benefits. This applies to spouses who are living, deceased or divorced from the person seeking coverage. OR
- You or your spouse worked long enough in a government job where Medicare taxes were paid. OR
- You are a dependent parent of a deceased child who is fully insured.
Social Security credits and Medicare eligibility
Most people become eligible for Medicare Part A free of charge by working and paying taxes long enough to earn enough Social Security credits. Social Security credits count toward social security Medicare eligibility for Medicare. Credits are earned by paying Social Security and Medicare payroll taxes while working.
Generally, 40 credits, equal to ten years of work from employment are required to receive Social Security benefits and qualify for premium-free Medicare Part A benefits. As of 2017, you earn one Social Security or Medicare work credit for every $1,300 you make. You can only earn a maximum of four credits each year, which means you need to earn $5,200 to earn the maximum four credits in 2017.
If more than 40 credits are earned over the years, the additional credits do not provide any added benefit. You may also qualify for Medicare if you are, or have been, a government employee who has paid Medicare payroll taxes during employment. If you do not have 40 credits, you will need to pay a monthly premium to be covered. If you have earned less than 30 credits, as of 2017 you must pay $413 each month, and $227 each month if you have earned between 30 and 39 credits
What does Medicare Part A cover if you are under 65?
Those under the age of 65 are eligible for Medicare if any of the following apply:
- You have received disability benefits from Social Security or the Railroad Retirement Board for 24 months. (You're automatically enrolled in Part A and Part B after you get Social Security or Railroad Retirement benefits for 24 months. The 24 months do not need to be consecutive.)
- You receive disability benefits because you have Amyotrophic Lateral Sclerosis (ALS, also called Lou Gehrig’s disease).
- You have end-stage renal disease (ESRD, permanent kidney failure requiring dialysis or a kidney transplant) and one of the following applies to your situation: you've worked the required amount of time under Social Security, the Railroad Retirement Board, or as a government employee; you’re already receiving or are eligible to receive Social Security or Railroad Retirement benefits; or you’re the spouse or dependent child of a person who meets one of the requirements listed above.
Cost of Part A Plans
Those who qualify for premium-free Medicare Part A don’t have to pay premiums for coverage. (Though there is a deductible for hospital stays.)
If you don’t qualify for premium-free Medicare Part A, you will need to sign up for it with Social Security and pay a monthly premium for coverage. The monthly cost will depend on how long you have worked and how close you are to meeting the 40-credit requirement. In 2017, it costs $413 each month for Medicare Part A for those who have earned fewer than 30 credits, and $227 each month for those who earned between 30 to 39 credits.
Those who pay for Part A (hospital insurance), must also enroll in Part B (medical insurance), and pay an additional monthly premium for Part B.
Enrollment in Part A
Some people are automatically enrolled in Part A (and Part B), while others must sign up.
Who is automatically enrolled in Parts A and B?
- Those already receiving benefits from Social Security or the Railroad Retirement Board automatically get Part A (and Part B) starting on the first day of the month they turn 65 years old.
- Those who are under 65 and have received disability benefits from Social Security or certain disability benefits from the Railroad Retirement Board will be automatically enrolled in Parts A and B after 24 months of disability benefits.
- Those who have Amyotrophic Lateral Sclerosis (or ALS, which is also called Lou Gehrig’s disease) get Parts A and B the month that Social Security disability benefits start.
Who needs to sign up for Parts A and B?
- Those who are within three months of age 65, but not receiving Social Security or Railroad Retirement Board benefits, must sign up for Medicare. (For example, this applies to those who are still working.)
- Those with End-Stage Renal Disease (ESRD) must sign up for Medicare.
- Residents of Puerto Rico who receive Social Security benefits or Railroad Retirement benefits automatically get Part A the first day of the month they turn 65 (or after receiving disability benefits for 24 months). However, to get Part B, they must sign up for it.
Initial enrollment period details for Medicare
The initial enrollment period consists of a seven-month period starting three months before the month you turn 65, including the month you turn 65, and extending three months after the month you turn 65.
Warning: Those who are not automatically enrolled and fail to sign up during the initial enrollment period may face late enrollment penalties and/or have a gap in coverage.
Coverage for Medicare Part A (and Part B) begins on the first day of your birthday month when you become 65 (so long as enrollment is automatic or you sign up during the first three months of the initial enrollment period), unless your birthday falls on the first day of the month. Then coverage begins on the first day of the previous month.
For example, if your birthday is June 6, 1952, then you get coverage on June 1, 2017. If your birthday is on the first day of the month (June 1, 1952), then Part A (and Part B) will start the first day of the prior month—May 1, 2017.
It’s not necessary to sign up for Medicare each year. Once you’re enrolled, you don’t have to sign up again.
Medicare General Enrollment Period Each Year: January 1 through March 31
Those who don’t sign up for Part A and/or Part B when first eligible, and who do not qualify for a Special Enrollment Period, can sign up between January 1 to March 31 each year, which is the General Enrollment Period. Coverage then begins July 1. Those who do this might have to pay higher premiums for late enrollment in Part A and/or Part B.
Medicare Part B
Medicare Part B covers things like doctor services, outpatient care, and other medical services provided by clinics and laboratories. This includes lab tests, preventative services, surgeries, and doctor visits, as well as supplies (including wheelchairs and walkers) that are considered medically necessary to treat a disease or condition.
Part B Eligibility
If you are eligible for Part A coverage at no cost, you are eligible to enroll in Medicare Part B coverage by paying a monthly premium. The amount of premium you pay may depend on what your income level is.
If you are not eligible for premium-free Medicare Part A, you can qualify for Medicare Part B if you are:
- age 65 or older and
- either a United States citizen or an alien lawfully admitted for permanent residence who has resided in the United States continuously during the five years immediately preceding the month before applying for enrollment in Part B.
Cost of Medicare Part B Plans
Unlike Part A, which is usually free, Part B requires a monthly premium.
Most people who sign up for Medicare Part B when first eligible pay $134 each month in 2017. (If you don't sign up for Medicare Part B when first eligible, you may have to pay a late enrollment penalty.)
Certain individuals must pay a higher premium each month for Mecicare Part B if their modified adjusted gross income falls above a certain amount. The Income Related Monthly Adjustment Amount (IRMAA) is the additional amount added to monthly Part B premiums. The Social Security Administration looks at your income from two years ago to determine if an IRMAA should be added to your monthly premium.
For example, if your yearly income in 2017 was between $85,000 and up to $107,000 and you filed an individual tax return, then Part B costs $187.50 each month of 2017. The IRMAA varies based upon income, but the most one would have to pay for Part B in 2017 is $428.60 per month, which applies to individuals who earned more than $214,000, or a couple who filed jointly and earned more than $428,000 in 2017.
The Medicare Part B premium is ordinarily taken directly out of a Social Security, Railroad Retirement, or Office of Personnel Management retirement check, which means most people will not receive a bill.
The Medicare late enrollment penalty
Medicare Part B coverage is not required. However, those who choose not to enroll in Part B, but later decide they want coverage, may have to pay a higher monthly premium for as long as they have Medicare (unless they qualify for a Special Enrollment Period).
The Part B monthly premium may increase by 10% for each twelve-month period of eligibility for Part B that was not elected. The penalty does not go away–you must pay it for as long as you have Part B.
Also, if you miss the initial enrollment period, you may have to wait to enroll at a specific, later time unless you qualify for a Special Enrollment Period. (For example, you may have to wait until the general enrollment period, which runs from January 1 to March 31, with coverage starting on July 1 of that year).
Deductible and co-pay
In 2017, the Medicare Part B deductible is $134 per year. After the deductible is met, you usually pay 20% for all approved Medicare services. For example, if you visit the doctor or have medical testing done, you will receive a bill for your 20% share.
There is no out of pocket limit for Medicare Part B and not all procedures are covered. If you need more information about whether a medical service or procedure is covered, contact Medicare or ask your doctor to find out more.
Enrollment in Medicare Part B
As with Medicare Part A, the enrollment period for Medicare Part B typically takes place during the seven-month period that begins three months before the month you turn 65, including the month you turn 65, and ending three months after the month you turn 65.
For example if your birthday is July 15th, the initial enrollment period includes the months of April, May, June, July, August, September, and October. (Certain people are automatically enrolled in Part B. See the “Enrollment [Medicare Part A]” section above to find out who is automatically enrolled and who needs to sign up.)
The general enrollment period each year takes place January 1 through March 31
If you fail to enroll during the initial enrollment period (and you don’t qualify for a special enrollment period), then you will have to wait to enroll in Medicare during the general enrollment period, which runs from January 1 through March 31 each year. Coverage then begins July 1st.
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Medicare Part C (Medicare Advantage)
Medicare Part C, also known as Medicare Advantage, provides an alternative way to get your Medicare Part A and Part B benefits. Medicare Advantage Plans are plans offered by private insurance companies approved by Medicare that must offer the same level of coverage as Original Medicare. The most common types are Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs) and Private-Fee-for-Service (PFFS) plans.
Medicare Advantage Plans include coverage for all Part A and B services in one plan (except hospice care and some care in qualifying clinical research studies). The private insurance companies offering these plans agree to follow Medicare’s rules about what care and procedures are covered, but have different out-of-pocket costs and rules about how services are provided. (For example, a copayment may be required for a doctor’s visit.) With a Medicare Advantage Plan, you are still enrolled in Medicare, but you are in a private health insurance plan that may have different restrictions and costs.
Depending on your health and any ongoing conditions you have, a Medicare Advantage Plan may make more sense than Original Medicare. One benefit of some Medicare Advantage Plans is that they may offer more coverage than Original Medicare, including vision, hearing, dental, and other health and wellness programs. Not all plans offer these benefits.
Most Medicare Advantage Plans include Prescription Drug coverage
Also, Medicare Advantage Plans include a yearly out-of-pocket maximum whereas Original Medicare does not. After the limit is reached, there is no charge for covered services.
The main reason you may want to consider Medicare Advantage plans, is because they offer additional benefits over and above the level of coverage provided by Original Medicare (Part A and Part B). Most Medicare Advantage Plans include prescription drug coverage. These plans are known as Medicare Advantage Prescription Drug Plans.
Medicare Part C eligibility
If you have Medicare Part A and Part B coverage, then you can enroll in Part C coverage. To enroll in an optional Medicare Advantage (Part C) Plan, you must first enroll in both Medicare Part A and Part B. Generally, if you have Medicare Parts A and B and you live in the area of coverage you will be eligible to enroll. In most cases, those with End-Stage Renal Disease (ESRD) usually get their benefits through Original Medicare and can only enroll in a Medicare Advantage Plan in certain situations.
Cost of Medicare Advantage Plans
Most people will continue to pay a Medicare Part B monthly premium and pay an additional monthly plan premium to be enrolled in a Medicare Advantage Plan. There may also be a copayment or coinsurance for services. Some Medicare Advantage Plans may offer zero-dollar premiums but you must still continue to pay your Part B premium.
Medicare Advantage Plans establish the amounts they charge for premiums, services, co-payments, and deductibles. For example, you may pay more per month for a smaller deductible or for cheaper doctor visit copayments.
Benefits, premiums, co-payments and co-insurance may change on January 1 of each year.
Enrollment in Medicare Advantage
It’s possible to enroll in a Medicare Advantage Plan or Medicare Advantage Prescription Drug Plan (or make changes to coverage you already have) during certain periods each year. Those periods are as follows.
During your Initial Enrollment Period (when you first get Medicare).
The Annual Election Period is from October 15 through December 7 each year. The AEP is also known as the Open Enrollment Period for Medicare Advantage and Medicare prescription drug coverage and allows you to make changes to your Medicare coverage for the following year.
You can also enroll during Special Enrollment Periods SEP, if you have a qualifying life event (e.g., moving out of your plan’s service area or if your plan changes its contract with Medicare, among others). The rules are different for each SEP about when you can make changes and the type of changes you are allowed to make.
You can switch to a 5-star Medicare Advantage Plan (or Medicare Cost Plan, or Medicare Prescription Drug Plan) once, between December 8 and November 30 as long as you meet the other requirements to enroll in that plan (e.g. living within the service area as well as requirements regarding end-stage renal disease.
Medicare Advantage Disenrollment Period
If you are enrolled in a Medicare Advantage Plan and are unhappy with the coverage or do not want to be enrolled in the plan any longer, you can leave the plan during a special disenrollment period. This period occurs from January 1 until February 14 each year.
However, if you leave a Medicare Advantage Plan during this period, you can only switch to Original Medicare. You cannot change to a new Medicare Advantage Plan. If you switch to Original Medicare during this time, you will have until February 14 to also enroll in a Medicare Prescription Drug Plan to add coverage for prescription drugs.
Medicare Part D
Medicare Part D is prescription drug coverage that helps cover the cost of prescription drugs. You can get Medicare prescription drug coverage two ways:
- Medicare Prescription Drug Plan (Part D) – These plans add drug coverage that work alongside of your Original Medicare (Part A and/or B), some Medicare Cost Plans, some Private-Fee-for-Service-Plans, and Medicare Medical Savings Account Plans.
- Medicare Advantage Plan (Part C) - Many Medicare Advantage Plans include prescription drug coverage as part of their benefits, though not all do. These Medicare Advantage plans are known as Medicare Advantage Prescription Drug Plans and you must have both Medicare Part A and Part B to enroll in a Medicare Advantage Plan.
Medicare Part D is only available through private insurance companies that are approved by Medicare.
Your monthly plan premium and out-of-pocket costs for prescription drugs will vary from plan to plan since different insurance companies offer different types of plans. All Medicare Prescription Drug Plans have a formulary which is a list of covered drugs. Please note that the formulary may change at any time but, you will receive notice from your plan when necessary.
Medicare Part D also covers certain vaccines that are not already covered under Part B.
Medicare Part D Eligibility
If you are eligible for Part A and Part B Medicare coverage, then you are eligible for Medicare Part D coverage. You must also live in the service area of the Medicare prescription drug plan you want to enroll in. Enrollment in Part D is optional, and you will be required to pay a monthly premium. Depending on your income level, this premium may be higher.
Cost of Medicare Part D Plans
Most Medicare Prescription Drug plans charge a monthly premium that varies by plan. You will make the following payments throughout the year:
Monthly premium (which is in addition to the Part B premium) (certain individuals with higher incomes pay a higher premium)
Yearly deductible, if there is one (no more than $400 in 2017), and
Copayments/coinsurance (these differ according to the plan chosen and are paid after meeting the deductible)
Costs in the coverage gap (which is also called the “donut hole”), and
Costs if you get Extra Help
Costs if you pay a late enrollment penalty.
What is the Medicare coverage gap (donut hole)?
The Medicare coverage gap (which is called the “donut hole”) is when you and your plan have paid a certain dollar amount during the year (a limit) for covered drugs. After you hit this limit, you then pay more out-of-pocket for drugs until you qualify for catastrophic coverage.
In 2017, you're in the coverage gap once you and your plan have spent $3,700 on covered drugs.
Health care reform law is gradually narrowing the coverage gap. For example, in 2017, you pay 40% for brand-name drugs and 49% for generic drugs when you’re in the coverage gap. However, by 2020, you’ll only have to pay 25% for covered brand-name and generic drugs during the gap.
Once your out-of-pocket costs (deductible, copays, and coinsurance, plus anything you paid for drugs in the gap) reach a certain amount ($4,950 for 2017), catastrophic drug coverage kicks in automatically and you only pay a small coinsurance or copayment for the remainder of the year. The discount you receive on drugs and amounts you pay count towards the out-of-pocket limit.
If you don’t enroll in a Medicare prescription drug plan when becoming eligible for Medicare and you don’t have other drug coverage that’s expected to pay at least as much as standard Medicare prescription drug coverage on average (“creditable prescription drug coverage”), you may have to pay a late enrollment penalty if you enroll later (in addition to your premium each month) for as long as you have a Medicare drug plan.
The amount of the penalty depends on how long you went without Part D or creditable prescription drug coverage.
Enrollment in Medicare Part D
You can enroll in a Part D prescription drug plan through a private Medicare-approved insurance company offering the coverage. You can enroll at the following times.
- During your initial enrollment period.
- If you get Part B for the first time during the general enrollment period, you can then enroll in a Medicare Prescription Drug plan (from April 1 to June 30).
- During the Annual Election Period from October 15 to December 7 each year, with your coverage beginning January 1st of the following year.
- At any time if you qualify for Extra Help. (“Extra Help” is a program under Medicare that helps people with limited income and resources pay for Medicare prescription drug costs, such as premiums, deductibles, and coinsurance.)
Extra Help is a program that offers assistance paying for a Medicare drug plan to those who qualify. You qualify automatically if you meet any of the following conditions:
- Have full Medicaid coverage
- Get help from your state Medicaid program paying your Medicare Part B premiums (in a Medicare Savings Program), or
- Get Supplemental Security Income (SSI) benefits.
If you don’t automatically qualify for Extra Help, you must apply to receive assistance under this program. As of 2017, if you earn less than $18,090 per year as an individual ($24,360 for a married couple living together) and you have financial resources that are less than $13,820 ($27,600 for a married couple living together) you may be eligible to receive assistance. Even if your yearly income limits are higher, you still may qualify if you or your spouse meet one of the following conditions:
- You support other family members who live with you;
- You have earnings from work; or
- You live in Alaska or Hawaii.
Note: Financial resources include the amount of cash you have in your savings account, any assets you may own like stocks and bonds and whether you own multiple properties.
If you qualify for assistance, the Part D premium may be lowered and you will pay less for prescription drugs.
Also, many states provide State Pharmacy Assistance Programs, or SPAPs, that help those with low-income or individuals with a disability or medical condition with the cost of pharmaceutical drugs.
Special Enrollment Periods
In some cases, you can enroll in, switch, or drop Medicare drug plans at other times of the year, such as when you move out of your plan’s service area or you lose other drug coverage, among other circumstances.
5-Star Special Enrollment Period
As with Part C, you can switch to a Medicare prescription drug plan that has a 5-star overall rating from December 8 to November 30, one time.
Warning: If you are part of a Medicare Advantage Plan that includes prescription drug coverage and you later enroll in a Medicare prescription drug plan, you’ll be disenrolled from your Medicare Advantage Plan and switched to Original Medicare.
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Medicaid and Medicare Supplement Insurance (Medigap Plans)
Medicare does not provide full coverage for healthcare in all instances, leaving some gaps in coverage. Fortunately, there are several ways to pay for medical services through supplemental coverage. These can include employment-based health insurance if a spouse is still working and has coverage, retiree insurance, or Veterans’ Administration benefits.
Medicaid helps low-income families pay for costs of long-term medical and custodial care. It is a joint program of the federal government and state governments. The federal government largely funds the program, but Medicaid is administered by state governments, and coverage may vary from state to state.
How can I apply for Medicaid?
Go to www.HealthCare.gov where you will find access to an online application as well as lots of information regarding Medicaid benefits.
What are the differences between Medicare and Medicaid?
The main difference is that Medicare is an insurance program and Medicaid is an assistance program.
Medicare helps people who are covered pay medical bills from funds they have paid into over the course of their working life. For the most part, Medicare serves people 65 and over, with some exceptions for younger disabled and dialysis patients. Premiums are many times required for certain parts of Medicare. It is a federal program and is uniformly administered across the United States.
Medicaid has no age restrictions and serves people of all ages based on income. Generally, patients are not required to pay any costs for medical services, except in a few limited circumstances. Although Medicaid adheres to federal guidelines, it is administered by state and local governments.
Medicare Supplement Insurance (Medigap)
Medigap is a supplemental insurance policy sold by private companies that helps to pay for some health care costs not covered by Original Medicare. This can include copayments, coinsurance, and deductibles. Most notably, unlike Medicare, Medigap policies cover medical care when you travel outside the United States. To qualify for a Medigap policy, you must already be enrolled in Medicare Part A and Part B.
A Medicare Supplement Insurance (Medigap) policy is an optional policy offered by a private company to fill in some of the gaps in coverage of Original Medicare (Part A and Part B). Because there is no out-of-pocket limit on spending for Original Medicare, obtaining a Medigap policy is a good idea for certain individuals.
Medigap can be used to pay for services not covered by Original Medicare including deductibles, coinsurance, and copayments. Also, some Medigap policies offer coverage for services that are not provided by Original Medicare. For example, a Medigap policy may provide coverage if you become sick while traveling internationally.
Policies sold on or after January 1, 2006, do not include prescription drug coverage. (Earlier policies may cover prescription drugs.)
A Medigap policy is only available to those who have Medicare Part A and Part B. If you have a Medicare Part C Advantage Plan, then you cannot purchase a Medigap policy.
Cost of Medigap Plans
A monthly premium for a Medigap policy is required in addition to the monthly Part B premium.
The cost varies widely based upon the benefits of the plan and the age and gender of the individual enrolled. There can even be differences in premiums charged by various companies for exactly the same coverage.
Enrollment in Medigap
You can enroll in a Medigap policy during the six-month open enrollment period, which begins the month you areboth65 and enrolled in Medicare Part B.
If you apply for a policy during the open enrollment period, the medical information that you provide can’t be used against you to deny coverage or increase the monthly price of the policy.
There are no guarantees that you can buy a Medigap policy after the open enrollment period ends if you don’t meet the medical underwriting requirements, unless you're eligible due to certain limited circumstances. And, if you are able to obtain coverage outside of the open enrollment period, the Medigap policy may cost more.
What does "Dual Eligible" for Medicare mean?
An individual is considered "dual eligible" when they qualify for both Medicare and Medicaid. This is also commonly referred to as "dual eligible beneficiaries" or "duals", in the insurance industry. Qualifying for Medicaid varies state-by-state and depends on your annual income.
How do I verify if I am eligible for premium-free Medicare?
You are eligible for premium-free Medicare Part A at age 65 if you or your spouse worked and paid Medicare taxes for at least 10 years. You get premium-free Part A if you are already getting retirement benefits from Social Security or the Railroad Retirement Board (RRB); if you are eligible to get Social Security or Railroad benefits but you have not yet filed for them; or if you or your spouse had Medicare covered government employment. If you are under 65 years old you can also get premium-free Part A benefits if you’ve received Social Security or Railroad Retirement Board disability benefits for 24 months, or you have End-Stage Renal Disease (ESRD) and meet certain requirements.
Most people do not have to pay for Part A benefits, but everyone who wants Part B coverage must pay for it. You must also pay a monthly premium for Part C and Part D coverage in addition to your Part B monthly premium.
How do I check Medicare eligibility online to see if I qualify for free coverage?
To check and see if you are eligible for premium-free Part A coverage, you can use the Medicare eligibility calculatorhere.
How do I check Medicare providers online?
Medicare maintains a comprehensive list of providers on its website at www.medicare.gov. Users can find out about what services are offered, make side-by-side comparisons on what care they provide and get tips and information to help make the best possible informed decision.
Providers are broken out by categories.
- Nursing homes
- Home health services
What is a Medicare eligibility letter?
A Medicare eligibility letter is a document that advises a provider of the date you and any qualifying family members became eligible for Medicare benefits.
To obtain an eligibility letter, visit any Medicare branch office and they will give you a letter while you wait, or you can call Medicare at 1-800-MEDICARE and(1-800-633-4227) to speak to a live customer service representative 24 hours a day, 7 days a week -- if you are hard of hearing or deaf, call Medicare’s TTY number at 1-877-485-2048to request a letter to be sent to you.
Medicare Savings Programs
Many states provide financial assistance (Medicare Savings Programs, or MSPs) for those who qualify and have a difficult time paying their Medicare premiums, deductibles, coinsurance, and copayments.
There are four kinds of MSPs: the Qualified Medicare Beneficiary (QMB) Program, Specified Low-Income Medicare Beneficiary (SLMB) Program, Qualifying Individual (QI) Program, and the Qualified Disabled and Working Individuals (QDWI) Program.
Generally, you must earn less than a certain amount per month and not own personal assets that exceed a particular threshold to qualify. (Personal assets include cash, stocks and bonds. Not included in the personal asset calculation are one house, car, and personal belongings such as clothing and furniture.) The limits vary from program to program and between states.
Ask your state’s Medicaid office if you meet eligibility requirements.
How to get more information about Medicare
To learn the specific steps you need to take to enroll in the various Medicare programs, go to www.medicare.gov.
To get further information about Medicare, go to www.medicare.gov or call Medicare toll-free at 1-800-MEDICARE (1-800-633-4227) to speak to a live customer service representative 24 hours a day, 7 days a week. If you are hard of hearing or deaf, call Medicare’s TTY number at 1-877-485-2048.