Medicare FAQs

➡️ What is Medicare?

Medicare is a health insurance program provided by the federal government to: • People age 65 and over, in most cases • Certain people with disabilities that are younger than 65 • People that have amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease • People that have permanent kidney failure or end-stage renal disease (ESRD)


➡️ I'm approaching age 65 and eligible for Medicare. How do I enroll?

If you are not yet 65 but are already receiving Social Security benefits or early Railroad Retirement, you will automatically be enrolled in Medicare Part A (hospital insurance) and Part B (medical insurance). You will receive your initial enrollment package approximately 3 months before your 65th birthday or 25th month of disability benefits. If you decide you want both Part A and B, you can sign your card and keep in your wallet. For more information about automatic enrollment call Social Security at 1-800-772-1213. If you are not receiving early retirement from Social Security or Railroad retirement benefits, you will need to apply for Medicare during your 7-month Initial Enrollment Period (IEP). This enrollment period begins 3 months before your birthday month, it includes your birthday month and will end 3 months after your birthday month. You can contact the Social Security website at or call 1-800-772-1213 to enroll.


➡️ What does Medicare cover?

Medicare helps to cover reasonable and medically necessary health care services and items in the following areas: • Medicare Part A helps to cover inpatient care in a hospital, skilled nursing facility care, inpatient care in a skilled nursing facility (not custodial or long-term care), hospice care, and home health care. • Medicare Part B helps to cover outpatient medical services including doctor and other health care providers’ services and visits, diagnostic lab tests, Durable Medical Equipment (DME), home health care, and some preventive care. • Medicare Advantage (MA) – Medicare Part C is an alternative plan to Original Medicare. Medicare pays the MA plan to manage your health care. Currently, there are 5 types of MA plans and we can help you decide if this alternative is right for you. • Medicare Part D helps to cover most prescription drugs.


➡️ How much does Medicare cost?

Medicare does require premiums, deductibles and cost-sharing for certain services. There are several programs for assistance to help cover some or all of your Medicare costs for those with limited incomes and assets.


➡️ Can I delay enrollment in Medicare Part B?

If you are still working and are covered by your employer’s group health insurance plan you can delay enrolling with Medicare. There are certain conditions regarding primary and secondary coverage and when you can apply for Medicare after you retire after age 65. If you delay in enrolling in Part B and were not covered by an employer’s group health insurance plan there will be penalties and a higher monthly premium, contact us to find out more.


➡️ Why do some people delay enrollment in a Medicare Part D plan?

You can delay or opt out of Medicare Part D prescription drug coverage if you currently are covered by a creditable plan that is as good as or better than Medicare’s plan. One such plan is the Veterans Affairs (VA) health care plan.


➡️ Since Medicare doesn’t cover all my health care costs, are there any alternatives?

To help offset some healthcare costs through Medicare, many people apply for an alternative insurance option called Medicare Advantage. Medicare Advantage Plans may have lower out-of-pocket costs and may offer additional benefits not covered by Original Medicare.


➡️ What's a Medicare MSA Plan?

Medicare works with private insurance companies that offer ways for you to receive health care coverage but with high deductibles and medical savings account for use to pay health care costs. The Medicare MSA Plan is a type of Medicare Advantage plan. The medical plan will begin to cover your costs after your yearly deductible has been met, deductible varies by plan.


➡️ Can I lose my Medicare Part B coverage if my premium is late?

If you fail to make your premium payment on time, First Bill, (due by the 25th of each month), you will receive a Second Bill and will include your late payment amount and next month’s premium amount. This Second Bill will be due by the 25th of the next month. If you fail to make the Second Bill payment you will receive a Delinquent Bill that is due by the 25th of the month. If you fail to pay your Delinquent Bill you will lose your Medicare coverage.


➡️ Will I receive Medicare Coverage if I am traveling outside of the U.S.?

Medicare coverage is very limited when you are outside of the U.S., even if you are on a cruise ship. Check with us about receiving Travel Insurance before you travel and with your Medicare Advantage Plan to see what they cover during travel outside the U.S.


➡️ Can I be billed by the doctor if Medicare didn't pay the total billed amount?

If your doctor has agreed to accept Medicare patients they also “accept assignment”. This means that your doctor has agreed to accept the amount that Medicare has approved for your service and they cannot bill you for the difference. It is very important to find out before you receive care if your doctor accepts assignment or not. If they do not, the doctor can bill you up to 15% above the amount Medicare has approved for your service.


➡️ Do I qualify for Medicare if I am eligible for disability benefits?

Medicare coverage begins at the beginning of the 25th month after you start receiving disability benefits. The 24 months of receiving disability benefits do not have to be consecutive to be counted. If you are eligible for a couple of months last year, then lose eligibility but qualify again at a later date the total of the months will count towards the 24 months. The 24- month waiting period can be waived if you have amyotrophic lateral sclerosis (ALS) or permanent kidney failure.


➡️ Will Medicare Part D change plan coverage at any time?

Yes, each year many parts of the plan can change including premiums, deductibles, copays and the drugs they will cover. September of each year you will receive a letter with details of the changes to the plan, called Annual Notice of Change and changes will take place the following year. This gives you the opportunity to make changes to your plan during the Annual Enrollment period, October 15th to December 7th) and have your new coverage begin January 1st the following year.


➡️ Will Medicare Part D change the drugs it covers?

Yes, Medicare Part D can make changes to its formulary at any time by adding drugs it hasn’t covered before or dropping some. If this change involves a drug you are taking you will receive a letter at least 60 days before this change takes effect and when you request a refill you will be provided a 60-day supply of your current drug under the same plan terms as before.


➡️ What if a drug I'm taking has a national recall for its safety?

Medicare Part D will drop this drug from its formulary and you may not be notified, this is not required. Please talk with your doctor or provider for a new drug to replace this recalled one.


➡️ What Medicare Part D plan covers the most or all drugs?

No Medicare Part D plan covers all drugs available but all of them will cover at least two drugs in each class of medications. Class means all drugs that are similar that are prescribed to treat the same medical condition. Each plan is required to cover all or mostly all of the drugs used to alleviate six serious conditions: cancer, depression, epilepsy, HIV/AIDS, organ transplants, and psychoses. If you are prescribed a certain drug and Part D doesn’t cover it or drops the coverage you and your doctor can request the plan to make an exception and cover the drug in your case.


➡️ How can I see what preventive services are covered?

The Centers for Medicare and Medicaid Services (CMS) created a new tool called “What’s Covered” and it’s an app for your phone. It is on Google Play and Apple Store to download and you can browse all services in alphabetical order or type in your test in the search bar. It is a current list of what Medicare covers for preventive services and lets you call the Medicare hotline or takes you to the full website.


➡️ I'm about to retire but my employer offered me an 18 COBRA plan, can I wait to sign up for Medicare until COBRA runs out?

COBRA is only a temporary extension of health insurance coverage you had while actively employed. To delay in enrolling in Medicare it must be because you were covered by your employer health insurance with active employment. If you wait until after your COBRA runs out to enroll in Medicare you will have late penalties and a higher premium that will be applied for as long as you have Part B.


➡️ My spouse has active employment and I am covered by his/her group health insurance. Do I still need to enroll in Medicare in my Initial Enrollment Period around my 65th birthday?

You can delay Medicare enrollment after the age of 65 if you are covered by your spouse’s employer group coverage from active employment. You should enroll no later than eight months after the employment ends, this is the period of your special enrollment.


➡️ I signed up for COBRA when I retired but before the age of 65. When I enroll in Medicare will I have both plans?

If you become entitled to Medicare and enroll your COBRA benefits will cease. If, however, your spouse and/or dependents are covered with the COBRA coverage it may be extended for them up to 36 months, under certain circumstances, because you qualified for Medicare.


➡️ If I retire before the age of 65 can I enroll early into Medicare?

No one is eligible for Medicare until the age of 65 or based on a disability. You must find private coverage or apply for COBRA through your employer before retirement until you are eligible for Medicare. Special conditions apply to be able to obtain health insurance through the Marketplace and changing jobs or retiring is one of those conditions.


➡️ I'm eligible for Medicare but my wife does not have other coverage and is not 65, will she be covered?

Medicare is not a family plan, it is coverage for individuals only.


➡️ When is the best time to buy Medicare Supplemental Insurance?

Federal law guarantees you the right to buy Medicare Supplemental Insurance that is available where you live during the 6 months after you turn 65 and your initial enrollment into Medicare Part B. They also can’t turn you down or base your premium on your current health if you buy the Medicare Supplement Insurance during the 6 months after you turn 65. Some plans can exclude a preexisting condition when you buy the plan for up to six months.


➡️ If I am eligible for Medicare because of a disability can Medicare Supplemental Insurance deny me or charge a high premium?

If you are under 65 and have Medicare due to a disability the federal law does not require insurance companies to sell you Medicare Supplement Insurance. Some states will provide this protection so check with your state. When you turn 65 you will be eligible for Medicare based upon your age and not your disability so you can buy Medicare Supplement Insurance within the 6 months after your 65th birthday with current health protection.


➡️ I am retired but currently live overseas and will turn 65 next year. Can I enroll in Medicare?

If neither you nor your spouse worked overseas, you can enroll in Medicare Part B, even though you can’t use the coverage until you return to the U.S. In this case, you would not be subject to the Part B late enrollment penalty; however, you would be responsible for Part B premiums during your time abroad.


➡️ I have been working overseas and I just retired but turned 65 last year. Will I have penalties when I return to the U.S. and enroll in Medicare?

When you stop working or lose your employer-based health insurance coverage you will be entitled to a special enrollment period of up to eight months to enroll in Medicare without late penalties. If you don’t return to the U.S. during this eight-month period, then you would have to either sign up for Part B and pay premiums for coverage that isn’t available or delay enrollment until you returned to the U.S. and be subject to late enrollment penalties.


➡️ I am 63 and live overseas but I've heard of a Catch-22 rule that may affect my Medicare enrollment. What is this rule?

Some people don’t qualify for Medicare Part A benefits without having to pay the premium, this is because they didn’t contribute enough payroll taxes during their working years. In this situation you can’t sign up for either Part A or Part B outside the U.S. so your initial enrollment period will begin during the month you return to the U.S. as a citizen and expires the end of the third month. You will be covered on the first day of the month after you enroll.


➡️ Is Medicare Part D enrollment the same as the other Parts while I live overseas?

Part D drug coverage has different enrollment rules while you live overseas. You can apply for Part D within 2 months of returning to the U.S. and your coverage will start on the first day of the month after you enroll and you avoid the late enrollment penalties. If you miss the two-month enrollment after returning you must wait until the next Annual Enrollment Period, October 15 to December 7 with coverage starting January 1, and you will be assessed permanent late penalties based on how many months elapsed between when you returned to the U.S. and when your coverage actually began.


➡️ Do I need to enroll in Medicare Part D drug coverage if I don't take any prescription drugs?

Medicare Part D is insurance and like your auto insurance, it is there when you need it. Your premiums are protection for when you need to take prescription drugs. If you decide to wait to enroll in Part D you risk having to wait until the Annual Enrollment and you risk permanent late penalties when you do sign up.


➡️ What are my options during Medicare's open enrollment of October 15 to December 7?

If you are already enrolled in Medicare plans the Annual Enrollment is when you can review your plan, compare it with other options, switch plans and make changes that will begin on January 1 of the following year. This is the time you can switch Part D drug coverage if your prescriptions are part of another plan, from one Medicare Advantage plan to another plan, switch from an Advantage plan to original Medicare, or from original Medicare to an advantage plan. If you decide to keep your current coverage you don’t need to do anything and your coverage will continue.


➡️ My Medicare Advantage plan is ending at the end of the year, what are my options?

Some Medicare Advantage plans cease to offer insurance in some areas, withdraw from Medicare or go out of business for financial reasons and they can be shut down by Medicare for poor service or violation of the law. You will receive notices warning you that your plan will be ending on the last day of the year. You have options to enroll in another Advantage plan that will begin on January 1 of the following year, or if your plan will discontinue during the year you will receive a letter from Medicare of other plans in your area that you can sign up with for a certain period of time. If you don’t sign up with another advantage plan coverage, the Original Medicare will kick in and you will not be without coverage.


➡️ What preventive yearly shots are a part of my Medicare Advantage Plan?

The following vaccines are a part of most Medicare plans for little to no money out of pocket. If there is a cost or copay it is a set amount for Medicare beneficiaries. Influenza Vaccine ~ the flu, a contagious respiratory illness that can be severe and life-threatening especially to the very young, the older, or those with compromised health. Shingles Vaccine ~ a painful skin rash that is caused by the same virus responsible for chickenpox. Pneumococcal Vaccine ~ a disease that causes severe infections throughout the bloodstream and/or major organs. Some conditions are caused by this disease including pneumonia, meningitis, and bacteremia. Hepatitis B Vaccine ~ a contagious virus that infects the liver and can either be acute, which lasts a few weeks, or chronic, which often has no symptoms but can cause liver damage or death.


➡️ If I have a Marketplace health insurance plan but will be eligible for Medicare this year, what are my options?

You can keep your Marketplace plan until your Medicare coverage begins and then cancel your Marketplace without penalty. You can keep your Marketplace plan with your Medicare plan but will not be eligible for the premium tax credits or other cost savings, you will be paying full premiums for the Marketplace coverage.


➡️ My doctor wants to perform a test but Medicare denied its coverage of the test. Can I appeal this decision?

If you disagree with a decision regarding your coverage you can appeal this decision either by filling out forms and with information from your doctor, or your doctor can appeal this decision for you. There are 5 levels in the appeal process, though it could get approved with one appeal. You can appeal to health care services, supplies, items, or a prescription drug that you believe you should be able to get. You can also appeal for services or items you have been getting and your plan stops supplying them and you think you still need.


➡️ Does Medicare make changes to their premium costs and other insurance costs every year?

Yes, Medicare premiums, copayments, deductibles and other health-related costs can change each year. You will receive notification of any changes for the next year in the fall of the current year, this gives you time to compare other plans and make changes during the Annual Enrollment period.


➡️ I have signed up for Medicare Part D but I've heard about 'phases' of the plan. What does this mean?

The premium that you pay throughout the year won’t change but the price you pay for your prescription drugs varies during the four different phases or periods during the year. The four phases are the Deductible period, Initial coverage period, Coverage gap, and Catastrophic coverage.

Deductible period ~ you will pay the full amount of the negotiated price for your prescription drugs until you met your yearly deductible. In 2020, no plan’s deductible is higher than $435.

Initial coverage period ~ After you meet your Part D yearly deductible, your plan will help pay for your covered prescription drugs. You will pay coinsurance or copayment and your plan will pay the rest of the negotiated price. You will stay in your initial coverage period, depending on your plan’s benefits structure, until your total drug costs have totaled $4,020 (this includes what you and your plan pays).

Coverage gap (donut hole) ~ After your Initial coverage gap period (total drug costs are $4,020 for most plans) you enter the coverage gap phase. During this period your plan does not pay for your prescription drugs but for now, the health reform offers federally funded discounts that help you pay for your drugs. In 2020, you will pay no more than 25% coinsurance for generic drugs or 25% coinsurance for brand name drugs, for any drug tier during the coverage gap.

Catastrophic coverage ~ All part D plans reach the phase where once you have paid $6,350 in out-of-pocket costs for your covered drugs (this is the amount YOU have paid, not the total drug cost or the amount your plan paid) you enter catastrophic coverage. During this phase, you pay $3.60 copay for generic (including brand drugs treated as generic) and a $8.95 copay for all other drugs, OR 5% coinsurance for your covered drugs for the remainder of the year.


➡️ It seems that to reach the Catastrophic coverage in Part D you have to pay a lot throughout the year. What part of my copays and coinsurance goes towards a total of $6,350?

The out-of-pocket costs you must pay to reach the catastrophic coverage includes: your deductible (up to $435), the amounts you paid during the initial coverage phase (up to $4,020), almost the full cost of brand name drugs (including the manufacturer’s discount) that you purchased during the coverage gap period, and any amounts that were paid on your behalf (including family members or charity). The costs that are not included are your monthly premiums, the cost of non-covered drugs, the cost of drugs in pharmacies outside of your plan’s network, and the 75% discount for generic drugs.


➡️ I've heard about a 'donut hole', what is this?

Part D has a coverage gap phase, also called ‘donut hole’ and it is when you will be responsible for the total negotiated cost for your covered prescription drugs. You reach this phase after your initial coverage period and have paid (depending on your plan’s benefits structure) up to $4,020. During this donut hole phase, you will pay no more than 25% coinsurance for generic drugs or 25% coinsurance for brand name drugs, for any drug tier during the coverage gap. Once you reach $6,350 out-of-pocket costs for your drugs you enter the catastrophic coverage and are out of the donut hole or coverage gap.

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