Medicare Facts

Who Qualifies?

People ages 65 and older

People under age 65 with certain disabilities

People of all ages with end-stage renal disease

When Do I Enroll?

Most people enroll around their 65th birthday.  You can enroll during the 3 months before your birth month, the month of your birth and 3 months after that month giving you a 7 month initial enrollment period.  Depending on when you enroll, coverage can start as early as the month of your 65th birthday.

If you miss your Initial Enrollment, you can sign up every year between January 1st and March 31.  If you enroll at that time, your coverage is effective July 1st of that year.

Under certain circumstances, you may be eligible for a special Enrollment Period.  If you have questions about that, please call me.

If you are still working and covered under employee group insurance you can either enroll in Medicare and drop your group coverage or you may be able to delay enrollment and stay with your employee program.  You need to compare your plan at work side by side with your Medicare coverage and decide which is better for you. Before deciding to leave your employer plan, always discuss all of your options with your benefits administrator, insurer, or plan provider. In most cases once you leave, you cannot return to the employer plan.

How Do I Sign Up?

If You Are Collecting Social Security

  • Enrollment in Medicare is Automatic
  • Card arrives in the mail about 3 or 4 months before your 65th birthday

If You Are Not Collecting Social Security

You can start the enrollment process around 100 Days before your 65th birthday.

You can enroll two different ways:

  1. Call Social Security to
    schedule an appointment
    800-772-1213
  2. Sign up at medicare.gov

What Exactly Is Medicare?

The original Medicare program was signed into law on July 30th, 1965.  Former President Harry Truman and his wife were the very first beneficiaries.  Today over 56 million Americans are enrolled in the Medicare program. That’s most Americans ages 65 and older, regardless of their income or health status.

You’re going to hear a lot about Medicare Supplement policies A through N.  Original Medicare has only 2 parts: A and B. Part A is for hospital care and Part B is for medical services.  Let’s start there.

Medicare Part A is usually free to you but you have to enroll.  Once you do that – you can rely on the basic coverage or purchase supplemental coverage for additional protection.



Part A Hospital Care

Premium Free
    • First 60 days covered 100%
    •  First 20 days of skilled nursing covered 100%
    •  $1,408 deductible per occurrence*

* for 2020 plans

Medicare Part A is for hospital care.  It covers things like your hospital room, meals, general nursing and hospital services and supplies.  It does not cover private duty nursing, comfort or convenience items.  

Coverage is for up to 90 days per Benefit Period and the first 60 days are covered at 100% after the Medicare Part A Deductible is met.  You pay an out of pocket cost for any days after 60. There is an additional 60 days of coverage called lifetime reserve days, but it can only be used once.

It’s important to note that the deductible is $1,408 and applies to any new Benefit Period.  So if you go into the hospital for a couple of days, get discharged and then return a week later – you are still in the same Benefit Period and will not be charged again for the $1408 Part A Deductible that you incurred on the first confinement.

If you are out of the hospital and/or Skilled Nursing Facility for at least 60 days in a row, a return to the hospital would begin a new Benefit Period and you would owe the Part A Deductible.

Most people do not pay a premium for Part A.

Part B Medical Services

$144.60 monthly premium*
    • Covers medical services outside the hospital
    • Doctor visits, lab work, x-rays, ambulance, emergency room,   outpatient surgery
    • An 80-20 plan with Medicare paying 80%
    • $198 annual deductible

*For 2020 the standard Part B premium amount is $144.60 (or higher depending on your income). 

Medicare Part B is optional.  It covers things like doctors visits, lab work and x-rays outside a hospital stay.  It is an 80 – 20 plan meaning Medicare pays 80% of the approved expenses and you are responsible for the remaining 20%.  The premium for Part B starts at $144.60 per month (or higher depending on your income). There is a $198 deductible but the deductible is for the whole calendar year, not per occurrence.  If you collect a Social Security check, your premium will most likely be deducted.

If you are a single person with an income of $87,000 or less OR a married couple with an income of $174,000 or less – the premium is $144.60 per month.  That covers a lot of people, however, depending on your income, the monthly premium can go up to $491.60. That would apply only to singles making $500,000 and above and to married couples with a combined income of $750,000 and above.

What you don’t get with A&B

Original Medicare doesn’t cover

      •  Dental
      •  Vision
      •  Prescription Drugs
      •  Hearing
      •  Help with long term care

When you DELAY Part B

Retired couple discussing Medicare options

If you or your spouse are working you may be able to delay enrolling in Medicare Part B, depending on the size of the employer…

If you are covered under an employer group health plan

You are covered under a spouse’s employer group health plan

  •  No Penalties
  •  No loss of Options

Now Where Do You Go…

Do you enroll in Part A, Parts A & B, Medicare Advantage or even a Medicare Supplement plan or do you continue with employer group health coverage or possibly union coverage? 

You may also have the option of retiree coverage for health care after you retire but it does not count as creditable coverage for delaying enrollment into Medicare Part B, and neither does COBRA.

Retiree* or Union Plan

First, if you have the option of continuing on an employer group health plan, a union plan or a retiree plan, you will want to compare it to Medicare A & B.  Medicare suggests that you talk with your Employee Health Benefits Administrator and ask these questions. Just remember that retiree coverage for health care after you retire does not count as creditable coverage for delaying enrollment into Medicare Part B, and neither does COBRA.

Ask questions

    •  Are there copays and deductibles?
    •  Does it include a drug plan?
    •  If I opt out, can I opt back in later?
    •  What’s the cost?
    •  Does it include dental and vision coverage?

*Note:  Retiree coverage is not creditable coverage if delaying enrollment into Medicare Part B.

Medicare Supplement

    • Federally standardized Medigap
      plans offered in all states and DC.
    • 10 Plans A – N offered in most states 
    • All policies will offer the same basic benefits.

If you want to explore Medicare Supplemental insurance or Medigap, there are lots of options.  You must have Medicare Parts A and B but then purchase a Medicare Supplement policy to cover certain costs that Medicare does not.  There are 10 federally standardized Medicare Supplement insurance plans that are offered in most states – Plans A through N. They are offered by many different insurance companies.

Here’s what’s important.  All Medicare supplement plans contain the same basic benefits and all plans with the same Plan letter provide identical coverage for medical expenses no matter where you buy them.  Plans have the same standardized benefits for each letter category, only the premiums may vary. Your policy may have a different cost depending on the insurance company, but still have the same coverage (although there may be a policy with an additional innovative benefit available in your area).  Look at proposed plans along side each other and compare those to what you already have with Medicare A & B, then decide.

When it’s the best path

      • Want to budget medical costs
      •  Travel and may need to see a doctor away from home
      •  See any doctor or specialist, no referrals
      •  Plans help pay some of the health care costs that Medicare does not pay (deductibles, coinsurance and/or copayments)
      •  You can keep it as long as you pay premiums on time

Medicare Supplement Insurance can help you pay for the gaps in Medicare coverage.  It helps if you want to budget your medical costs or if you travel often and may need to see someone other than your hometown doctor.   If you want health care coverage for things outside Parts A & B, like vision and dental, you can purchase additional insurance coverage.

Medicare Supplement policies are guaranteed renewable.

Medicare Advantage

  •  Part C replaces A&B and can include Part D
  • PPO or HMO network of doctors
  • Usually one or more plans available in a county
  • Includes a Maximum Out of Pocket
    •  

Medicare Advantage is another option.  Medicare Advantage plans require that you have original Medicare Parts A & B.  It provides coverage though provider networks also called HMOs, PPO, and MSAs. Medicare Advantage Part C basically replaces original Medicare Parts A and B and can include coverage for Medicare Part D.  The key benefit is that Medicare Advantage plans include a maximum out of pocket feature to help you control costs.

When it’s the best path

  •  Pay a lower premium
  •  Use as a backup for VA services
  •  Like the network of doctors
  •  On a low-income subsidy for Medicare

Medicare Advantage is good if you like the network of doctors in your area and want to pay a lower premium.  Medicare Advantage is a good idea if you are a veteran and use VA services or if you have a low-income subsidy for Medicare.

Prescription Drugs

  • Part D
  •  Prices vary by county, depending on the plan
  •  Included with some retirement plans
  •  Late enrollment penalties may be imposed
  •  Vets are not required to enroll, but may choose to do so
Retired couple no stress.

Extra Help with Rx

  • Apply for a low income subsidy
  •  Annual income less than $18,735 for singles and $25,365 for couples*
  •  Resources less than $14,390 for singles and $28,720  for couples*
  •  May also help with deductibles, co-pays and premiums

* Amounts based on yearly income and resources in 2019. These amounts may change in 2020.

2020 Rx Gap

  • Coverage gap begins when you and your drug plan spends $4,020*
  •  From $4,021 to $6,350
    •  You pay 25% of generic drugs
    •  You pay 25% of brand-name drugs, but 95% counts toward your out-of-pocket 
  •  Catastrophic coverage after $6,350*

* for 2020 plans

Do You Have Any Questions?