FAQ (video)

Since Congress created the Medicare program in 1965, its benefits have expanded along with the number of its beneficiaries. The program now covers 57 million older Americans, plus 9 million disabled people. There are now four main parts to Medicare:

• Part A helps pay for the cost of inpatient stays in hospitals and short-term skilled nursing facilities, home health services and hospice care.

• Part B helps pay for doctors’ services (including those in the hospital), outpatient care (in or out of a hospital), diagnostic tests, preventive care and some medical equipment and supplies.

• Part C, or Medicare Advantage, is an alternative coverage option to original Medicare that allows you to choose to receive all of your Medicare health care benefits through one plan. These plans must cover all Part A and Part B services, and most include Part D drug coverage. Some plans also provide extra benefits that original Medicare doesn’t offer.

• Part D helps cover the cost of outpatient FDA-approved prescription drugs.

Medicare Advantage plans are an alternative to Original Medicare. They are known as Medicare Part C plans. These plans are offered by private insurance companies and cover all Medicare-covered services. Medicare Advantage plans cover Medicare Part A (hospital services) and Part B (physician services). Most Medicare Advantage plans also include Medicare Part D (prescription drug coverage). They also may pay for additional services that aren’t covered by Original Medicare. In most Medicare Advantage plans, you can only go to doctors, specialists and hospitals on the plan’s list. Otherwise, you may pay more or you may not be covered for services at all. However, if you need urgent or emergency care, you will be covered even if you receive care outside the plan’s participating providers. Examples of Medicare Advantage plans include Health Maintenance Organizations (HMO) or Preferred Provider Organizations (PPO). Add an answer to this item.

You can get Medicare prescription drug coverage (Part D) in one of two ways: through a “stand-alone” Part D drug plan (which provides only prescription drugs and is used by people enrolled in the original Medicare program) or through a Medicare Advantage managed care plan (such as an HMO or PPO) which includes Part D drug coverage in its benefits package. Both types of plan are offered by private insurance companies that are regulated by Medicare. Whether you choose a stand-alone Part D drug plan or a Medicare Advantage plan, you must enroll during a designated enrollment period:

• Your initial enrollment period  (IEP), which runs for seven months, of which the fourth is the month of  your 65th birthday.
• A special enrollment period  (SEP), which you’re entitled to in certain circumstances:

• If you qualify for Extra Help (which provides low-cost Part D coverage to people with limited incomes) or enter or leave a nursing home, you can join a Part D drug plan or switch to another at any time of the year.• If you lose creditable drug coverage from elsewhere — such as an employer, union, retiree benefits, COBRA, Medicaid, or the Veterans Affairs health care program — you can sign up with a drug plan within two months of this coverage ending. 

• If you move outside of your current drug plan’s service area (which means to another state if you’re enrolled in a stand-alone Part D plan), you can sign up with a new plan, either before   or within two months of the move.• If your current Part D plan withdraws service from your area, you can switch to another plan before or when your current coverage ends.• If you return to the United States after living abroad, or are released from prison, you can sign up with a Part D drug plan within two months of your return or your release.

• If you want to switch to a Part D plan or a Medicare Advantage plan that has earned Medicare’s highest quality rating (five stars) and is available in your area, you can do so at any time of the year  except for the first week of December .• If a plan violates its contract with you, you can ask Medicare to investigate; if Medicare agrees, you can switch to another plan at that time. 

 *****If you fail to sign up during one of these time frames, you face two consequences. You will be able to enroll in a Part D plan only during open enrollment, which runs from Oct. 15 to Dec. 7, with coverage beginning Jan. 1. And you will be liable for late penalties, based on how many months you were without Part D or alternative creditable coverage since turning 65, which will be added to your Part D drug premiums for all future years. 

The original Medicare program (which began in 1966) consists of Part A (hospital insurance) and Part B (medical insurance). If you’re enrolled in original Medicare and want Part D prescription drug coverage (a benefit that was added to Medicare in 2006), you must actively choose and join a Part D drug plan in your area. Medicare offers these different types of coverage so that you can choose which ones you want, according to your individual circumstances. Here are points to consider in different situations:  

• You can delay enrollment in Part B (which covers doctors’ services, outpatient care and medical equipment) after age 65, without adverse consequences, for as long as you receive primary health care from an employer for which you or your spouse actively works.  

• If you receive Social Security benefits at the time you turn 65, or apply for them at a later date, the Social Security Administration (which handles Medicare enrollment) will automatically enroll you in both Part A and Part B and send your Medicare ID card through the mail. But (if you have primary insurance from a current employer, as described above) you can decline Part B, following the instructions that Social Security includes in its letter that      accompanies your card and meeting the deadline.  

• If you work for an employer that offers health insurance in the form of a high-deductible plan paired with a health savings account (HSA), be aware that under IRS rules you cannot contribute to an HSA in any month that you are enrolled in any part of Medicare. (If you do, you’ll pay tax on the contributions at the end of the tax year.) If you wish to continue contributing to your account, you need to delay enrollment in Part A as well as Part B. Note that you cannot delay or opt out of Part A if you receive any Social Security benefits (retirement, disability or spousal). 

• You do not need Part D prescription drug coverage if you have “creditable” coverage from elsewhere — such as from a current or former employer, COBRA, the federal employees health benefits (FEHB ) program, the military’s TRICARE programs, the Veterans Affairs health system, or individual health insurance you’ve purchased yourself. “Creditable” coverage means that Medicare considers it to be of equal or better value than Part D. 

• If you receive your coverage from Medicaid, the state-run system that provides health insurance to people with incomes under a certain level, this becomes secondary insurance when you become eligible for Medicare. Medicare will settle your Part A and Part B medical bills first and Medicaid will pay for any services that it covers but Medicare doesn’t — plus your premiums, deductibles and copays. You also automatically qualify for full Extra Help, a program that provides Medicare Part D drug coverage at low or reduced cost, but you must actively join a Part D drug plan to get this coverage and pay small copays for your prescriptions. Add an answer to this item.

Yes, people with limited incomes and resources may be eligible for help paying their Medicare premiums, deductibles and cost sharing. The program that helps with these costs is called the Medicare Savings Program (MSP). For more information on MSP, contact Medicare at 800-633-4227 or www.medicare.gov. Add an answer to this item. 

 Before you choose a Medicare plan, think about your options carefully. Read through the information that is available on all the plans. Talk to your doctor and friends who have Medicare. Compare the costs, benefits, and quality of the plans you are considering.  Ask yourself the following questions:  

• What is most important to you in a Medicare plan — cost, coverage or convenience?

• Will you have your choice of health care providers?

• Will the plan you choose meet your needs? How does the plan’s quality ratings compare with others in your area? With those nationally?

• How much will you have to pay for your health care and prescription drugs?

• Will you have coverage if you travel frequently or leave your hometown for long periods of time?

To compare Medicare plans, use the Medicare Plan Finder at www.medicare.gov/find-a-plan, on the official U.S. government site for people with Medicare, which allows you to compare plans by cost, by quality and by other features that may be of importance to you. dd an answer to this item. 

You'll need to do some homework before you start assessing options and picking plans. Make a list of your doctors and decide how important it is to you that you can continue seeing them once you are on Medicare. Also make a list of any medications you take so you can make sure any prescription drug plan you select will meet your needs. With that kind of information I can help you choose a plan that best fits your needs. Think about your lifestyle. Are you a homebody and never travel outside the U.S.? Or are you an adventurer who goes abroad frequently? Do you split your time between residences and need medical care in different states? All these factors are likely to figure into the decisions you make.
Your financial situation also is important. You'll learn through this guide that Medicare helps pay for medical care for older Americans and people with disabilities. But it's not free. You'll want to choose an option you can afford and build the array of out-of-pocket costs into your budget. And take time to review the ways the federal government can help you pay Medicare's costs if you can't afford them.

You need to pay attention to all of Medicare's parts: Part A covers hospital and hospice care and some skilled nursing services after you've been in the hospital. Part B includes doctor visits and other outpatient services. Part C is Medicare Advantage, which is a combination of Parts A and B — and usually Part D, which helps pay for prescription drugs. 

 1.Opticians and eye exams
While original Medicare does cover ophthalmologic expenses such as cataract surgery, it doesn’t cover routine eye exams, glasses or contact lenses. Nor do any Medigap plans, the supplemental insurance that is available from private insurers to augment Medicare coverage. Some Medicare Advantage plans cover routine vision care and glasses.
 

2. Hearing aids

Medicare covers ear-related medical conditions, but original Medicare and Medigap plans don’t pay for routine hearing tests or hearing aids.  If you are in a Medicare Advantage plan, check your policy to see if it covers hearing-related needs. If it doesn’t, or if you have original Medicare, consider buying insurance or a membership in a discount plan that helps cover the cost of such hearing devices. Also, some programs help people with lower incomes to get needed hearing support. Or you can pay as you go. Congress passed legislation in 2017 that allows some hearing aids to be sold over the counter without a prescription. The Food and Drug Administration has until August to issue proposed guidelines for the sale of these devices.

3. Dental work

Original Medicare and Medigap policies do not cover dental such as routine checkups or big-ticket items, including dentures and root canals. Some Medicare Advantage plans offer dental coverage. If yours does not, or if you opt for original Medicare, consider buying an individual dental insurance plan or a dental discount plan.

4. Overseas care

Original Medicare and most Medicare Advantage plans offer virtually no coverage for medical costs incurred outside the U.S. Some Medigap policies cover certain overseas medical costs. If you travel frequently, you might want such an option. In addition, some travel insurance policies provide basic health care coverage — so check the fine print. Finally, consider medical evacuation (aka medevac) insurance for your adventures abroad. It’s a low-cost policy that will transport you to a nearby medical facility or back home to the U.S. in case of emergency. 

5. Podiatry

Routine medical care for feet, such as callus removal, is not covered. Medicare Part B does cover foot exams or treatment if it is related to nerve damage because of diabetes, or care for foot injuries or ailments, such as hammertoe, bunion deformities and heel spurs. If you face these costs, you may want to set up a separate savings program for them.   

6. Cosmetic surgery

Medicare doesn’t generally cover elective cosmetic surgery, such as face-lifts or tummy tucks. It will cover plastic surgery in the event of an accidental injury. If you face these costs, you also may want to set up a separate savings program for them. 

7. Nursing home care

Medicare pays for limited stays in rehab facilities — for example, if you have a hip replacement and need inpatient physical therapy for several weeks. But if you become so frail or sick that you must move to an assisted living facility or nursing home, Medicare won’t cover your custodial costs. (Nursing homes average about $90,000 a year for a semiprivate room and more than $100,000 for a private room. Costs vary based on where you live and what facility you choose. Planning for nursing home care is a big issue, with lots of choices and decisions. But for those with limited income and savings, Medicaid might help fill in the gaps. 

 1. Not signing up for Medicare at the right time.

Timing, as they say, is everything. It’s especially important when it comes to enrolling in Medicare. As you approach 65, you’ll want to enroll during what the government calls your initial enrollment period (IEP). This seven-month period goes from three months before the month in which you turn 65 until three months after. If you don’t sign up during your IEP, you will get another chance to enroll during Medicare’s annual general enrollment period, from Jan. 1 through March 31 of each year. However, if you enroll at that time, your coverage won’t begin until July. And, because you enrolled late, your monthly premiums for Medicare Part B — which covers your doctor visits and other outpatient services—will likely cost you more.

2. Blowing the special enrollment period.

If you are 65 or older, when you stop working and lose your health insurance coverage or when the insurance you have through your spouse ends, you’ll need to sign up for Medicare. Medicare has created a special enrollment period (SEP) that lets you do that without facing a late enrollment penalty. Again, timing is everything. What many people don’t realize is that you can only use this SEP either while you are covered by job-based insurance or for eight months after you no longer have job-based insurance. Note: Medicare does not count retiree health insurance or COBRA as job-based coverage. So, if that’s the insurance you have, you’ll need to reread mistake number one and sign up when you turn 65 or face that late enrollment penalty.

3. Delaying enrollment when your job insurance is second in line.

Even when you have job-based insurance, some employers, depending on their size, can designate Medicare as your primary health coverage when you turn 65. And if you have Retiree coverage or Cobra, those are considered secondary coverage. If your job-based or other private insurance is considered secondary coverage, it will only pay for a medical claim after Medicare has paid its share. So, if your job-related insurance becomes your secondary coverage, it’s important to sign up for Medicare. If your job-based insurance is primary, then Medicare becomes your secondary coverage. The way to find out if your job-based insurance is considered primary or secondary is to ask your benefits manager or human resources department, or seek help from 800-MEDICARE. 

4. Not understanding Part B and Part D late enrollment penalties.

For every 12 months you delay enrolling in Part B, your monthly Part B premium may be 10 percent higher. The penalty won’t apply if you have job-based insurance or are still under your special enrollment period. For every 12 months you delay signing up for a Part D plan, your monthly premium may be 1 percent higher. Part D plans cover prescription drug costs. You won’t have to pay the Part D penalty if you can show Medicare that you have drug coverage as good as that provided by a Medicare Part D plan. You should receive a letter from your employer — or insurance plan — in September of each year letting you know if you have drug coverage comparable to a Part D plan. If you lose your drug coverage, you’ll be eligible for a two-month special enrollment period, during which you can sign up for a Part D plan without a penalty. But keep that letter so you can show Medicare you did have Part D-comparable prescription drug coverage when the time comes to enroll in Part D. Note: Usually, these penalties last for as long as you have Medicare. But if you are paying this penalty and qualify for and enroll in a Medicare Savings Program or the Extra Help program — which helps low-income older adults pay for Medicare out-of-pocket costs — you will no longer have to pay the penalty.

5. Not fully comparing original Medicare with Medicare Advantage plans.

If you are eligible for Medicare, you have a choice to receive your benefits through original Medicare or a Medicare Advantage plan. The type of Medicare coverage you choose depends on factors such as your health care needs, the insurance your doctors accept, where you live, whether you travel often and your financial situation.

Original Medicare. is the traditional program offered directly through the federal government. It comprises Part A, which covers hospital costs, and Part B, which covers doctor visits and other outpatient services. The vast majority of doctors in the country take this insurance. To help pay for your out-of-pocket costs, you can buy a Medigap policy, which has its own separate monthly premium. Original Medicare does not include Part D (prescription drug coverage), so you must sign up for a stand-alone Part D plan if you do not have other drug coverage. Original Medicare does not have a limit on your annual out-of-pocket costs.

Medicare Advantage (MA) is a private insurance alternative to original Medicare. These plans provide Part A, Part B and usually Part D benefits. They may also offer certain benefits that original Medicare does not cover, such as dental or vision care. Some MA plans may also provide some nontraditional services, such as paying for wheelchair ramps, meals delivered to beneficiaries’ homes and transportation to medical appointments. These plans may also have different costs and rules than Original Medicare. For example, an MA plan can require you to get a referral from a primary care physician before it will cover care from a specialist. And Medicare Advantage plans generally have a network of providers in your geographic area and may not cover care if you see an out-of-network provider (except in emergencies). MA plans have an annual out-of-pocket limit, and you cannot buy a Medigap policy when you are enrolled in Medicare Advantage.

Medicare Advantage. a Medigap policy. Medigaps are supplemental health insurance policies that work with original Medicare. If you have a Medigap policy, it pays part or some of the out-of-pocket costs that Medicare doesn’t cover, such as your Part A hospital deductible or the 20 percent coinsurance in Part B. Depending on where you live, you can choose from as many as 10 different Medigap plans. Each policy has a different letter name (for example, Plan A) and offers a different set of standardized benefits. Policies with the same letter name offer the same benefits, but premiums can vary from company to company. The best time to buy a Medigap policy is during your Medigap open enrollment period. That six-month window starts when you turn 65 years old and have enrolled in Medicare Part B. It’s important to enroll then because during that time the insurance companies that sell Medigap policies cannot deny you coverage if you have a preexisting condition, and they have to sell you a plan at the best available rate. If you try to buy a plan outside of this window, companies may refuse to sell you a policy or may deny you coverage for your existing health problems. Some states have their own rules governing Medigap policies, so if you made this mistake and didn’t sign up during your enrollment period, check with your State Health Insurance Assistance Program (SHIP) at shiptacenter.org to ask about state-specific Medigap rights.

6. Not understanding your out-of-pocket costs.

Although Medicare pays the lion’s share of the medical costs for its enrollees, you need to be prepared for sometimes substantial out-of-pocket costs. Here’s a rundown:

• Premium: Each part of Medicare may have its own monthly premium. Most people have no premium for Part A, which covers hospital services. You will be responsible for the Part B premium, which will be deducted from your monthly benefit if you are collecting Social Security. If you enroll in a Medicare Advantage (MA) plan or a Part D plan, you may also owe a monthly premium, depending on the plan you select.   

• Deductible: Before Medicare starts paying for the cost of your care, you may have to pay a flat amount, called a deductible. Parts A and B in original Medicare have annual deductibles, and some MA and Part D prescription drug plans also have deductibles. Medigap policies often cover original Medicare deductibles.   

• Copayment: This is a fixed amount you pay for specific services. For example, under MA plans you may have a copay — usually around $25 — every time you see a doctor or get another medical service.   

• Coinsurance: This is where your plan will charge you a percentage of the cost of a medical visit or service. If you have original Medicare, you will owe 20 percent of the cost of the service. So, if you get a blood test that costs $100, Medicare will pay $80 and you’ll be responsible for $20. Medigap policies also usually cover your 20 percent share.

7. Choosing a Medicare Advantage plan that doesn’t include your health care providers.

Each type of Medicare Advantage plan has different network rules. Most plans are either health maintenance organizations (HMOs), which often require referrals to specialists and rely on primary care physicians to coordinate a patient’s care, or preferred provider organizations (PPOs), which have networks of doctors, hospitals and medical facilities that contract with a plan to provide services. Your costs are typically lowest when you use in-network providers and facilities, regardless of your plan. If you decide to enroll in an MA plan, check with your providers to learn which plans they accept. If you have questions, contact your plan for more information. If your providers are not in the plan’s network, check to see how much, if anything, the plan will pay for their services.

8. Choosing drug coverage that doesn’t fully and affordably cover your prescriptions.

Whether you’re planning to get your prescriptions covered through a stand-alone Part D plan or under a Medicare Advantage plan, take some time to learn about the rules, what drugs are covered and what your costs will be. Make sure your plan covers your needed drugs. Each Part D plan has a list of covered drugs, called a formulary. If your drug is not on your plan’s formulary, you may have to request an exception, pay out of pocket for the cost, or file an appeal.  Also find out whether your plan places any restrictions (sometimes called utilization management strategies) on coverage. Some plans may place a restriction on a certain drug, but others may not. One restriction might be requiring you to get prior approval from the plan before it will pay for a particular drug. Another example of a coverage restriction is step therapy, which means your plan requires you to try other, less expensive drugs before it will cover a more expensive medicine that you may need. You should also take a look at whether the plan you’re considering will give you a good deal at the pharmacy of your choice — or through mail order. Each Part D plan has a network of pharmacies that include both preferred and non-preferred pharmacies. You typically pay less for your prescriptions at preferred pharmacies.

9. Assuming you can’t afford Medicare.

If you have a limited income, you may be able to get assistance with your health costs through certain programs. Medicare Savings Programs (MSPs) help pay the monthly Part B premium and may help with Medicare cost sharing, depending on the program (there are three types of MSPs). Contact your SHIP at shiptacenter.org to learn if you are eligible for an MSP. Extra Help is a federal program that helps pay for some to most of the costs of Medicare Part D prescription drug coverage. Contact the Social Security Administration at 800-772-1213 or visit ssa.gov to learn if you are eligible for Extra Help and to start an application. State Pharmaceutical Assistance Programs (SPAPs) are offered in some states to help eligible individuals pay for prescriptions. Contact your SHIP at shiptacenter.org to learn if there is an SPAP in your state.