Are You New to Medicare?
Am I eligible for Medicare? When should I apply? How do I sign up? These are common questions that must be answered to ensure you don’t miss the enrollment period.
US citizens are eligibility for Medicare coverage when they turn 65. These benefits are also offered for non-citizen permanent residents of the same age, but they must have lived in the country for a minimum of five years.
Additionally, there are other eligibility qualifications for people under the age of 65. You might qualify for Medicare if you:
- Have a permanent disability and have received benefits through the Social Security Disability program for at least 2 years.
- Have kidney failure (end-stage renal disease).
- Have Lou Gehrig’s disease (Amyotrophic Lateral Sclerosis) and are receiving Social Security Disability benefits.
As you learn more about the Medicare program, it might seem overwhelming to know if you qualify and how you apply. Most people do not realize that you actually apply for Medicare through Social Security. You will apply for both Part A and Part B. When you turn 65 you are eligible for Part A. You can also enroll in Part B at 65, but you don’t have to if you are still working and receive credible health insurance benefits through your employer. Luckily, our team at Amante and Associates is here to help you navigate the system and make the transition as simple as possible. We also have a link to the Social Security website on our resources tab.
Medicare: When to Apply
Even though Medicare eligibility starts at 65, the Initial Enrollment Period (IEP) is open 3 months before your 65th birthday. This enrollment period is available for 7 months total, continuing through your entire birthday month and an additional 3 months after.
Your Medicare effective date will typically be the 1st of the month that you turn 65. The exception to this is if your birthday is on the 1st day of the month, your effective date and IEP will begin one month earlier.
If you are already receiving Social Security benefits, then Medicare enrollment typically happens automatically on your 65th birthday – you will receive both Medicare Parts A and B. Even if you are receiving Social Security benefits we always recommend that you sign up for Medicare to make sure that you are enrolled and do not miss the initial election period. You will need to speak to an insurance provider if you would like to enroll in other Medicare programs; such as Medicare Advantage plans (Part C), Medicare Supplements, or Part D Prescription Drug plans.
What Happens When You Miss the IEP?
If you aren’t already receiving Social Security benefits, then you must apply for Medicare when turning 65 through Social Security. Don’t miss the Initial Election Period (IEP) because if you do, it means you will need to pay higher premiums through the rest of your life. Certain conditions might allow you to avoid the penalty, but it’s rare if you miss the enrollment period. It is important to remember that if you are still working and receive credible health insurance through your employer you do not need to enroll on Part B. When you retire and lose your health coverage you will be able to enroll onto Part B and will not incur a penalty since you had coverage while working.
In addition to the Initial Enrollment Period, a General Enrollment Period happens every year between January 1st and March 31st. If you want to enroll in Medicare and you missed your IEP, this open enrollment is your opportunity. You will need to pay a late penalty, and coverage goes into effect starting July 1st of that year. Currently coverage under COBRA does not qualify as employer coverage and you may have to pay a penalty if you miss your IEP and enroll during this General Enrollment.
If you have questions about Medicare enrollment, then Amante & Associates is here to assist. Contact our team for more information.
Medicare Enrollment Periods
Medicare enrollment is only available during specific periods of time of the year. When you enroll in Medicare during the Initial Enrollment Period (IEP) you will have the opportunity to enroll onto a Medicare Advantage plan (known as Part C). You also have the option to enroll onto a Medicare Supplement and Part D for prescription drug coverage.
Making these selections during your initial enrollment period doesn’t lock you into this coverage for life. Medicare provides the option to change your plan at certain times of the year.
Annual Election Period (AEP) for Medicare
Each year, you have the opportunity to review your plan and make changes if desired. The Annual Election Period (also known as AEP) happens every year between October 15 and December 7. During this enrollment period, you can:
- Drop an Advantage plan and go back to Original Medicare
- Switch from Original Medicare to an Advantage plan
- Change to a different Medicare Advantage Plan
- Enroll, cancel, or change a Part D prescription drug plan
When you make changes during the AEP, your new coverage goes into effect starting January 1st.
An additional enrollment period is open each year for Medicare Advantage plans between January 1st and March 31st. You have the opportunity to make one change, such as:
- Return to Original Medicare and drop your Advantage Plan
- Switch from one Medicare Advantage plan to another
- Add Part D prescription drug plan if you return to original Medicare
Keep in mind that you can’t count on a Medicare Supplement (Medigap plan) if you decide to drop your Medicare Advantage plan and go back to Original Medicare. Insurance companies have the option to examine your health and prescriptions, which means they can choose to deny enrollment.
Changing Your Plan at Other Times
In addition to the enrollment periods listed above, there are times when you might qualify for a Special Enrollment Period (SEP), which allows you to make changes to your Medicare plan outside of the annual enrollment period and open enrollment. An example of Special Enrollment includes moving from one geographic area to another.
During this SEP, there is no penalty if you choose to return to Original Medicare or switch to a Medicare Advantage plan or Part D plan. Sometimes, there is an option to enroll in a Medicare Supplement with guaranteed issue rights – which means that the requirement for medical underwriting is waived.
Whether you are preparing for your Initial Enrollment Period, Annual Enrollment Period, Open Enrollment Period, or you qualify for a Special Enrollment, it’s wise to work with an experienced insurance advisor. Talk to us at Amante & Associates to learn more about these important enrollment periods.
Defining the ABC’s of Medicare
As you are learning about Medicare coverage, do you understand the difference between the various parts of Medicare: A, B, C, and D? Medicare is divided into these parts, and it’s important to know the coverage available through them.
Medicare Part A
Part A is nicknamed hospitalization insurance. It covers services, such as:
- Hospital in-patient services
- Short-term care in a skilled nursing home
- Hospice services
- Home health care
Medicare Part B
The next part takes care of healthcare needs outside of hospitalization. Part B coverage includes:
- Medically necessary services, such as visits with a doctor, tests, diagnostics, and treatments
- Preventive services including check-ups, routine screenings, and vaccinations
- Ambulance services
- Durable medical equipment
- Mental health support
Keep in mind that Original Medicare includes both Medicare Parts A and B.
Medicare Part C
Medicare Part C, known as Medicare Advantage plans combines Parts A and B into one plan, as well as including Part D prescription drug coverage. The difference between Original Medicare and Part C is that the Medicare Advantage Plans is offered by a private health insurance company, with a contract in place with Medicare.
Advantage Plans must include a minimum of the same coverage available through Original Medicare. Often, Advantage Plans also include Part D to provide coverage for prescription drugs.
In addition, Medicare Advantage plans offers various services that Original Medicare doesn’t. Sevices that might include routine dental and vision, chiropratic , in-home support and non emergent transportation.
There are numerous types of Medicare Advantage Plans (Part C) which include:
- Preferred Provider Organization (PPO) plans
- Health Maintenance Organization (HMO) plans
- HMO Point of Service Plans (HMOPOS)
- Private Fee-for-Service (PFFS) plans
- Medicare Medical Savings Account (MMSA)
- Special Needs Plans (SNPs)
Medicare Part D
Original Medicare does not include full prescription coverage, which is where Part D comes into the picture. Medicare drug coverage through Part D plans helps to lower overall costs when using prescription medications.
Which Medicare Plan is Right for You?
As you are exploring your options, Amante and Associates is here to guide you through the possibilities. Talk to our team to learn more about the right Medicare coverage for you.
Medicare Part D
For years, one undeniable gap in Medicare coverage was the lack of coverage for prescription medications. Beneficiaries had to pay out of pocket for their medications, making it hard to keep up with healthcare costs because of the increasing price of prescription drugs. The federal government opened Medicare Part D in 2006 to address this issue, giving beneficiaries the option to enroll for prescription coverage through private insurance companies.
As with Medicare Advantage plans, Part D coverage allows you to comparison shop to find the program that is the right fit for your unique needs.
Keep in mind that you are not required to enroll into a Medicare Part D plan – it is optional. The benefit of enrolling is that you can access prescription medications at a cheaper rate, with protection against unreasonable costs if you require expensive medications.
It is important to note that while it is optional, if you do not enroll when you become eligible for Medicare and then enroll at a later date, Medicare will asses a late enrollment penalty (LEP). This is a penalty that you will pay monthly for as long as you have Part D coverage.
Cost of Medicare Part D
Your monthly premiums vary depending on the coverage you receive through a selected Part D plan. Prices can range anywhere from $10 – $170 per month, depending on the list of prescriptions included in the plan, copayments and deductibles.
It’s also important to note that Medicare enforces a customized premium for people who make more money. For example, for individuals making more than $88,000 a year or married filing jointly with a taxable income that is more than $176,000 a year in 2021, you will be assigned to pay an Income Monthly Adjusted Amount (IRMAA).
When you have Part D coverage, you will pay an affordable co-pay for prescription medications, based on the negotiated amounts through your plan administrator. Usually, there are different tiers of pricing, with more affordable options available when you choose generic drugs.
Also, many Part D plans include an annual deductible. Each year, you need to pay a specific amount for prescription medications before your Part D insurance benefits kick in. The deductible threshold is set by Medicare each year. Insurance companies can set lower deductibles, but they are restricted from charging higher deductibles than the annual threshold.
How to Enroll in Medicare Part D
If you’d like to enjoy the benefits of Medicare coverage for prescriptions, then consider your options for Medicare Part D. Eligibility begins when you turn 65, with enrollment periods matching open enrollment for Original Medicare and Medicare Advantage Plans. You can add, change, or drop your Medicare Part D plan each year during the Annual Election Period.
While it’s possible to enroll in a Part D plan through Medicare directly, consider a consultation with a licensed insurance agent to determine the right coverage for your needs. You might already have Part D coverage through a Part C (Medicare Advantage) plan. Since private insurance companies provide Part D coverage, you must consider how this coverage matches your unique needs. Talk to us at Amante & Associates to learn more about your options.
Medicare Advantage Plans
When you become eligible for Medicare, there isn’t a one-size-fits-all solution for choosing the right coverage. It can be helpful to talk to an insurance agent to learn more about the types of coverage available to assure it suits your unique needs.
Original Medicare encompasses both Parts A and B. But you also have the option to enroll for coverage through a private health insurance company for Part C, referred to as a Medicare Advantage Plan. Medicare Advantage plans includes everything available through Original Medicare, with options for additional coverage if desired. For example, Advantage plans often include Part D prescription drug coverage as well. You must be enrolled in Part A & B in order to enroll into a Medicare Advantage plan and you will continue to pay your premium to Medicare for Part B. You must also live in the plans coverage area.
Original Medicare vs. Medicare Advantage
The main difference between these types of Medicare plans is how you access available benefits. With Original Medicare, you can visit any doctor or hospital that accepts Medicare.
On the other hand, a Medicare Advantage plan offers benefits through a provider network in a specific coverage area. Co-pays vary depending on the services you need and the type of Advantage plan you choose.
Keep in mind that Original Medicare coverage is offered nationwide. But different Medicare Advantage plans are only available in some geographical regions.
One notable benefit of a Medicare Advantage plan is having all coverage managed through a single comprehensive plan. Medicare Advantage companies are contracted through Medicare, with Medicare paying a set monthly amount to the health plan company. All of your health care needs will be managed and deliverd through the private Medicare Advantage plan.
Medicare Advantage coverage tends to change more than Original Medicare from one year to the next. But you can always review your plan and switch coverage during the Annual Election Period to assure the plan suits your needs for the upcoming year.
Medicare Advantage Plan Benefits
Is a Medicare Advantage Plan right for you? These plans were created to help people avoid high medical expenses when a severe illness or accident happens.
A Medicare Advantage plan is like having a safety net for unexpected medical expenses. Since there is a cap for out-of-pocket spending, you can be rest assured knowing that the plan will cover the rest of your medical expenses after you meet the maximum out of pocket requirements.
Additionally, many Medicare Advantage Plans also provide prescription coverage, eliminating the need to pay for a separate Part D plan.
Things to Consider When Choosing an Advantage Plan
There are many options out there – how do you choose the Medicare plan that is right for you? Since coverage varies, it’s a personal decision to find the right plan for your unique needs. The simplest way to navigate this process is by talking to an experienced insurance agent to compare the different options available. Your agent will guide you to find the coverage that is a good fit for your medical needs.
Identify your priorities when choosing a Medicare Advantage Plan by asking these questions:
- If you prefer visiting specific healthcare providers, do they accept only Original Medicare or Medicare Advantage plans also?
- Does your preferred hospital accept the type of insurance you are choosing?
- Do you travel often? If so, do you have insurance coverage in the areas where you travel?
- What is your tolerance for financial risk? Do you have savings available to pay for significant medical bills if needed?
- Do you want the peace of mind knowing you will have steady healthcare costs over time?
HMO or PPO: What You Need to Know
There are differences in the way your insurance coverage works, depending on whether you choose an HMO or PPO plan. HMO is an abbreviation for Health Maintenance Organization, and you will need to select a Primary Care Physician (PCP) within the network. This doctor coordinates all of your care and is the first point of contact for your healthcare needs (with the exception of an emergency). If you need to visit a specialist, then your PCP will provide a referral to a specialist in the network.
The benefit of an HMO is the low premiums, but they usually come with less flexibility when choosing healthcare providers.
On the other hand, a Preferred Provider Organization (PPO) doesn’t require you to have a primary care physician. You have the option by “self-referring” to choose the specialist you would like to visit. PPOs offer both in-network and out-of-network services, but the costs are higher if you choose a doctor out of your network.
Choosing a Medicare Plan
It takes research and expertise to choose the right Medicare plan. Many factors influence the overall coverage available for your medical care. This information provides a general overview of your options, but nothing matches the personalized recommendations you can get by talking to an insurance agent. For more information, Amante & Associates is here to answer your questions and help you find the optimal plan for your unique needs.
Medicare Supplement Plans
Medicare coverage is broken into several“Parts,” these parts fit together to provide comprehensive coverage. But many people find gaps in their coverage, which means that they end up with out-of-pocket costs. If you want to close these gaps, then a Medicare Supplement Plan (also known as Medigap plans) might be right for you.
When you have Original Medicare paired with a Medicare Supplement program, you will have nationwide coverage. This combination usually results in the lower out-of-pocket costs and optimal flexibility. Your premiums vary depending on the plan, insurance provider you choose, as well as your age, geographic location, gender, tobacco use, and other discounts available through household eligibility.
How a Medicare Supplement Plan Works
The purpose of a Medigap Plan is to cover the costs that Medicare doesn’t pay, such as co-pays, deductibles, and coinsurance.
Medicare will pay it’s share of medical expenses. Then, the supplement plan kicks in to help cover the remaining out-of-pocket costs. The overall coverage varies depending on the supplement plan you choose.
Types of Medigap Plans
In 1990, Medicare standardized all Medigap (supplement) plans with letter designations. There are various supplement plans to choose from: A, B, C, D, F, G, K, L, M, and N. Regardless of the private insurance provider, you receive the same benefits from plans with the same letter. Since there are varying premiums, shop around to compare supplement plans that match your budget and needs.
Certain medical costs aren’t covered by Medicare Supplement plans, including:
- Routine hearing exams and hearing aids
- Regular vision exams, glasses, and contacts
- Routine dental exams
- Custodial care or long-term care
- Retail prescription drugs
Things to Know About Medicare Supplement Plan Enrollment
It’s important to know that the Open Enrollment Period for Medicare Supplement plans differs from the Annual Election Period that happens in the fall each year. Supplement Open Enrollment varies, so you need to know when enrollment is available. A few details include:
- Medicare Supplement Open Enrollment starts the day of activation for your Medicare Part B coverage
- Most individuals have one Medicare Supplement Open Enrollment period
- Since Open Enrollment isn’t an annual occurrence, you will miss the opportunity once it passes
- You have a six-month window of time for Medigap Open Enrollment
- If you want to enroll or change plans in the future, you might be subject to health questions
- Insurance companies are not required to accept you into a Medicare Supplement Program outside of the Open Enrollment Period.
In most situations, you have the opportunity to enroll in a Supplement plan when you turn 65. But if you are still working and decide to delay Part B coverage, then the Open Enrollment period happens later – when Part B coverage begins.
In both situations, this is the opportunity you have to enroll in a Supplement Plan without going through a health questionnaire process. If you decide to enroll in the future, then you could be denied coverage because your plan will go through a health screening process.
If you have a disability and receive Medicare eligibility before the age of 65, then a 2nd Supplement Open Enrollment period happens when you turn 65. This is the only circumstance that offers someone who missed enrollment to have another chance for a Medigap policy without underwriting.
Don’t Miss Your Open Enrollment Window
You must take advantage of the Medicare Supplement Plan Open Enrollment Window if you want this coverage – you may NOT get another chance to enroll without going through a health questionnaire process (and potentially being denied coverage). For more information about available coverage, talk to our team at Amante & Associates. Our insurance agents can help you evaluate your unique needs to find the optimal Medicare insurance coverage and Supplement plans.
Medicare Special Needs Plans
If you have a unique medical situation, then it might require a specialized plan– known as Medicare Special Needs Plans (SNPs). These Medicare Advantage Plans are designed to support people with specific circumstances or health conditions. Not only do the benefits, network, and prescription coverage cater to your needs, but SNPs often provide care coordinators to help with the management of health conditions to ensure you have access to community and health plan resources as well as making sure you receive prescriptions at the right time.
SNPs are available for people with specific chronic illnesses, such as:
- Cardiovascular disease, including chronic heart failure or stroke
- COPD or other chronic lung disorders
- Dementia or Alzheimer’s
- Disabling or chronic mental illness
- Kidney disease requiring dialysis (end-stage renal disease)
- Neurologic conditions
Available SNPs vary depending on the insurance companies in your geographical area. So, there isn’t always a plan open for patients with chronic conditions. Also, eligibility changes if you move to a different coverage area.
The best solution is to work with a professional insurance agent to find available coverage in your local area. You can discuss SNPs and look for options for Institutional SNPs if institutional care is needed for more than 90 days.
Dual Eligible SNPs
DSNPs are Dual-Eligible Special Needs Plans, with coverage coordination for those who qualify for both Medicaid (Medi-Cal in California) and Medicare. Often, Medi-Cal will pay for the DSNP premiums, as well as many of the co-pays and deductibles. Benefits of a DNSP vary, but they might include additional offerings, such as:
- Transportation to pharmacies and medical appointments
- Telemedicine services
- Vision, hearing, and dental coverage
- Coverage for over-the-counter medical supplies
- Gym memberships
Your option to enroll in an SNP is determined by your geographical location. If you choose an SNP, then you must maintain Original Medicare enrollment. You will need to pay Part B premiums to Medicare unless your Medi-Cal eligibility specifically covers these premiums. The SNP premium is a separate charge, and patients also maintain responsibility for deductibles and co-pays based on the plan coverage.
A Special Enrollment Period is available if you become eligible for a SNP outside of the annual enrollment periods. For more information about enrolling in a SNP or other Medicare plans, talk to our knowledgeable team at Amante & Associates.