An overview of Medicare and the Medicare enrollment process
Medicare is the U.S. government’s health insurance program for seniors and those younger than age 65 with certain qualifying medical conditions. It is a program that tends to be complicated to the uninitiated. To help you understand Medicare better, we’ve put together this helpful article outlining everything you need to know.
For starters, let’s talk eligibility. Just about every citizen 65 years or older is eligible for Medicare coverage in the United States. Individuals under age 65 may still qualify due to certain medical conditions. For example, any sort of kidney disease requiring regular dialysis or a kidney transplant (End Stage Renal Disease) or people with amyotrophic lateral sclerosis (ALS, or Lou Gehrig’s disease) will also be eligible for Medicare benefits. Additionally, people who are under the age of 65 and receiving disability benefits from the Social Security Administration (SSA) or the Railroad Retirement Board are eligible.
Medicare enrollment for seniors
The vast majority of Medicare participants are seniors with varying levels of healthcare needs. The nice thing for them is that they don’t need to jump through any hoops to be enrolled in the program. It’s done automatically, by way of the Social Security system. An exception to this rule might be certain kinds of workers, like religious ministers, who did not contribute to Social Security during their working years. They will have to go through the enrollment process by applying on their own.
Another exception would be those individuals who reach age 65, but are not yet drawing Social Security payments. Such individuals will also have to apply on their own. This can be done by visiting the Social Security website (SSA.gov) or calling the SSA directly. If there’s a local Social Security office in your area, you could sign up through them, as well.
Seniors already receiving Social Security benefits will receive a Medicare card in the mail several months before they turn 65. This gives them plenty of time to learn about the program, what it offers and what’s required of them. This is also the time to ask questions about anything that is not understood. Medicare Parts A and B will then kick in on the first day of whatever month the individual turns 65. If your birthday were to fall on October 12, for example, your coverage would be valid on October 1st.
Quick summary of Medicare benefits
Medicare benefits are divided into four primary classifications known as “parts.” The classifications are as follows:
- Medicare Part A – Also known as hospital insurance, this covers the care received at a hospital, assisted living facility, skilled nursing home or hospice. Patients who have paid into Social Security for less than 10 years are required to pay a monthly premium for this coverage. Medicare Parts A and B are together known as Traditional or Original Medicare.
- Medicare Part B – Also known as medical insurance, Part B is standard medical coverage intended to pay for routine care. It covers things like doctor visits, X-rays and outpatient hospital services.
- Medicare Part C – Rather than being a separate benefit, Part C, which is also referred to as Medicare Advantage (MA), is what allows private insurance companies to provide Medicare Advantage benefits. Medicare Advantage or Medicare Part C is an alternative to Original Medicare. If you receive Medicare coverage through a private insurance company, it is facilitated through Part C.
- Medicare Part D – This is the Medicare program’s prescription coverage for seniors.
Because Medicare can be so confusing, it’s a good idea to do some research before you turn 65. It’s important to make sure you thoroughly understand the program in order to make wise decisions about your coverage options.
Have questions about Medicare Enrollment or Medicare Advantage? Simply call us toll-free at any time to speak with a licensed healthcare professional.
Medicare enrollment periods
Just like private health insurance, Medicare has very specific enrollment periods consumers must adhere to. Individuals are not allowed to change their coverages once the enrollment period has passed for the year. This limitation makes it very important to know exactly what you need before the enrollment period begins.
Seniors already receiving Social Security benefits will be allowed to begin making enrollment choices three months prior to their 65th birthday. They’ll be able to continue making changes until three months after the month of their 65th birthday. Those who sign up on their own will have a total of seven months to enroll, beginning three months prior to their 65th birthday. Please note that if you wait until the month of your 65th birthday, there will be a three-month delay in the start of coverage. Therefore, it’s best just to take care of things ahead of time.
During the initial enrollment period, individuals can choose either Part A alone or a combination of Parts A and B together. If a person neglects Parts A and B during the initial enrollment period, he is not eligible to sign up for them again until the open enrollment period, which begins on January 1st of the following year. He’ll then have until March 31st to enroll. Coverage will begin in July.
Individuals who would prefer Part C (Medicare Advantage) coverage, rather than A or B, can be added or dropped any time between October 15 and December 7. Understand that even if you drop Part C late in the year, you still won’t be able to enroll in Parts A or B until the following January.
A person is required to enroll in a Part D plan through a private carrier during their initial enrollment period. If a person chooses not to enroll in a Part D plan during the initial enrollment period, they can enroll in Part D prescription coverage during the open enrollment period between October 15 and December 7. It’s important that you understand how part D coverage works with your current health insurance plan before you make a Part D choice. Part D plans from some insurance companies may not work well with your current health insurance.
You should also be aware that certain penalties apply for not adhering to the initial enrollment periods. Those penalties come by way of higher premiums and out-of-pocket expenses. Do your best to make sure you follow the rules.
Lastly, Medigap Supplemental Insurance coverage should be purchased within the first six months of signing up for Part B. Signing up during this time frame will guarantee that you get the Medigap coverage you want. After six months, you could be turned down for coverage. You could also be accepted, but forced to pay a higher rate.
Medicare for individuals with disabilities
Individuals suffering from certain disabilities may qualify for Medicare well before their 65th birthdays. As we mentioned previously, a person with a kidney disease requiring regular dialysis or kidney transplant (End Stage Renal Disease) is automatically eligible. Patients with Lou Gehrig’s disease are also automatically eligible.
In order to apply, a person’s medical condition would have to be documented accordingly. There are waiting times, as well. For example, a patient suffering from kidney failure is not eligible for Medicare until three months after the beginning of dialysis. The good news is that coverage begins immediately at the three-month mark, provided the patient notifies the Social Security Administration.
For disabilities other than Lou Gehrig’s disease and kidney failure, Medicare eligibility is linked directly to receiving Social Security disability benefits. Simply put, a person is not eligible for Medicare until they’ve already been receiving disability payments for two years. The silver lining here lies in the fact that the SSA will automatically sign up an individual for Medicare when that two-year mark is reached.
As for what disabilities qualify, it comes down to anything that would necessitate an individual having to apply for Social Security disability. Any disability that would prevent you from working and leading a normal life would be considered for disability benefits. That’s not to say you would be approved, but your case would be looked at.
Medicare information resources
Information about the government’s Medicare program is available directly from the Medicare website. The address for that site is: www.medicare.gov/. The website offers a plethora of helpful information that should answer all of your questions. If not, we recommend visiting your local Social Security office.
The Centers for Medicare and Medicaid Services (CMS) is another great resource for helpful information. This government agency is tasked with responsibility of administering Medicare at the federal level, while also assisting the states to administer other insurance programs like Medicaid and the State Children’s Health Insurance Program (CHIP). You can find the website at: www.cms.gov/.
Finally, the Social Security Administration offers limited information on their website, as well. When you visit the site you’ll be able to apply for Medicare, download important documents or find the location of the Social Security office nearest to you. The website address is: www.ssa.gov/pgm/medicare.htm
In addition to those links, you can also find additional information at Medicare.net. This new site is focused on bringing consumers together with Medicare specialists.