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Which services does Medicare cover?
Medicare covers certain medical services and supplies in hospitals, doctors’ offices, and other health care settings. If you have both Part A (Hospital) and Part B (Medical), you can get all Medicare services covered under Part A or Part B, whether you have Original Medicare or a Medicare Advantage Plan (like an HMO or a PPO). To get Medicare-covered Part A and/or Part B services, you must be a U.S. citizen or be lawfully present in the U.S. To learn more about your options, call Medicare Plan Options at 888-619-7088.
When can I enroll?
Initial Enrollment Period
When you’re first eligible for Medicare, you have a 7-month Initial Enrollment Period to sign up for Part A and/or Part B.
For example, if you’re eligible for Medicare when you turn 65, you can sign up during the 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65.
If you sign up for Part A and/or Part B during the first 3 months of your Initial Enrollment Period, in most cases, your coverage starts the first day of your birth month. However, if your birthday is on the first day of the month, your coverage will start the first day of the month prior.
If you enroll in Part A and/or Part B during the month you turn 65, or during the last 3 months of your Initial Enrollment Period, the effective start date for your Medicare coverage will be delayed.
If you did not sign up for Part A (or if you have to buy it) and/or Part B (for which you must pay premiums) during your Initial Enrollment Period, you can sign up between January 1–March 31 each year. Your coverage will not start until July 1 of that year, and you may have to pay a higher Part A and/or Part B premium for late enrollment.
Special Enrollment Period
If you or your spouse are still working, and you did not sign up for Part A or Part B because you are covered under a group health plan based on current employment, (your own, your spouse’s, or if you are disabled – your family member’s), you may still have a chance to sign up for Medicare during a Special Enrollment Period.
You can sign up for Part A and/or Part B at any time in which you are covered by the group health plan or during the 8-month period beginning the month after the employment ends or the coverage ends, whichever happens first.
Usually, you do not pay a late enrollment penalty if you sign up during a Special Enrollment Period. This Special Enrollment Period does not apply to people with End-Stage Renal Disease (ESRD).
Note: If you are disabled, the employer offering the group health plan must have 100 or more employees.
COBRA (Consolidated Omnibus Budget Reconciliation Act) coverage and retiree health plans
are not considered coverage based on current employment.
You are not eligible for a Special Enrollment Period when that coverage ends. To avoid paying a higher premium, make sure you sign up for Medicare when you are first eligible.
What is a Medicare Advantage Plan?
A Medicare Advantage Plan (like an HMO or PPO) is another way to get your Medicare coverage. A Medicare Advantage Plan, sometimes called “Part C” or “MA Plan,” is a Medicare health plan offered by a private company that contracts with Medicare to provide you with all of your Part A and Part B benefits. If you join a Medicare Advantage Plan, you will still have Medicare but you will get your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage from your Medicare Advantage Plan, not Original Medicare. You will generally get your services from a plan’s network of providers. Remember, in most cases, you must use the card from your Medicare Advantage Plan to get your Medicare-covered services. Keep your Original Medicare card in a safe place because you will need it if you ever switch back to Original Medicare.
Make sure you understand how a plan works before you join. Providers can join or leave a plan’s provider network anytime during the year. Your plan can also change the providers in the network anytime during the year. If this happens, you may need to choose a new provider.
What does a Medicare Advantage Plan Cover?
Medicare Advantage Plans cover all Medicare Part A and Part B services except hospice care and some costs in qualifying research studies. They also cover emergency and urgent care. Original Medicare will cover hospice care and some costs for clinical research studies, even if you are in a Medicare Advantage Plan.
Medicare Advantage Plans may offer extra coverage such as vision, hearing, dental, and other health and wellness programs such as a gym membership. Most plans include Medicare prescription drug coverage (Part D). In addition to your Part B premium, you might pay a monthly premium for the Medicare Advantage Plan, however some plans offer a Part B premium reduction or “buy down” as a benefit.
Medicare pays a fixed, monthly amount for your coverage to the companies offering Medicare Advantage Plans, so these companies must follow the rules set by Medicare. Each Medicare Advantage Plan can charge different out‑of‑pocket costs and have different rules regarding your services. These rules can change each year. The plan must notify you about any changes before the start of the next enrollment year.
Note: You have the option to keep your current plan, choose a different plan or switch to Original Medicare each year during the Open Enrollment Period. Medicare Open Enrollment begins on October 7th and ends on December 7th.
Make sure you understand how a plan works before you join. Providers can join or leave a plan’s provider network anytime during the year. If this happens, you may need to choose a new provider.
What are the different types of Medicare Advantage Plans?
Health Maintenance Organization (HMO) Plans – With most HMO plans, you can only go to doctors, other health care providers or hospitals in the plan’s network except in an urgent or emergency situation. You may also need to get a referral from your primary care doctor for tests or to see other doctors and specialists.
Preferred Provider Organization (PPO) Plans – With a PPO plan, you pay less if you use doctors, hospitals and other health care providers that belong to the plan’s network. You usually pay more if you use doctors, hospitals and providers outside of the network.
Special Needs Plans (SNPs) – SNPs provide focused and specialized health care for specific groups of people, such as those who have both Medicare and Medicaid, live in a nursing home, or have certain chronic medical conditions.
HMO Point-of-Service (HMOPOS) Plans – these are HMO plans that may allow you to get some out-of-network services for a higher copayment or coinsurance.
Private Fee-for-Service (PFFS) Plans – PFFS plans are similar to Original Medicare in that you can generally go to any doctor, other health care provider or hospital as long as they accept the plan’s payment terms. The plan determines how much it will pay doctors, other health care providers and hospitals, as well as how much you must pay when you receive care.
Medical Savings Account (MSA) Plans – These plans combine a high-deductible health plan with a bank account. Medicare deposits money into the account (usually less than the deductible). You can use the money to pay for your health care services during the year. MSA plans do not offer Medicare drug coverage. If you want drug coverage, you have to join a Medicare Prescription Drug Plan.
Note: It is important to check with the plan for information about your rights and responsibilities. You must follow plan rules. If you go to a doctor, other health care provider, facility or supplier that does not belong to the plan’s network, your services may not be covered or your costs could be higher. In most cases, this applies to Medicare Advantage HMOs and PPOs.
You can join a Medicare Advantage Plan even if you have a preexisting condition, except for End-Stage Renal Disease (ESRD), for which there are special rules.
How does Medicare Prescription Drug Coverage (Part D) work?
Medicare offers prescription drug coverage to everyone with Medicare. You must join a prescription drug plan approved by Medicare in order to receive the drug coverage. Each plan can vary in cost and cover specific drugs. Even if you do not take many prescriptions now, you should consider joining a Medicare drug plan. If you decide not to join a Medicare drug plan when you’re first eligible, you don’t have other creditable prescription drug coverage and you don’t get Extra Help, you will likely pay a late enrollment penalty if you join a plan later. Generally, you will pay this penalty for as long as you have Medicare prescription drug coverage.
If you have a higher income, you might pay more for your Part D coverage. If your income is above a certain limit ($85,000 if you file individually or $170,000 if you’re married and file jointly), you will pay an extra amount in addition to your plan premium. This does not affect everyone, so most people will not have to pay a higher amount.
Usually, the extra amount will be deducted from your Social Security check. If you get benefits from the Railroad Retirement Board (RRB), the extra amount will be deducted from your RRB check.
If you are billed the amount by Medicare or the RRB, you must pay the extra amount to Medicare or the RRB and not your plan. If you don’t pay the extra amount to Medicare (or RRB), you could lose your Part D coverage. You may not be able to enroll in another plan right away and you may have to pay a late enrollment penalty for as long as you have Part D. If you have to pay an extra amount and you disagree (for example, you have a life event that lowers your income.
Yearly deductible is the amount you must pay before your drug plan begins to pay its share of your covered drugs. Some drug plans do not have a deductible.
Copayments or coinsurance are the amounts you pay for your covered prescriptions after the deductible (if the plan has one). You pay your share and your drug plan pays its share for covered drugs. These amounts may vary.
How can I get Medicare prescription drug coverage?
Enroll in a
Medicare Prescription Drug Plan (sometimes called “PDPs”)
You must have Part A or Part B to join a Medicare Prescription Drug Plan. Another option is to enroll in a Medicare Advantage Plan (like an HMO or a PPO plan) or other Medicare health plans that offer Medicare prescription drug coverage. You can get all of your Part A, Part B, and prescription drug coverage (Part D) through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA‑PDs.”
Generally, you must stay enrolled throughout the calendar year, however, in certain cases you may be able to join, switch or drop a Medicare drug plan. Some examples are if you:
If you want to drop your Medicare drug plan and you don’t want to join a new plan, you can disenroll by calling 1-800-MEDICARE (1‑800‑633‑4227). TTY 1‑877‑486‑2048. You can also send a letter to the plan to tell them you want to disenroll.
Move out of your plan’s service area
Lose other creditable prescription drug coverage
Live in an institution (such as a nursing home)
Qualify for Extra Help
What is a Medicare Supplement or “Medigap Policy”?
Original Medicare pays for many health care services and supplies, but not all. Medicare Supplement Insurance policies (also called Medigap policies), sold by private companies, can help pay some of the health care costs that Original Medicare does not cover, like copayments, coinsurance, and deductibles.
If you have Original Medicare and you buy a Medigap policy, Medicare will pay its share of the Medicare-approved amount for covered health care costs and your Medigap policy pays its share. You have to pay premiums for a Medigap policy. Some Medigap policies offer coverage for services that Original Medicare does not cover, such as medical care when you travel outside of the U.S.
The best time to buy a Medigap Policy is during your Medigap Open Enrollment Period. This 6 month period begins on the first day of the month in which you are 65 or older and enrolled in Part B. After this enrollment period, you may not be eligible to buy a Medigap policy.
Important facts: You
must be enrolled in Medicare Part A and Part B.
You pay the private insurance company a monthly premium for your Medigap policy in addition to the monthly Part B premium that you pay to Medicare.
Contact the private insurance company to find out more about how to pay your monthly premium.
Additionally, a Medigap policy only covers
one person. Spouses must buy separate policies. It is important to compare Medigap policies since the costs can vary and may go up as you get older. Some states limit Medigap premium costs. You cannot have prescription drug coverage on both your Medigap policy and Medicare drug plan.
What is a Coverage Gap?
Most Medicare drug plans have a Coverage Gap (also called the “donut hole”). The coverage gap begins after you and your drug plan together have spent a certain amount for covered drugs.
In 2016, once you enter the coverage gap, you pay 45% of the plan’s cost for covered brand-name drugs and 58% of the plan’s cost for covered generic drugs until you reach the end of the coverage gap. Not everyone will enter the coverage gap because their drug costs won’t be high enough.
The drug plan premium and what you pay for drugs that are not covered
do not count toward getting you out of the coverage gap. Some plans offer additional cost sharing reductions in the gap beyond the standard benefits and discounts on brand-name and generic drugs, but they may charge a higher monthly premium. Check with the plan first to see if your drugs would have additional cost sharing reductions during the gap. In addition to the discount on covered brand‑name prescription drugs, there will be increasing coverage for brand-name and generic drugs in the coverage gap each year until the gap closes in 2020.
Once you get out of the coverage gap, you automatically get “catastrophic coverage.” With catastrophic coverage, you only pay a coinsurance amount or copayment for covered drugs for the rest of the year.
Note: If you get Extra Help, you will not have some of these costs.