Medicare is the federal health insurance program for people age 65 and older. Certain people younger than age 65 can qualify for Medicare, including those who receive Social Security Disability Income and those who have permanent kidney failure. Because Medicare is health insurance, you share the costs of your care.
Traditional Medicare is also called Original Medicare or “Fee-For-Service” Medicare. This federal program starts with Part A and Part B. For most people, Original Medicare Part A and Part B is a starting point for assembling more complete coverage.
This helps pay for inpatient care in a hospital or skilled nursing facility (following a hospital stay), some home health care, and hospice care. Part A is premium-free for most people, but beneficiaries share costs through deductibles and co-insurance.
This helps pay for doctors’ services and many outpatient medical
services and supplies. Part B is technically optional because most
beneficiaries must pay a monthly premium; it comes with an annual
deductible plus a 20 percent co-pay. If you want a Medigap supplement or
a Medicare Advantage plan to help pay the co-pays, you must have both
Parts A and B.
Instead of getting your Medicare benefits through the original federal
government program, you can get them through a private insurance
company’s Medicare Advantage (MA) plan. These plans combine all your
Medicare-covered Part A and Part B benefits in a single package and can
include prescription drug coverage (Part D). You must have Parts A and
B before you can enroll in a Medicare Advantage plan. Medicare
Advantage plan members pay a premium for Part B, plus usually a premium
for the Medicare Advantage plan, and co-pays or co-insurance for
services. Medicare Advantage plans are not the same as Medicare
supplements (Medigaps), which work only with Original Medicare.
This Medicare coverage is offered through private companies – either as part of a Medicare Advantage plan or as a stand-alone prescription drug plan for those with Original Medicare. Having either Part A or Part B, or both, makes you eligible for Part D. Part D plan members pay a premium and pharmacy co-pays; some plans also include a deductible. Some people can get Part D through their employer group plan; the Department of Veterans Affairs offers similar coverage.
- If you are turning 65 and have already applied for or already receiving Social Security or Railroad Retirement Board benefits, you should get a Medicare card and packet in the mail about three months before your birthday.
- If you have not applied for Social Security benefits, you need to contact Social Security to sign up for Medicare, even if you are still working. Online Medicare enrollment is available at socialsecurity.gov; however, if one-on-one assistance is needed, SHIBA suggests visiting a Social Security field office in person for assistance. You can do this up to three months before your birthday month.
- If you have questions about eligibility or enrollment in Medicare, call Social Security at 800-772-1213. Always keep a record of the date, time, and name of the service representative, and take careful notes. You may have to call ahead to set up an appointment with Social Security.
Your initial enrollment period is the seven months surrounding your 65th birthday. In this period you can enroll in Parts A, B, C, and D. Your seven months are:
- The three months before your birthday month.
- The month of your 65th birthday.
- The three months following your 65th birthday month. If you sign up during these last three months, your start date will be delayed one to two months.
If you receive Medicare due to Social Security disability, your Parts A and B automatically start in your 25th month of disability income. The initial enrollment for Parts C and D starts in the 21st month and ends in the 28th month.
Note: If your birthday falls on the first day of a month, you start Medicare a month early. Your enrollment period moves up a month, as well. Example: If your birthday is Jan. 1, you can start Medicare on Dec. 1. You can sign up as early as Sept. 1. See the deadlines page.
If you receive your red, white, and blue
Medicare card in the mail, you will be set up to start Parts A and B
beginning the first of the month you turn 65. You must decide:
- Whether to keep Part B coverage (see next question) and
- What, if any, other Medicare insurance you want,
especially if you are not working. Parts A and B do not include
prescription drug coverage. You are responsible for deductibles, 20
percent of medical bills, and other costs. Many people buy additional
coverage. It might be a Medicare supplement (also called Medigap) plus a
prescription drug plan or it might be a Medicare Advantage plan.
Unless you qualify to delay enrollment in Parts B and D, you could face
lifetime penalties later for not enrolling during the seven-month period
surrounding your 65th birthday.
If I am covered by my employer coverage, do I need to bother with Medicare?
Yes, you have choices to make as you turn 65. Some people who are actively working and have insurance (but not COBRA) can delay enrollment in Parts B and D without a penalty. However, if you don’t qualify for a penalty-free delay, you’ll pay higher premiums for the rest of your life. Key points:
- Most people take Part A because it is premium-free. Even if you delay your Part B, signing up for your Part A now makes it simpler whenever you start your Part B.
- However, if you are participating in a Health Savings Account (HSA) as part of your employer’s High Deductible Health Plan (HDHP) coverage, signing up for any part of Medicare will prohibit you from contributing further to the HSA. You can still use the HSA funds to pay medical expenses, but once your Medicare begins, tax-free contributions must end.
- You or your spouse’s employer is key to whether you need Medicare Parts B and D at this time. First, you need a letter from your employer stating whether your prescription drug coverage is determined to be "creditable" – as good as Medicare’s.
- Additionally, you need to ask your or your spouse’s employer how your group insurance works with Medicare and whether you may want to buy Part B. Employer group plans with less than 20 employees only pay 20 percent or charges as if they were secondary to Medicare.
- Once you have this information, you can decide whether you need Part B and/or Part D. If you plan to delay enrollment in Part B, visit Social Security (not Medicare) to make sure you won’t be penalized later. Document the conversation by writing down the name of the person you spoke with, the date, the time, and what was said.
If you decide to delay enrollment in Part B, your Welcome to Medicare packet contains an explanation on how to do this. If you delay enrollment in Part B, Part D, or both, you have enrollment deadlines soon after your employer-provided coverage ends.
It depends. If you or your spouse have a large group employer or union coverage based on active work, then you might qualify to put off taking Part B and paying its premium until you no longer have this insurance. See the previous question on employer coverage.
When your active work employer group coverage (not COBRA) ends, you will have an eight-month Special Enrollment Period (SEP) in which you can sign up to have your Part B begin. It can start without a lapse in coverage or a penalty on your Part B premium. Again, be sure to confirm with Social Security now that you will qualify for the special enrollment period. Document the contact – keep a record of the date, time, name of the representative, and information.
If you delay Part B and do NOT qualify for a special enrollment period, you will be able to enroll only in the General Enrollment Period, which is every year from Jan. 1 to March 31. Coverage begins July 1 that year. In addition, you will be charged a 10 percent premium penalty for every year that you were eligible to have Part B but did not. That penalty will be added to your Part B premium for as long as you have Medicare.
No. COBRA refers to a federal law that lets some
people keep their employer coverage going temporarily when they lose
their job. Being on COBRA doesn’t count as actively working. To delay Part B enrollment without penalty, you or a spouse must be actively working and receiving coverage under a group health plan.
If you’re already on COBRA and then your Medicare starts, turning 65
will change your status. Your COBRA will end. You will not qualify to
delay your Part B without penalty. If you are already on Medicare and
then start COBRA, you will still need to have Part B.
There are two general routes for assembling your Medicare insurance if you don’t have an employer group plan or Veterans Affairs (VA):
- You can keep Original Medicare (Parts A and B) and use any doctor that accepts Original Medicare. Ask your doctor if he or she accepts Original Medicare, because not every doctor does. You can then add a Medigap supplement insurance plan to help cover the deductibles and other medical cost sharing plus enroll in a stand-alone Part D prescription drug plan.
- If you have Parts A and B, you can enroll in one of the Medicare Advantage plans offered in your area. These plans, through private companies, combine your Part A and Part B Medicare coverage and typically include prescription drug coverage. You need to determine what plans are available and which ones your doctor accepts. Typically, you must use doctors and hospitals in the plan’s network. Also, check out how well the plan’s Part D covers your list of prescriptions. SHIBA is a good source for this information.
Here are some charts of your choices:
- The Medicare website offers this diagram of the two choices.
Which route is best for me?
The best Medicare insurance for you depends on such key factors as what your doctor accepts, your health and prescription drug needs, your budget, and whether you plan to travel a lot. A SHIBA counselor can help you understand your choices, call 800-722-4134.
- During the fall, SHIBA publishes its annual "Oregon Guide to Medigap, Medicare Advantage & Prescription Drug Plans" that shows the different plan costs and benefits for the year that starts in January. You can view the guide online.
- The best way to select a drug plan (whether looking for a stand-alone plan or integrated into a Medicare Advantage plan) is to use the Plan Finder tool. This tool allows you to enter your unique list of prescription drugs, then searches the plans and creates a list of choices starting with the least expensive for you. If you need help with this search, contact a local SHIBA counselor at 800-722-4134.
If you have an individual/family plan (not group coverage) when you become Medicare-eligible, turning 65 will change your status and your coverage may end. You will be expected to enroll in Medicare. Many government assistance programs also require you to enroll in Medicare when you become eligible.
You can combine Medicare with some health insurances, such as group coverage through an employer or retiree coverage. In fact, you may have to enroll in Medicare to continue to have this medical coverage or to avoid expensive medical bills.
How employer coverage works with Medicare varies. The key is to contact your employer or benefits administrator to see what happens when you turn 65. Some examples of where to call:
- State of Oregon employees: 800-768-7377 or visit the PERS Health Insurance Program online.
- Federal employees (Office of Personnel Management): 888-767-6738 or visit the website.
- Veterans: Contact your local veterans’ service officer if you have questions about whether to enroll in Medicare; contact SHIBA if you have questions about how Medicare works once you enroll, if you are not close to a veterans’ medical facility. Visit the veterans' office locator website.
Medicare will send an “Initial Enrollment Questionnaire” asking about
other insurance so that it can set up your file and make sure your
claims are paid correctly. If you don’t receive this questionnaire
before your Medicare starts, contact Medicare or fill out the form
online through MyMedicare.gov
Medicare does not cover
long-term custodial care, routine dental care, dentures, cosmetic
surgery, acupuncture, naturopathy, hearing aids, routine eye exams,
eyeglasses (except after cataract surgery), care outside the United
States, or exams for fitting hearing aids. Medicare Advantage plans may
cover some of these services (such as providing a limited benefit for
routine vision or preventive dental care).
does not cover outpatient prescription drugs. However, if you have
Medicare Part A, Part B, or both, you can enroll in a stand-alone Part D
plan to help pay for prescription drugs. Most Medicare Advantage plans include Part D coverage.
There is no “season”; you can apply for a Medigap supplement policy at any time. However, insurance companies generally may increase your starting premium because of your medical history (underwrite) and refuse to issue a policy. You have “guaranteed issue” (they may neither deny nor underwrite) during your six-month Medigap open enrollment period. This period begins the day your Part B starts and lasts for six months. This is the best time to purchase this insurance if you want to try it.
Other situations, such as employer coverage ending, may open a 63-day guaranteed issue opportunity. The SHIBA publication, Oregon Guide to Medigap, Medicare Advantage & Prescription Drug Plans, has information on Medigap carriers, premium comparisons, and a list of guaranteed issue situations.
This depends on what type of Medicare insurance package you assemble.
For example, if you have Original Medicare (Parts A and B), you will use
your Medicare card when you get hospital or medical services. You will
also use a separate card if you have a supplement and yet another card
if you have a prescription drug plan. However, if you have a Medicare
Advantage plan, you will use that plan’s card.
Once in Medicare, most people can change Medicare Advantage and prescription drug plans once a year. The date is Oct. 15 through Dec. 7. Changes are effective Jan. 1 of the next year. If you have Medicare and Medicaid (“dual eligible”), you can enroll in a plan, disenroll, or change plans at any time.
Other options are:
- Medicare Advantage Disenrollment Period (MADP) – You can switch from Medicare Advantage to Original Medicare from Jan. 1 to Feb. 14.
- 5 Star SEP – If the Medicare Advantage plan has five stars on Medicare.gov, you may enroll in the plan at any time.
- Low-performing SEP – If the plan you are in is low performing (under three stars for three years in a row) you may leave this plan at any time.
Changes involving a Medigap are different. If you want to switch from a Medicare Advantage plan, you may have to wait until an open enrollment period in order to leave the plan.
- New Birthday Rule – You may change to another Medigap policy with the same or lesser benefits starting on your birthday and ending 30 days later. Click here for more information.
It depends on your insurance choices and your annual income. Most people get Part A at no cost but Part B has a monthly premium. Most people on entering
Medicare in 2017, pay $134 monthly for Part B but people with higher incomes pay more.
- If all you have is Medicare Part A and Part B, you pay the Part B premium plus a significant share of the costs when you use medical services. For example, you pay a deductible ($1,316 in 2017) for hospital stays, and an annual deductible ($183 in 2017) plus 20 percent co-insurance for doctor bills and outpatient coverage. The deductibles change annually.
- You can pay a monthly premium for a Medicare supplement to cover part or all of the Part A and Part B cost sharing listed above. Premium costs vary widely for Medigaps.
- Part D plans have a monthly premium. Some plans have a deductible. You have a co-pay when you get prescription drugs at the pharmacy.
- If you join a Medicare Advantage plan, you will pay the Part B premium, a premium (although $0 plans exist in some areas) for the Medicare Advantage plan, which can include your Part D coverage, plus co-pays when you use services or get prescription drugs.
If you are receiving a monthly retirement or disability (Social Security) check, your Part B premiums will be deducted from your check. If you are not receiving Social Security, you have two options:
- You can be billed once every three months. If you choose to mail in a check, be sure to send it registered mail/return receipt requested every time.
- Medicare Easy Pay: sign up for a monthly electronic fund transfer from your bank account.
Medicare has savings programs that help some limited-income people pay the Part B premium and other Medicare medical costs, and with Part D prescription drug costs.
- Part B premium: To see if you qualify for help with the Part B premium, apply at your local office of Seniors and People with Disabilities (part of the Oregon Department of Human Services). This is part of the Medicaid program. To find your local office, call 800-282-8096.
- Extra Help with Part D: You may qualify for financial help paying for a Medicare prescription drug plan through Social Security. You may apply online, or call Social Security at 800-772-1213, TTY 800-325-0778, to apply over the phone or to request an application. You can also call SHIBA at 800-722-4134 or Medicare Savings Connect at 855-447-0155.
Medicaid is a state-run assistance program that provides varying levels
of hospital and medical coverage for people with low income and
resources. Some “dual eligible” people qualify for both Medicare and
Medicaid. Beneficiaries who qualify for the Medicare Savings Program can
receive help with Medicare medical and prescription drug costs. For
Medicaid information, contact your local Department of Human Services
(DHS) office by calling 800-282-8096 or going here
- Part A or Part B eligibility and enrollment questions are answered by Social Security, 800-772-1213, which has local offices.
- Part C (Medicare Advantage) or Part D (Rx) enrollment questions go to Medicare, 800-633-4227.
- In all cases, document your call – save information on the date, time, the name of the person you spoke with, and the key parts of the conversation.
- Contact your benefits administrator or group plan if you have other insurance, or questions about what happens when you turn 65.
- Contact the Senior Health Insurance Benefits Assistance (SHIBA) program by calling 800-722-4134 or visit the SHIBA website to find an office in your area. The state of Oregon SHIBA program offers free information to help you make your Medicare choices.
What if I act on wrong information?
- If you get wrong enrollment information from federal officials (Social Security or Medicare) and you documented the conversation (date, time, name of person you spoke with, and the key information provided), you may get “equitable relief” from any resulting problems or penalties.
- If you get information from any other sources – whether it is insurance agents, human resources benefits administrators, volunteer counselors or news articles – you may not be able to fix the problem. Example: You missed the deadline to enroll in Part B because someone other than Social Security erroneously said you didn’t need it. You probably will have a lapse in coverage and be stuck with the lifetime penalty.