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Frequently asked questions about Medicare

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At first glance, Medicare can seem confusing, especially as your health care needs change over time. Whether you’re turning 65 soon, thinking about how Medicare fits with your job’s health insurance or helping a loved one to figure out coverage, Higginbotham is here to help answer some of the most common questions about Medicare.

Medicare FAQs

Medicare vs. Medicaid

Medicare and Medicaid often get confused since they both deal with providing health care to target demographic groups. Here are the differences between Medicare and Medicaid:

  • Medicare is a federal government-sponsored healthcare program for those 65 and older and for younger people with disabilities.
  • Medicaid is a federal health care program for lower-income individuals who may not otherwise be able to afford health insurance.

Are Social Security and Medicare the same thing?

Social Security and Medicare are not the same, but they do share many similarities and older Americans often receive benefits from both programs. Some of the confusion between these two programs stems from the fact that the Social Security Administration (SSA) is responsible for Medicare eligibility, enrollment and administration.

  • Social Security is a federally funded program that provides income benefits to retirees who have worked and paid Social Security taxes for at least ten years. Social Security also provides spousal and survivor benefits, and individuals under 65 with a qualifying disability can also receive benefits.
  • Medicare is also a government-run program that provides health insurance coverage for anyone 65 or older who has worked and paid Medicare taxes for at least ten years.

Different Parts of Medicare

Understanding what Medicare covers is essential to knowing what services you have access to. Part A helps pay for hospital stays and inpatient care. Part B helps to cover doctors’ visits and outpatient care. Part C provides Medicare Advantage plans. Part D covers prescription drugs. You also have the option to add supplemental coverage, also known as Medigap, for Parts A and B.

Eligibility Requirements for Medicare

To qualify for Medicare, there are certain requirements that must be met to receive coverage. Both U.S. citizens and qualified legal residents (residents who have lived in the United States for at least five consecutive years before applying for Medicare) have to be one of the following:

  • Age 65 or older
  • Younger than 65 with a disability
  • Any age with a diagnosis of End-Stage Renal Disease (ESRD) or ALS (also known as Lou Gehrig’s Disease)

What if I continue to work past age 65?

Even if you have health insurance through your employer or your spouse’s employer, if you’re eligible, you will still need to consider getting Medicare coverage. In fact, in some cases, you may not be able to delay Medicare enrollment. Depending on your employer’s coverage or your spouse’s employer coverage:

  • You may be required to enroll in Medicare (both Part A and Part B) by your employer or your spouse’s employer.
  • You may be required to enroll in Medicare Part A with the option to enroll in Medicare Part B and/or D at a later date.
  • If you have coverage through an employer with less than 20 employees, you will need to confirm if you need to enroll in Part A and B.
  • If you have a Health Savings Account (HSA) and want to continue contributions, you might want to consider delaying enrollment into Medicare.

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What do I need to do when I’m eligible for Medicare?

Some individuals are automatically enrolled in Original Medicare (Parts A and B) upon reaching age 65 if they were receiving Social Security or Railroad Retirement Board benefits prior to age 65. If you qualify for Medicare due to a disability or specific medical condition, such as ALS, you’ll also automatically be enrolled.

If you are not receiving these benefits, you can find enrollment instructions online at SocialSecurity.gov or medicare.gov.

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Coverage Choices After Enrolling in Medicare

Depending on the state you reside in, you may be required to enroll in both Medicare Part A and Part B or to enroll in Part A with the ability (but not requirement) to add Part B. Once you are enrolled in Medicare Part A and/or B, you have the option to secure additional coverage through a private insurance company.

Depending on your needs, you may want to consider a Medicare Advantage plan (Part C), a Medicare prescription drug plan (Part D) and/or a Medicare supplement insurance plan (Medigap) to complete your Medicare coverage.

Dental coverage isn’t included in Part A and B or Medicare supplemental plans. Additionally, Medicare does not pay for custodial care, commonly referred to as personal care, such as bathing, dressing, transferring, etc. Medicare generally covers skilled care provided in an approved skilled nursing facility for a limited time if it is preceded by a hospital stay. Medicare Advantage plans often offer additional benefits for this type of care.

What preventive services does Medicare cover for free?

Medicare offers a “Welcome to Medicare” physical exam, which is a one-time review of your health that includes counseling about preventive services and referrals for other care if needed. You can only get this within 12 months of signing up for Medicare Part B.

If you’ve had Part B for longer than 12 months, you can get a yearly wellness visit. There are also several free tests and screenings available; these are listed on the Medicare website.

Do you have to sign up for Medicare?

If you are planning to continue working past 65, you may be able to delay enrolling in Medicare. If you have credible health coverage from your employer or are covered under your spouse’s employer-provided plan, you may qualify for a Special Enrollment Period (SEP) and be able to delay enrolling without penalty.

In certain situations, you may still be required to enroll in Parts A and B of Medicare at age 65, even if you plan to continue working. For example, if your employer has fewer than 20 employees, you might be required to enroll in Medicare at age 65.

When am I eligible to sign up for Medicare?

You become eligible for Medicare during the month of your 65th birthday and have a seven-month window of time to sign up for Medicare. This is referred to as your Initial Enrollment Period (IEP). Your IEP includes your birth month and the three months before and after it. If you enroll in Medicare during the three months prior to your 65th birthday, your Medicare coverage will begin on the first day of your birth month.

What happens if I miss my Initial Enrollment Period?

If you miss your IEP, Medicare offers a General Enrollment Period (GEP) from January 1 to March 31 for those who did not sign up around their 65th birthday. However, you may face late enrollment penalties if you wait too long to sign up.

There is also a Special Enrollment Period (SEP) when you have a special event occur, such as loss of coverage through an employer.

Will I be penalized if I don’t sign up for Medicare?

If you meet certain conditions that allow you to sign up for Medicare during a Special Enrollment Period, you usually will not pay a late enrollment penalty. But, if you don’t sign up when you are eligible and not enrolled in a qualified health plan, your monthly premium could go up by 10 percent.

Cost of Medicare

If you paid into Medicare for ten years (or 40 quarters), you likely won’t have to pay a monthly premium for Part A. Your premium for Medicare Part B is based on your Modified Adjusted Gross Income (MAGI), as reported on your tax returns.

How does Medicare work with my group coverage?

If you have Medicare and other health insurance, like a group health plan or retiree plan, each plan is referred to as a payer. When you have more than one payer, coordination of benefits rules will decide which plan is the primary payer (or which plan pays first).

The primary payer pays what it owes on your bills first and then sends the remaining balance to the secondary payer, also known as the supplemental payer, to pay. For example, if you have coverage through an employer that has more than 20 employees, the group plan is the primary payer and Medicare is the secondary payer.

It’s important to note that when you transition from a group health plan to Medicare, Medicare will typically not provide coverage for your spouse or dependents.

Is Medicare’s coverage as good as my employer-sponsored insurance?

While it varies from person to person and plan to plan, usually, if you opt for Parts A and B along with a Medicare supplement and prescription drug plan (Part D), your coverage under Medicare will be just as good as your employer-sponsored plan.

In fact, depending on which Medicare supplement and Part D plan you choose, your out-of-pocket expenses could be very minimal. Some Medicare supplements cover most or all of Part A and B’s out-of-pocket charges, with the exception of prescriptions, which are covered by Part D.

Original Medicare (Parts A and B) paired with a Part D plan and Medicare supplement provides solid coverage while giving you access to most doctors and hospitals. When compared with the provider networks that group health insurance plans typically have, the access to doctors and hospitals under Medicare is likely to be the same or similar.

Need help with Medicare?

Understanding your coverage choices can help you make informed health care decisions. Whether you’re approaching eligibility or supporting a loved one, Higginbotham is here to assist you with your health insurance coverage. Request a quote today and get in touch with one of Higginbotham’s Medicare specialists.

Not sure where to start? Talk to someone who wants to listen.

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