Medicare is a federal government national healthcare program created to give medical coverage to people age 65 or older, people with certain disabilities, and people diagnosed with End-Stage Renal Disease (ESRD) or Lou Gehrig’s disease (Amyotrophic Lateral Sclerosis or ALS). It consists of four parts named alphabetically, each of them offering different types of medical services for the beneficiary.
The first two parts, named Part A (hospital insurance) and Part B (medical insurance), are known as Original Medicare. Part C is known as Medicare Advantage and it must offer at least the same coverage as Original Medicare, but often with some other benefits. Part D is known as Prescription drug coverage and it provides drug coverage only, and it can be a stand-alone plan, as well as a part of benefits in the Medicare Advantage plan.
MEDICARE PART A
Medicare Part A is hospital insurance that covers a wide range of hospital services. Part A offers coverage for inpatient hospital stays, skilled nursing care, hospice care, and limited home health care services. In addition, it includes inpatient care received through Acute care hospitals, Critical access hospitals, Inpatient rehabilitation facilities, Long-term care hospitals, Mental Health care, and Participation in qualifying clinical research studies. Medicare Part A covers the entire cost of covered home healthcare services.
Most people who qualify for Medicare do not pay for Part A. The only condition is that you or your spouse worked for at least 40 quarters (10 years) paying Medicare taxes. For the period of 30-39 worked quarters, you will be paying $274, and if you have worked less than 30 quarters then your premium for Medicare Part A will be $499 per month.
MEDICARE PART B
Medicare Part B is medical insurance. It provides insurance for outpatient medical care such as doctor visits, preventative services, ambulance services, mental health costs, and the cost of durable medical equipment. Under Part B insurance, in most cases, you will pay 20% of the Medicare-approved amount for each item or service.
People who are automatically enrolled in Part A are also automatically enrolled in Medicare Part B. But because beneficiaries must pay a premium for Part B coverage, they have the option of turning it down.
If you enroll in Medicare Part B your costs will include Medicare Part B monthly premium, coinsurance, and a yearly deductible. The average monthly fee for Part B is $164.90 in 2023, and the annual deductible is $226.
Medicare Advantage replaces the coverage of Original Medicare. Individuals who enroll in a Part C plan will no longer receive their benefits directly from the federal government, but from a private insurance company instead. These companies have been approved by the Medicare program to offer Part C plans. Medicare Advantage plans must contain at least as much coverage as Original Medicare – Parts A and B are offered. But, Medicare Advantage plans often come with additional benefits like coverage for routine dental, vision, and hearing care as well as prescription and over-the-counter drug coverage. Offering benefits vary from plan to plan and from carrier to carrier.
Medicare beneficiaries must already be enrolled in Medicare Parts A and B before applying for Medicare Advantage coverage. The only thing that can disqualify someone from enrolling in a Part C plan is if they have End-Stage Renal Disease (ESRD).
There are many Medicare Advantage plans that have $0 monthly premiums, but the average plan cost is $23 per month. Location is a prime factor in determining the cost and type of Part C plan you choose.
There are four main Medicare Advantage plans available. They have Preferred Provider Organization plans (PPO), Health Maintenance Organizations (HMO), Private Fee-for-Service plans (PFFS), and Special Needs Plans (SNP).
MEDICARE PART D
Medicare Part D is a prescription drug benefit program intended for persons 65 years and older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD). Part D is an optional benefit that is administered by private insurance companies and available to anyone who has Medicare. Part D can be approached as a standalone plan or picked through the Medicare Advantage plan.
Part D is simply insurance for your medication needs. You pay a monthly premium to an insurance carrier and in return, you use the provider’s network of pharmacies to purchase your prescription medications. Instead of paying the total price, you will pay a copayment or percentage of the drug’s cost. The insurance company will pay the rest.
MEDICARE SUPPLEMENT PLANS
Medicare Supplement Plans are insurance that helps fill the remaining costs of Original Medicare and they are sold by private companies. Original Medicare pays for much, but not all of the cost for covered health care services and supplies. A Medicare Supplement Insurance (Medigap) policy can help pay some of the remaining health care costs, like Copayments, Coinsurance, and Deductibles. There are 10 Medicare Supplement plans available, named alphabetically from the letter A to the letter N.
MEDICARE VS MEDICAID
Medicare and Medicaid are both federal government programs that provide healthcare coverage for their beneficiaries. They are set apart by qualifications unique to each program, including age, income, covered services, and costs. Check .
For most people, Medicare eligibility begins when they turn 65. If you’re under 65, you may qualify for Medicare if you meet specific criteria. The team at Jersey Medicare Solutions wants to help you understand Medicare eligibility.
Who Is Eligible for Medicare
You are eligible for Medicare when you turn 65 if you’re a citizen of the United States (or a permanent resident) and you have lived in the country for five consecutive years.
If you are under 65, you may be eligible if you:
- Are continually disabled and have received Social Security disability benefits for at least two years.
- Have been diagnosed with End-Stage Renal Disease (ESRD)
- Have been diagnosed with Amyotrophic Lateral Sclerosis (ALS or “Lou Gehrig’s Disease”)
Below, we will break down what makes you eligible for each part of Medicare.
Medicare Part A Eligibility
You are eligible for Part A (premium-free) at 65, as long as you or your spouse has worked here for ten years while paying Medicare taxes. If not, you may still be eligible for Part A but you will be required to pay a monthly premium.
If you’ve enrolled in Social Security, you will be auto-enrolled in Part A. Otherwise, you will need to contact the Social Security office to register.
Medicare Part B Eligibility
The criteria for Part A eligibility also apply to Part B. However, there’s a monthly premium for Part B.
Medicare Part C Eligibility
To be eligible for Part C, also called Medicare Advantage, you must enroll in Parts A and B (Original Medicare).
Medicare Part D Eligibility
You must be enrolled in either Part A or B to be eligible for Medicare Part D (prescription drug coverage).
You can enroll in Medicare at different times, depending on your plan. Each enrollment period has unique rules about when to apply and when your benefits will kick in. It’s critical to understand Medicare enrollment so that you sign up on time and avoid having to pay late enrollment fees. Jersey Medicare Solutions will explain the different Medicare enrollment periods.
Initial Enrollment Period (IEP)
The Initial Enrollment Period (IEP) is the first time you can sign up. A seven-month period during which you can enroll in Parts A, B, C, and D:
- The three months before your 65th birthday
- The month of your birthday and the three months after your 65th birthday
At the earliest, your Medicare coverage will take effect during your birth month. If your birthday is in July, your IEP starts on April 1 and ends on October 31. If you don’t enroll in this seven-month window, you could face penalties and have a coverage gap.
Annual Open Enrollment (AEP)
Suppose you already have Medicare coverage but want to make changes. In that case, you can do so during Medicare’s Annual Open Enrollment Period (AEP) — from October 15 to December 7. During this window:
- Anyone with Original Medicare can switch to an Advantage plan.
- Anyone with an Advantage plan can return to Original Medicare.
- Anyone who has or is signing up for Part A or B can join, drop, or switch to a Part D drug plan.
- Anyone with an Advantage plan can switch to a new advantage program.
Once you’ve made changes, your coverage will take effect on January 1 of the following year.
Special Enrollment Periods (SEP)
There are situations where a beneficiary can enroll in Medicare outside of the regular periods due to qualifying circumstances called the Medicare Special Enrollment Period (SEP). If you qualify for the SEP, you can sign up outside your IEP and the GEP.
Suppose you’re 65 or older and have group health insurance through your (or your spouse’s) employer. In that case, you get a particular period during which you can enroll in Part B. You can delay Medicare Part B enrollment without penalty and without having to wait for the GEP.
General Enrollment Period (GEP)
If you miss your IEP or SEP, you have another chance to enroll. You can sign up for Part A and Part B during the General Enrollment Period (GEP) — from January 1 to March 31. Your Medicare coverage would take effect on July 1 of that same year. If you enroll in Part A, you must also enroll in Part B during the GEP.
MEDICARE COMMON QUESTIONS
How does enrolling in Medicare work?
There are select times when you can enroll in a Medicare plan, depending on the plan you choose. You can view our website to learn about the Medicare enrollment periods. Remember that waiting to enroll could result in a penalty, and you may have a coverage gap. It’s simply wise to sign up when you’re first eligible.
When Is Medicare Automatic?
Some people get Medicare automatically, while others don’t. You’ll enroll in Part A if you already receive Social Security benefits. If not, you’ll need to register on your own.
What is covered under Medicare?
While Original Medicare offers primary coverage for testing, surgeries, hospital stays, and doctor’s visits, it doesn’t cover everything. You may consider other options to cover the out-of-pocket costs, like copayments and deductibles.
When Is Enrollment Automatic?
Some can obtain an Original Medicare policy without applying, but it is limited to specific individuals.
You will be automatically enrolled if:
- You get Social Security or Railroad Retirement Board benefits
- You have been getting disability benefits from Social Security for 24 months.
If you qualify for automatic enrollment, you will get a red, white, and blue Medicare card three months before your 65th birthday. If you have been receiving disability benefits, you will get your card after 24 months.
How To Apply for Medicare?
You don’t have to sign up for Medicare every year. However, you can review your plan’s benefits each year and switch plans when necessary.
If you’re not automatically enrolled, you can apply for Medicare over the phone, online, or in person at the Social Security office. Phone applications usually take longer.
The Social Security office deals with Medicare applications for Parts A, and B. Medicare agents and insurance carriers sell Part C, Part D, and Medicare Supplement plans.
Tips for Finding The Best Coverage
Everyone’s situation differs, affecting how you shop for a Medicare plan. You’ll need to get the right coverage if you need long-term care. The same idea applies if you need dental, vision, or hearing insurance — which Original Medicare doesn’t typically cover. Try taking these steps to find the best Medicare plan:
- Prove your eligibility. What is your age? Are you disabled?
- See if you need additional coverage beyond what Medicare Parts A and B offer
- Apply for Original Medicare at the Social Security office or online
- Shop for extra coverage