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Turning 65 FAQ 

New to Medicare? 

What are My Two Medicare Choices?

You have two choices for receiving your Medicare coverage when you turn 65. You can get your Medicare benefits through Original Medicare or a Medicare Advantage Plan. It is very important for everyone becoming eligible for Medicare to get accurate information about coverage and delivery options, including supplemental health insurance, Medicare health plans, and prescription drug coverage. Attention to these issues will help you avoid serious and costly problems later.

Understanding the difference between Original Medicare and a Medicare Advantage Plan is the first step in getting the coverage that is right for you and protecting the quality of your healthcare now and in the future. Don’t be fooled or misled. Get the facts.

Several months before turning 65 you should begin to learn more about Medicare and how it relates to your circumstances. For example:

If you or your spouse have paid into the Social Security System for 10 or more years, you are eligible for premium-free Medicare Part A (Hospital Insurance) at age 65. If you have paid in fewer than 10 years, you can buy Medicare Part A coverage. Everyone pays a premium for Medicare Part B (Medical Insurance).

If you have been on Medicare due to disability, you have a brand new six-month Open Enrollment Period for purchasing Medicare supplemental insurance when you turn 65.

Talk to your employer's benefits officer and ask for any information about company health insurance after age 65. If you have an Employer Group Health Plan (EGHP) that will continue to pay secondary after you become eligible for Medicare, study the benefits booklet to find out the cost and benefits of the plan. You will then need to decide if you should keep your EGHP as secondary to Medicare or if you need to drop your EGHP and purchase a Medicare supplement or join a Medicare Advantage Plan. If your EGHP has drug benefits, make sure they are as good as or better than Medicare Part D.

If you will not be covered by an EGHP plan that will pay secondary to Medicare, begin to investigate other health insurance options - either an individual Medicare Supplement Policy or a Medicare Advantage Plan.

When to Enroll in Medicare?

What is the Automatic Enrollment Period?

If you are already receiving Social Security benefits, Railroad Retirement benefits, or Federal Retiree benefits, your enrollment in Medicare is automatic. Your Medicare card should arrive in the mail shortly before your 65th birthday. Check the card when you receive it to verify that you are entitled to both Medicare Parts A and B.

What is the Initial Enrollment Period?

If you are not eligible for Automatic Enrollment, contact the Social Security Administration at 800-772-1213 or enroll online at www.socialsecurity.gov, or visit the nearest Social Security office to enroll in Medicare Part A and Medicare Part B. You have a seven-month window in which to enroll in Medicare without incurring a penalty. If you’re not automatically enrolled in premium-free Part A, you can sign up for it once your Initial Enrollment Period starts. Your Part A coverage will start six months back from the date you apply for Medicare, but no earlier than the first month you were eligible for Medicare. However, you can only sign up for Part B (or Part A if you have to buy it) during the seven-month time window listed below:

Three months before 65th birthday - enroll during this time and your Medicare is effective the first day of your birth month.

Birthday month - enroll during this time and your Medicare effective date will be delayed until the first day of the month following the month you actually enrolled.

The first month after 65th birthday enroll during this time and your Medicare effective date will be delayed until the first day of the second month following the month you actually enrolled.

Two to three months after 65th birthday - enroll during this time and your Medicare effective date will be delayed until the first day of the third month following the month you actually enrolled.

During this Initial Enrollment Period, you will also have the option to enroll in a Medicare Prescription Drug Plan (PDP) available under Medicare Part D. Enrollment in a Medicare PDP is strictly voluntary. These plans are offered by private insurance companies approved by Medicare. Information about PDPs can be found on the SHIIP website. If you fail to enroll in a Medicare PDP during your Initial Enrollment Period and you do not have equal or better coverage through an EGHP, you will incur a one percent penalty for each month that you are late enrolling, and you will only be allowed to enroll during the annual Open Enrollment Period of October 15 through December 7 for Medicare Advantage and Medicare Part D.

What is the General Enrollment Period?

If you do not enroll in Medicare Parts A and B during your seven-month window of eligibility, you cannot enroll until the General Enrollment Period, which is January 1 through March 31 each year (unless you are entitled to Special Enrollment). Your Medicare eligibility will not begin until the following July 1. Your monthly Medicare Part B premium will increase to include a permanent ten percent penalty for each year of delayed enrollment (unless you are eligible for Special Enrollment):

January 1 through March 31Enroll during this time

April 1 through June 30No Medicare coverage during this time

July 1Medicare coverage begins with a penalty

Are You Working Past Age 65? (Special Enrollment)

If you or your spouse are actively working at age 65, are covered by an Employer’s Group Health Plan (EGHP) and the company has 20 or more employees, you may be able to delay Medicare Part B coverage without penalty. You will still be eligible for Part A without paying a premium (as long as you or your spouse has 40 credits of work).

Talk to your employer's benefits officer and ask for information about company health insurance options for people who continue working past their 65th birthday. Ask specifically how many hours you must work to keep your health insurance plan and whether the EGHP will be "primary" or "secondary" coverage to Medicare. Carefully study the company's current benefit booklet to determine the cost and benefits of the plan.

If your EGHP is primary to Medicare, you do not have to enroll in Medicare Part B at this time. You will need to enroll in Medicare Part B within eight months of the EGHP's termination of coverage or when it stops being primary. If your EGHP will be secondary to Medicare despite active employment, you must enroll in Medicare Part B during the seven-month Initial Enrollment Period to avoid future penalties. If you voluntarily disenroll from your EGHP before terminating your employment, you could lose any EGHP benefits when you retire.

Contact the Social Security Administration at 800-772-1213 or www.socialsecurity.gov or the nearest Social Security Administration office to confirm that you have enrolled in Medicare Part A (Hospital Insurance).

Give written notice to your company of your intention to continue working past age 65. When you decide to stop working, notify the Social Security Administration immediately. It is also advisable to notify the Social Security Administration that you or your spouse will continue to work beyond age 65 if covered under your EGHP.

What is Original Medicare?

Original Medicare is the federal government-run health insurance program for people who are 65 or older. One of the many benefits of turning 65 is receiving Medicare benefits regardless of your health. If you are receiving social security benefits, you will be automatically enrolled in Medicare Part A and Part B when you turn 65. Your Medicare benefits will become effective on the first day of your birth month. The only exception is if your 65th birthday falls on the first day of the month. In this case, your effective date would be the first day of the previous month. Your Medicare card will be mailed to you approximately three months before your 65th birthday.

Under Original Medicare, the government pays healthcare providers directly for the services you receive. With Original Medicare, there are no network restrictions. That means you have the freedom to choose any doctor, specialist or hospital anywhere in the USA when you need care. When enrolled in Original Medicare you do not need to get prior approval, referral or permission from Medicare or from your primary care doctor when you need care. You just provide your red, white and blue Medicare card to receive Original Medicare services. Most people with Medicare get their health coverage directly through Original Medicare.

What is a Medicare Advantage Plan?

Don't be fooled by a Medicare Advantage Plan. A Medicare Advantage Plan is health insurance provided by private insurance companies that are contracted by Medicare and provide a different way to get your Medicare benefits. Each Medicare Advantage Plan must provide services offered by Original Medicare, but can do so with different rules, costs and restrictions that can affect how and when you receive care.

If you enroll in a Medicare Advantage Plan, there are network restrictions. This means you are required to see the healthcare providers in the Medicare Advantage network; plus, in most cases, you will need to get prior approval when you need care, except in case of an emergency. With a Medicare Advantage Plan, the insurance company has been given the ability to make its own claims decisions, and some claims decisions have been made with profitability in mind. If you enroll in a Medicare Advantage Plan, you MUST follow the rules of the Medicare Advantage Plan you have joined.

Also, if you enroll in a Medicare Advantage Plan you will automatically be dis-enrolled from Original Medicare and you will NOT be able to use your Medicare card.

What Is Medicare Supplement Insurance? 

Medicare supplement insurance is offered by private insurance companies. Medicare supplement insurance covers some of the gaps not paid by Original Medicare Parts A and B. With Original Medicare and a Medicare supplement, you are protecting the quality of your healthcare NOW and in the FUTURE. Medicare supplement insurance provides choice, control, freedom, flexibility, and value. With a Medicare supplement, there are no network restrictions. That means you can choose any doctors and hospitals, and visit any specialists anywhere in the USA that accepts Medicare patients.

All Medicare supplement insurance plan benefits are set by the federal government. That means the basic benefit structure for each plan is the same, no matter which insurance company is selling it to you. However, the prices vary widely among the various insurance companies. Plan G and Plan G High Deductible are popular Medicare Supplement Plans today. Companies cannot deny coverage or charge more for current or past health problems. If you fail to apply for a Medicare supplement within your Open Enrollment Period, you may lose the right to purchase a Medicare supplement policy without regard to your health. 

How do I enroll in a Prescription Drug Plan?

Medicare Prescription Drug Plans (PDPs) are sold by private insurance companies approved by Medicare. All people new to Medicare have a seven-month window to enroll in a PDP – three months before, the month of and three months after their Medicare becomes effective. The month you enroll affects the PDP’s effective date. All people with Medicare are eligible to enroll in a PDP; however, unless you are new to Medicare or are entitled to a Special Enrollment Period, you must enroll or change plans during the Open Enrollment Period for Medicare Advantage and Medicare Part D, Oct. 15 through Dec. 7. There is a monthly premium for these plans. If you have limited income and assets/resources, assistance is available to help pay premiums, deductibles, and co-payments. You may be entitled to “Extra Help” through the Social Security Administration. To apply for this benefit contact SHIIP at 1-855-408-1212 or the Social Security Administration at 800-772-1213 or www.socialsecurity.gov.

How do I enroll in a Medicare Advantage Plan?

Medicare Advantage Plans are health care options provided under Medicare Part C of the Medicare program. These plans are approved by Medicare but sold and serviced by private companies. There are several plan options available under Medicare Advantage Plans such as managed care plans that involve a provider network (HMOs and PPOs) to those that are specially designed for people with certain chronic diseases and other specialized health needs (SNPs) and some that may or may not have a provider network (PFFS) requirement. Most Medicare Advantage plans include Medicare prescription drug coverage.

To enroll in any Medicare Advantage plan option, you must have both Medicare Part A and Medicare Part B. Once you enroll in a Medicare Advantage plan, you will not use your Original Medicare (red, white and blue) card as your Medicare Advantage plan will replace Original Medicare. Instead, the Medicare Advantage plan will provide you with a member ID card to use when visiting your medical provider. Please note, you will continue to pay the Medicare Part B premium, and you might also have to pay an additional monthly premium charged by the Medicare Advantage plan.

It is important to remember to check with your healthcare providers before making any change to your Medicare coverage to make sure they will accept the Medicare Advantage plan you are considering.

When do I use my Medicare card?

Everyone who enrolls in Medicare receives a red, white, and blue Medicare card. This card lists your name and the dates that your Original Medicare hospital insurance (Part A) and medical insurance (Part B) began. It will also show your Medicare number, which serves as an identification number in the Medicare system. (If you get Medicare through the Railroad Retirement Board, your card will say Railroad Retirement Board at the bottom.) However, if you enroll in a Medicare Advantage Plan you will automatically be dis-enrolled from Original Medicare and you will NOT be able to use your Medicare card. This means you are no longer enrolled in the federal government-run Medicare program. This also means you must follow the rules of the Medicare Advantage Plan you have joined. 

Does Medicare cover the costs of diabetic supplies?

Medicare does cover certain supplies if you have diabetes. Part B covered supplies include blood sugar self-testing equipment and supplies, insulin pumps, and therapeutic shoes or inserts. To get Medicare drug coverage, you must join a Medicare prescription drug plan. These plans typically cover insulin, anti-diabetic drugs, and certain diabetes supplies such as syringes and needles.

Does Medicare cover the costs of durable medical equipment?

Medicare does cover durable medical equipment, which is equipment that serves a medical purpose, is able to withstand repeated use, and is appropriate for use in the home. Original Medicare normally pays 80% of the Medicare-approved amount after you meet your Part B deductible and you are responsible for a 20% coinsurance. Medicare only covers durable medical equipment if your provider says it is medically necessary for use in the home. You must also order the equipment from suppliers who contract with Original Medicare or your Medicare Advantage Plan. If you have a Medicare Advantage Plan, your plan will have its own cost and coverage rules for durable medical equipment.

Do you have Employer Group or Military Retiree Coverage?

If you or your spouse has an Employer Group Health Plan (EGHP) as retiree health coverage from an employer or the military (TRICARE for Life), you may not need additional insurance. Review the EGHP’s costs and benefits and contact your employer benefits representative to learn how your coverage works with Medicare.

 

 

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