Learn About Medicare Basics
What Should You Know About Medicare?
Medicare can be overwhelming to learn about, so we wanted to break down the basics for you. Here you’ll learn about Medicare Parts A, B, C, and D, eligibility and enrollment, and how Medicare pays when you have other coverage! Medicare is the nation’s largest health insurance program, covering health care services such as hospital stays, skilled nursing and physician services to tens of millions of Americans. There are four parts to Medicare, each providing different types of health care services.
When Are You Eligible to Enroll?
Are You Eligible to Enroll in Medicare Part A and Part B? If you answer yes to at least one of the following questions, you may be eligible.
- Are you age 65 or older and have Social Security or Railroad Retirement Board benefits?
- Are you under age 65 with certain disabilities?
- Have you or your spouse worked for at least 10 years in Medicare-covered employment?
Are You Eligible to Enroll in a Medicare Prescription Drug Plan (Part D) or in a Medicare Advantage Plan (Part C)?
In addition to qualifying for Medicare Part A and Part B by answering yes to one of the above questions, you must live in a plan’s service area to be eligible for that plan. Each plan has a geographic boundary.
See our “Eligibility” toggle below to learn more about eligibility for Medicare.
Have You Received Your Medicare Card?
Those turning 65 and getting Social Security or Railroad Retirement Board benefits will automatically be enrolled in Medicare Part A and Part B. Part A benefits are premium free for most Americans and begin on the first day of your birthday month. However, because there is a monthly premium for Part B coverage, you have the option of turning Part B coverage down. Medicare sends out a package with Medicare cards and benefit information about 90 days before your 65th birthday.
PART A – Hospital Insurance
Helps pay for inpatient hospital care, skilled nursing facility care, home health care, and hospice care. While most Americans are enrolled automatically in Medicare Part A, it may not cover all of your health care costs. Parts B, C, and D are voluntary programs that provide additional coverage.
PART B – Medical Insurance
Helps pay for covered doctor’s services and many other medical services and supplies. If you don’t enroll in Part B when you are first eligible, you may have to pay a penalty later.
PART C – Medicare Advantage Plans
Offers medical coverage through a network of providers, such as an HMO or PPO, that is an alternative to Original Medicare (Parts A & B). These plans may or may not cover prescription drugs.
Part D – Prescription Drug Coverage
Helps pay for covered prescription medications. As with Part B, if you do not enroll when first eligible, you may have to pay a penalty later.
Medicare Supplement Insurance
Optional coverage helps to pay for expenses beyond what is covered by Medicare. There are several Medicare Supplement insurance plans, each with different benefits and premiums, so you can choose the plan that works bset for your specific needs. Medicare Supplement insurance plans are identified by the separate letters “A” through “N”. The basic benefits of each plan are exactly alike for all insurance companies.
When Are You Eligible to Enroll?
Initial Enrollment Period: Medicare Part A and Part B, Medicare Advantage Plans (Part C), and Medicare Prescription Drug Plans (Part D)
The Initial Enrollment Period is only for those turning 65 and reaching Medicare eligibility for the first time — not for those who are switching Medicare plans. It is a seven-month period — the three months before your birthday month, your birthday month, and the three months after your birthday month:
- If you sign up before your birthday month, and your birthday isn’t on the first day of the month, your coverage begins the first day of your birthday month.
- If your birthday is on the first day of the month, coverage may start the first day of the prior month.
- If you sign up during your birthday month, coverage begins one month after you enroll.
- If you sign up a month after you turn 65, coverage begins two months after you enroll. And if you sign up two or three months after you turn 65, coverage begins three months after you enroll.
Open Enrollment Period: Medicare Supplement Insurance Plans (Also Known as Medigap):
You have a one-time, six-month Open Enrollment Period that starts the first month you are 65 and enrolled in Part A and Part B. This period gives you the guaranteed right to buy any Medicare Supplement Insurance Plan sold in Texas, regardless of your health status. After that period, insurance companies selling
Medicare Supplement Insurance Plans may refuse to sell a plan based on your health status.
General Enrollment Period: Medicare Part A and Part B
If you didn’t sign up for Part A and/or Part B when you were first eligible, and you aren’t eligible for a Special Enrollment Period (see below), you can sign up during the General Enrollment Period from January 1 through March 31 of each year. Your coverage will start July 1. You may have to pay an ongoing penalty for late enrollment if you didn’t have creditable health insurance coverage beforehand.
Special Enrollment Period: Medicare Part A and Part B
If you’re covered under a group health plan based on current employment, for an employer with 20 or more employees, you have a Special Enrollment Period in which to sign up for Part A and/or Part B. You can do this as long as you or your spouse work, and you’re covered by a group health plan through the
employer or union based on that work. You also have an eight-month Special Enrollment Period to sign up for Part A and/or Part B that starts the month after the employment ends or the group health plan insurance based on when your current employment ends, whichever happens first. Usually, you don’t pay a late enrollment penalty if you sign up during a Special Enrollment Period. COBRA and retiree health plans aren’t considered coverage based on current employment. You’re not eligible for a Special Enrollment Period when that coverage ends.
Annual Enrollment Period: Medicare Advantage Plans (Part C) and Medicare Prescription Drug Plans (Part D)
From October 15 to December 7, any qualified Medicare member can join a Medicare Advantage Plan or prescription drug plan. Or, you may switch Medicare Advantage Plans or prescription drug plans.
Special Enrollment Periods (SEP): Medicare Advantage Plans (Part C) and Medicare Prescription Drug Plans (Part D)
You may be able to join, switch or drop a plan during any time of the year due to certain special circumstances. This is known as a special enrollment period. Check with the plan to find out if you can enroll outside of the typical enrollment periods. These are some reasons you might qualify:
- You moved out of a plan’s service area
- You qualify for ‘extra help’ with Medicare prescription drug costs
- You receive care in an institution (like a long-term care facility)
- You are eligible for Medicaid
- You lost your group employer retiree coverage
- Check with your plan to determine when coverage begins, as the time may vary.
The Bottom Line
To avoid paying a higher premium, make sure you (and your spouse, if applicable) sign up for Medicare when you’re first eligible, or during a Special Enrollment Period. COBRA and retiree insurance participants are not eligible for a Special Enrollment Period. You may also want to consider enrolling in a Medicare Supplement Insurance Plan and/or a prescription drug plan (Part D), or a Medicare Advantage Plan (Part C) at that same time. When you enroll in a Medicare Advantage Plan you cannot have a Medicare Supplement Insurance Plan as well.
What You Need to Know About Medicare Part A
Part A (Hospital Insurance) Helps Pay For:
- Inpatient care in a hospital
- Care at a skilled nursing facility (SNF) after a hospital stay
- Some home health care and hospice care services
You Are Eligible at Age 65 for Part A Coverage at No Cost if Any of These Apply to You:
- You receive or are eligible to receive Social Security benefits
- You receive or are eligible to receive Railroad Retirement Board benefits
- You may be eligible for Medicare Part A based on your spouse’s work history if:
- You are currently married and your spouse is eligible for Social Security benefits (either retirement or disability). In addition, you must have been married for at least one year before applying.
- You are divorced and your former spouse is eligible for Social Security benefits (either retirement or disability). In addition, you must have been married for at least 10 years and you must be single.
- You are widowed and you were married for at least nine months before your spouse died. In addition, you must be single.
Even if you do not meet any of these requirements at age 65, you may be able to get Part A by paying a monthly premium. Usually you can sign up for this hospital insurance only during certain enrollment periods.
What You Need to Know About Medicare Part B
Some Important Things to Know About Medicare Part B:
- Medicare Part B covers doctors’ office visits and services, lab tests and most outpatient care.
- Most people pay a monthly premium for Part B.
- You can enroll in Part B during your Initial Enrollment Period. This is a seven-month period — the three months before your birthday month, your birthday month, and the three months after your birthday month.
- If you decline Part B during your Initial Enrollment Period and enroll during the General Enrollment Period, you may pay a penalty. The monthly premium for Part B goes up 10 percent for each 12-month period that you could have had Medicare, but didn’t sign up for it. The penalty increases as Medicare premiums increase.
- If you decline Part B during your Initial Enrollment Period because of coverage due to active employment for a company with 20 or more employees, you should enroll during your Special Enrollment Period.
Be Sure to Enroll in Part B if You:
- Are retired
- Are not working
- Have COBRA or retiree health coverage
- Have a group health plan that pays second after Medicare pays
What You Need to Know About Medicare Advantage Plans
A Medicare Advantage Plan is another plan choice you may have as part of Medicare. These plans, sometimes called ‘Part C’ or ‘MA Plans,’ are offered by private insurance companies approved by Medicare. The premiums are a flat rate, regardless of age.
If You Join a Medicare Advantage Plan, It Will Provide:
- Medicare Part A (Hospital Insurance) coverage
- Medicare Part B (Medical Insurance) coverage
- Limits on the out-of-pocket costs you pay
- Medicare prescription drug coverage (Part D)
- Extra coverage, such as vision, hearing, dental,
and/or health and wellness programs
Depending on the Medicare Advantage Plans Offered in Your Area, You May Have These Options:
|HMO – Health Maintenance Organization||PFFS – Private Fee For Service|
|In most HMOs, you can only go to doctors, specialists, or hospitals on the plan’s list except in an emergency. You may also be required to get a referral from your primary care physician before visiting a specialist.||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 agree to treat you. The Medicare Advantage Plan determines how much it will pay doctors, other
health care providers, and hospitals, and how much you must pay when you get care.
|HMO-POS – HMO Point of Service Plan||SNP – Special Needs Plan|
|This is an HMO Plan that allows you to get some services out-of-network for a higher cost||SNPs provide focused and specialized health care for specific groups of people, such as those who have both Medicare and Medicaid, who live in a
nursing home, or have certain chronic medical conditions.
|PPO – Preferred Provider Organization||MSA – Medical Savings Account|
|In most PPOs, you pay less if you use doctors, hospitals, and other health care providers that belong to the MA plan’s network. You can use doctors, hospitals, and providers outside of the network but you may pay higher copays and
|This is a plan that combines 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|
You Must Continue to Pay Your Part B Premium
If you enroll in a Medicare Advantage Plan you will need to continue paying your Medicare Part B premium, as well as any premium charged by the plan you choose. A monthly premium may apply and can vary based on the plan selected.
You Can’t Have a Medicare Supplement Insurance Plan and a Medicare Advantage Plan at the Same Time.
Medicare Advantage Plans are health insurance plans approved by Medicare and offered by private companies. Medicare Advantage Plans are different from Medicare Supplement Insurance Plans. If you enroll in a Medicare Advantage Plan, you cannot purchase a Medicare Supplement Insurance Plan.
What a Medicare Advantage Plan Covers
In All Types of Medicare Advantage Plans, You’re Always Covered For:
- Emergency and urgent care
- Hospice care (covered by Original Medicare)
Medicare Advantage Plans Provide All of Your:
- Medicare Part A (Hospital Insurance) benefits
- Medicare Part B (Medical Insurance) benefits
They Usually Offer Extra Benefits Such As:
- Dental, hearing and/or vision
- Health, wellness, and fitness programs
- Prescription drug coverage
- Provider networks to help manage costs
Plans can charge different copays, coinsurance, and deductibles for these services. Remember, if you enroll in a Medicare Advantage Plan you will need to continue paying your Medicare Part B premium, as well as any premium charged by the plan you choose.
Medicare Supplement Insurance
What You Need to Know about Medicare Supplement Insurance Plans
You have two paths from which to choose when making Medicare decisions. One path is to sign up for Medicare Part A and Part B, and then choose a Medicare Advantage Plan, which often includes a prescription drug plan.
The other path is to sign up for Medicare Part A and Part B — and supplement your Medicare benefits by adding a Medicare Supplement Insurance Plan (Medigap) and/or a prescription drug plan (Part D).
How Do Medicare Supplement Insurance Plans Work?
The federal government has designed standardized Medicare Supplement Insurance Plans. Each plan’s benefits are the same no matter what company sells them. Premiums may vary.
In most states, these plans are identified by the letters A through N. Each plan is designed to help cover the costs that Original Medicare leaves you to pay. Premiums for these plans typically go up as a person ages.
If an individual enrolls in a Medicare Supplement Insurance Plan within six months of turning 65, and has enrolled in Medicare Part A and Part B, they have a guaranteed right to purchase any Medicare Supplement Insurance Plan sold in their state and cannot be turned down or charged more because of a pre-existing condition.
Do Medicare Supplement Insurance Plans Use Network Providers?
In some states, Medicare Select plans are available. These plans require members to use Medicare Select network hospitals for non-emergency care, or be on the hook for some expenses. (Emergency care is always covered at any hospital.) In some cases, members may need to use specific doctors or other providers to get full coverage. However, most Medicare Supplement Insurance Plans allow members to go to any hospital or physician that accepts Medicare.
Is Emergency Care while Traveling Outside the U.S. Covered?
An important feature of some Medicare Supplement Insurance Plans is that they provide limited emergency health care coverage for individuals traveling outside of the United States. Medicare alone does not cover emergency health care expenses incurred outside the U.S.
Are Prescription Drugs Covered?
Medicare Supplement Insurance Plans do not cover outpatient prescription drugs. To have these drugs covered you must also enroll in a prescription drug plan (Part D).
Part D - Prescription Drug Plans
What You Need to Know About Medicare Prescription Drug Plans
Medicare Part D prescription drug plans help to pay for your prescription drugs. These plans are offered by private insurance companies approved by Medicare. Part D plans often have a monthly premium, copays and coinsurance, and a deductible. While a variety of plans are available, all Part D plans have the phases below. Benefits offered can be richer or more enhanced than what is below:
Annual Deductible: You pay this amount for your prescriptions before the plan begins to pay.
Initial Coverage: You pay a copay or coinsurance for each eligible prescription filled. The plan pays the rest until total costs reach the Initial Coverage Limit. This is an amount determined by the Centers for Medicare and Medicaid Services (CMS) each year.
Coverage Gap: Once you and your plan have spent up to the Initial Coverage Limit on covered drugs (the combined amount plus your deductible), you’ll be in the coverage gap. While you are in the coverage gap, you pay different copays or coinsurances for generic and brand drugs in the coverage gap, depending on your Part D plan.
After the Coverage Gap: You get out of the coverage gap when your out-of-pocket costs for covered drugs reaches an amount that is determined by CMS each year. During this phase, you will pay a small copay or coinsurance for covered drugs for the rest of the calendar year.
How Much Does a Medicare Part D Plan Cost?
There are several factors that can affect how much a Medicare Part D plan may cost you per year. Here Are Some Typical Expenses:
You may have one premium each for your Part B and Part D plans.
You pay this at the time you receive a covered prescription drug.
The plan may require that you pay a percentage of the cost of certain covered prescription drugs. For example, if your plan has a 25% coinsurance, you would pay $25 and your plan would pay $75 of a $100 prescription drug cost. Look at it this way:
$100 Charge for Covered Prescription Drug
– $ 75 Paid by Plan
= $25 Paid by Member
You pay all costs toward a deductible before your plan begins to pay. Plans with higher deductibles generally offer lower premium payments.
When Can You Switch or Drop a Medicare Advantage Plan or Prescription Drug Plan?
Annual Enrollment Period
October 15 – December 7
During the Annual Enrollment Period, anyone can join, switch, or drop a Medicare Advantage Plan or prescription drug plan. Your coverage will begin on January 1, as long as the plan gets your request by December 7.
Medicare Advantage Plan Open Enrollment Period
January 1 – March 31
If you would like to change your Medicare Advantage plan coverage after the AEP, you may choose to switch to Original Medicare (Part A+B) and purchase a stand-alone Part D plan (PDP). During Open Enrollment, you may also choose to switch to:
- A different Medicare Advantage Prescription Drug Plan
- A different Medicare Advantage-only plan
Special Enrollment Periods (SEP)
In most cases, you must stay enrolled for the calendar year starting the date your coverage begins. However, in certain situations you may be able to join, switch, or drop a Medicare Advantage Plan or a prescription drug plan during a special enrollment period. Contact your plan if any of these situations apply to you:
- You move out of your plan’s service area.
- You have Medicaid.
- You qualify for Extra Help.
- You live in an institution (like a nursing home).
Medicare Advantage SEP Trial Rights
Special Enrollment Period (SEP) Trial Rights are available for people who have joined a Medicare Advantage Plan for the first time but decide that they want to go back to Original Medicare and a Medicare Supplement Insurance Plan. SEP Trial Rights allow them to disenroll from their Medicare Advantage Plan and join Original Medicare and they have the guaranteed right (regardless of health status) to purchase a Medicare Supplement Insurance Plan.
The SEP Trial Rights would apply in the following instances:
- A person joins a Medicare Advantage Plan when they were first eligible for Medicare Part A at age 65, and within the first year of joining, they decide they want to switch to Original Medicare and a Medicare Supplement Insurance Plan.
- A person dropped a Medicare Supplement Insurance Plan to join a Medicare Advantage Plan for the first time, they have been in the plan less than a year, and want to switch back to Original Medicare and a Medicare Supplement Insurance Plan.
What Are Your Options When You or Your Spouse Retires?
Medicare covers individuals under Part A (hospital insurance) and Part B (medical insurance). You may also want to consider enrolling in a Medicare Supplement Insurance Plan and a prescription drug plan or Medicare Advantage Plan. Medicare, Medicare Supplement Insurance Plans, Medicare Advantage Plans and prescription drug plans do not provide family or dependent benefits.
Your Spouse May Purchase Individual Health Insurance Coverage if He or She Is under Age 65 and:
- Is losing coverage under your group health plan
- Does not have the option to enroll in group health coverage through his or her own employer or a union ANDIs not yet eligible for Medicare
If your spouse is under 65 and will not have group health coverage through an employer or union after you retire, he or she may purchase individual health insurance coverage through a health insurance company. Medicare does not provide family or dependent benefits.
If You Have Group Retiree Health Insurance, When Should You Enroll in Medicare?
If you retire from your current employer, you can enroll in Medicare during your Initial Enrollment Period
If you do not enroll in Medicare during your Initial Enrollment Period, you will have to wait until the next General Enrollment Period, which is January 1 to March 31, after your Initial Enrollment Period.
If you don’t enroll in Medicare during your Initial Enrollment Period, you will pay a penalty when you enroll later. Your monthly premium will go up 10 percent for each 12-month period when you were eligible for Medicare but didn’t sign up for it. The penalty increases as Medicare premiums increase.
This also applies to your spouse who is covered under your retiree insurance if he or she does not have group health coverage based on current employment. He or she should enroll in Medicare during the Initial Enrollment Period to avoid paying the higher Medicare premium for late enrollment.
Consider These Important Points
- You should keep your retiree insurance if you can afford it and if it covers the gaps in Medicare.
- If you have retiree insurance from your or your spouse’s former employer, you should take both Medicare Parts A and B to have more complete coverage of doctors’ services and other medical care.
Retiree insurance isn’t considered coverage based on current employment. Unlike active employees who work past 65, you’re not eligible for a Special Enrollment Period (the eight-month period that begins the month after the employment ends or the group health plan insurance based on current employment ends, whichever happens first).
To avoid paying a higher premium, make sure you (and your spouse, if applicable) enroll in Medicare Part B when you’re first eligible. Speak to your plan administrator to determine how your retiree insurance will work with Medicare. You may also want to consider enrolling in a Medicare Supplement Insurance Plan and a prescription drug plan.