What is Medicare?
Medicare is our country’s health insurance program for people age 65 or older. Certain people younger than age 65 can qualify for Medicare, too, including those who have disabilities, permanent kidney failure or amyotrophic lateral sclerosis (Lou Gehrig’s disease). The program helps with the cost of health care, but it does not cover all medical expenses or the cost of most long-term care.
Medicare is financed by a portion of the payroll taxes paid by workers and their employers. It also is financed in part by monthly premiums deducted from Social Security checks.
The Centers for Medicare & Medicaid Services is the agency in charge of the Medicare program. But you apply for Medicare at Social Security, and we can give you general information about the Medicare program.
Medicare has four parts
Hospital insurance (Part A) helps pay for inpatient care in a hospital or skilled nursing facility (following a hospital stay), some home health care and hospice care.
Medical insurance (Part B) helps pay for doctors’ services and many other medical services and supplies that are not covered by hospital insurance.
Medicare Advantage (Part C) plans are available in many areas. People with Medicare Parts A and B can choose to receive all of their health care services through one of these provider organizations under Part C.
* Prescription drug coverage (Part D) helps pay for medications doctors prescribe for treatment.
You can get more detailed information about what Medicare covers from Medicare & You (Publication No. CMS-10050). To get a copy, call the Medicare toll-free number, 1-800-MEDICARE (1-800-633-4227), or go to www.medicare.gov. If you are deaf or hard of hearing, you may call TTY 1-877-486-2048.
A word about Medicaid
You may think that Medicaid and Medicare are the same. Actually, they are two different programs. Medicaid is a state-run program that provides hospital and medical coverage for people with low income and little or no resources. Each state has its own rules about who is eligible and what is covered under Medicaid. Some people qualify for both Medicare and Medicaid. For more information about the Medicaid program, contact your local medical assistance agency, social services or welfare office.
Who can get Medicare?
Most people age 65 or older who are citizens or permanent residents of the United States are eligible for free Medicare hospital insurance (Part A). You are eligible at age 65 if:
* You receive or are eligible to receive Social Security benefits; or
* You receive or are eligible to receive railroad retirement benefits; or
* Your spouse is eligible; or
* You or your spouse (living or deceased, including divorced spouses) worked long enough in a government job where Medicare taxes were paid; or
* You are the dependent parent of a fully insured deceased child.
If you do not meet these requirements, you may be able to get Medicare hospital insurance by paying a monthly premium. Usually, you can sign up for this hospital insurance only during designated enrollment periods.
NOTE: Even though the full retirement age is no longer 65, you should sign up for Medicare three months before your 65th birthday.
Before age 65, you are eligible for free Medicare hospital insurance if:
* You have been entitled to Social Security disability benefits for 24 months; or
* You receive a disability pension from the railroad retirement board and meet certain conditions; or
* If you receive Social Security disability benefits because you have Lou Gehrig’s disease (amyotrophic lateral sclerosis); or
* You worked long enough in a government job where Medicare taxes were paid and you meet the requirements of the Social Security disability program; or
* You are the child or widow(er) age 50 or older, including a divorced widow(er), of someone who has worked long enough in a government job where Medicare taxes were paid and you meet the requirements of the Social Security disability program.
* You have permanent kidney failure and you receive maintenance dialysis or a kidney transplant and:
o You are eligible for or receive monthly benefits under Social Security or the railroad retirement system; or
o You have worked long enough in a Medicare-covered government job; or
o You are the child or spouse (including a divorced spouse) of a worker (living or deceased) who has worked long enough under Social Security or in a Medicare-covered government job.
Medical insurance (Part B)
Anyone who is eligible for free Medicare hospital insurance (Part A) can enroll in Medicare medical insurance (Part B) by paying a monthly premium. Some beneficiaries with higher incomes will pay a higher monthly Part B premium. For more information, ask for Medicare Premiums: Rules For Higher-Income Beneficiaries (Publication No. 05-10536) or visit www.socialsecurity.gov/mediinfo.htm.
If you are not eligible for free hospital insurance, you can buy medical insurance, without having to buy hospital insurance, if you are age 65 or older and you are—
* A U.S. citizen; or
* A lawfully admitted noncitizen who has lived in the United States for at least five years.
Medicare Advantage plans (Part C)
If you have Medicare Parts A and B, you can join a Medicare Advantage plan. Medicare Advantage plans are offered by private companies and approved by Medicare. With one of these plans, you do not need a Medigap policy, because Medicare Advantage plans generally cover many of the same benefits that a Medigap policy would cover, such as extra days in the hospital after you have used the number of days that Medicare covers.
Medicare Advantage plans include:
* Medicare managed care plans;
* Medicare preferred provider organization (PPO) plans;
* Medicare private fee-for-service plans; and
* Medicare specialty plans.
If you decide to join a Medicare Advantage plan, you use the health card that you get from your Medicare Advantage plan provider for your health care. Also, you might have to pay a monthly premium for your Medicare Advantage plan because of the extra benefits it offers.
People who become newly entitled to Medicare should enroll during their initial enrollment period (as explained under Signing up for Medicare) or during the annual coordinated election period from October 15 – December 7 each year. The effective date for the enrollment is January 1 of the upcoming year. There also will be special enrollment periods for some situations.
Medicare prescription drug plans (Part D)
Anyone who has Medicare hospital insurance (Part A), medical insurance (Part B) or a Medicare Advantage plan (Part C) is eligible for prescription drug coverage (Part D). Joining a Medicare prescription drug plan is voluntary, and you pay an additional monthly premium for the coverage. Some beneficiaries with higher incomes will pay a higher monthly Part D premium. For more information, ask for Medicare Premiums: Rules For Higher-Income Beneficiaries (Publication No. 05-10536) or visit www.socialsecurity.gov/mediinfo.htm. You can wait to enroll in a Medicare Part D plan if you have other creditable prescription drug coverage but, if you don’t have prescription coverage that is, on average, at least as good as Medicare prescription drug coverage, you will pay a penalty if you wait to join later. You will have to pay this penalty for as long as you have Medicare prescription drug coverage.
People who become newly entitled to Medicare should enroll during their initial enrollment period (as explained under Signing up for Medicare). After the initial enrollment periods, the annual coordinated election period to enroll or make provider changes will be October 15 – December 7 each year. The effective date for the enrollment is January 1 of the upcoming year. There also will be special enrollment periods for some situations.
Help for some low-income people
If you cannot afford to pay your Medicare premiums and other medical costs, you may be able to get help from your state. States offer programs for people who are entitled to Medicare and have low income. The programs may pay some or all Medicare premiums and also may pay Medicare deductibles and coinsurance. To qualify, you must be eligible for Part A (hospital insurance) and have limited income and resources.
You can go online to get more information about these programs from the Centers for Medicare & Medicaid Services (CMS) website. Visit www.medicare.gov and request Get help with your Medicare costs (Publication No. CMS-10126).
Only your state can decide if you qualify for help under these programs. To find out, contact your state or local medical assistance (Medicaid) agency, social services or welfare office.
You also may be able to get extra help paying for the annual deductibles, monthly premiums and prescription co-payments related to the Medicare prescription drug program (Part D). You may qualify for extra help if you have limited income (tied to the federal poverty level) and limited resources. These income and resource limits usually change each year, and you can contact us for the current numbers.
You automatically qualify and do not need to apply for extra help if you have Medicare and meet one of the following conditions:
* Have Medicaid with prescription drug coverage;
* Have Supplemental Security Income (SSI); or
* Participate in a state program that pays your Medicare premiums.
For more information about getting help with your prescription drug costs, call Social Security’s toll-free number or visit our website. You also can apply online at Social Security’s website.
Signing up for Medicare
When should I apply?
If you are already getting Social Security retirement or disability benefits or railroad retirement checks, you will be contacted a few months before you become eligible for Medicare and given the information you need. If you live in one of the 50 states or Washington, D.C., you will be enrolled in Medicare Parts A and B automatically. However, because you must pay a premium for Part B coverage, you have the option of turning it down.
NOTE: Residents of Puerto Rico or foreign countries will not receive Part B automatically. They must elect this benefit.
If you are not already getting retirement benefits, you should contact us about three months before your 65th birthday to sign up for Medicare. You can sign up for Medicare even if you do not plan to retire at age 65.
Once you are enrolled in Medicare, you will receive a red, white and blue Medicare card showing whether you have Part A, Part B or both. Keep your card in a safe place so you will have it when you need it. If your card is ever lost or stolen, you can apply for a replacement card on the Internet at www.socialsecurity.gov/medicarecard or call Social Security’s toll-free number.You also will receive a Medicare & You handbook (Publication No. CMS-10050) that describes your Medicare benefits and plan choices.
You also should contact Social Security about applying for Medicare if:
* You are a disabled widow or widower between age 50 and age 65, but have not applied for disability benefits because you are already getting another kind of Social Security benefit;
* You are a government employee and became disabled before age 65;
* You, your spouse or your dependent child has permanent kidney failure;
* You had Medicare medical insurance in the past but dropped the coverage; or
* You turned down Medicare medical insurance when you became entitled to hospital insurance (Part A).
Initial enrollment period for Part B
When you first become eligible for hospital insurance (Part A), you have a seven-month period (your initial enrollment period) in which to sign up for medical insurance (Part B). A delay on your part will cause a delay in coverage and result in higher premiums. If you are eligible at age 65, your initial enrollment period begins three months before your 65th birthday, includes the month you turn age 65 and ends three months after that birthday. If you are eligible for Medicare based on disability or permanent kidney failure, your initial enrollment period depends on the date your disability or treatment began.
When does my enrollment in Part B become effective?
If you accept the automatic enrollment in Medicare Part B, or if you enroll in Medicare Part B during the first three months of your initial enrollment period, your medical insurance protection will start with the month you are first eligible. If you enroll during the last four months, your protection will start from one to three months after you enroll.
The following chart shows when your Medicare Part B becomes effective:
If you enroll in this month of your Initial enrollment period:
Then your Part B Medicare coverage starts:
One to three months before you reach age 65
The month you reach age 65
The month you reach age 65
One month after the month you reach age 65
One month after you reach age 65
Two months after the month of enrollment
Two or three months after you reach age 65
Three months after the month of enrollment
General enrollment period for Part B
If you do not enroll in Medicare Part B during your initial enrollment period, you have another chance each year to sign up during a “general enrollment period” from January 1 through March 31. Your coverage begins on July 1 of the year you enroll. However, your monthly premium increases 10 percent for each 12-month period you were eligible for, but did not enroll in, Medicare Part B.
Special enrollment period for people leaving Part C
If you have a Medicare Advantage plan (Part C), you can leave your plan and switch to original Medicare from January 1 through February 14. If you use this option, you also have until February 14 to join a Medicare prescription drug plan. Your coverage begins the first day of the month after the plan gets your enrollment form.
Special enrollment period for people covered under an employer group health plan
If you are 65 or older and are covered under a group health plan, either from your own or your spouse’s current employment, you have a “special enrollment period” in which to sign up for Medicare Part B. This means that you may delay enrolling in Medicare Part B without having to wait for a general enrollment period and paying the 10 percent premium surcharge for late enrollment. The rules allow you to:
Enroll in Medicare Part B any time while you are covered under the group health plan based on current employment; or
Enroll in Medicare Part B during the eight-month period that begins following the last month your group health coverage ends, or following the month employment ends—whichever comes first.
Special enrollment period rules do not apply if employment or employer-provided group health plan coverage ends during your initial enrollment period.
If you do not enroll by the end of the eight-month period, you will have to wait until the next general enrollment period, which begins January 1 of the next year. You also may have to pay a higher premium, as described in General enrollment period for Part B.
People who receive Social Security disability benefits and are covered under a group health plan from either their own or a family member’s current employment also have a special enrollment period and premium rights that are similar to those for workers age 65 or older.
Medicare beneficiaries may have choices for receiving health care services.
If you have other health insurance
Medicare hospital insurance is free for almost everyone, but you do pay a monthly premium for medical insurance. If you already have other health insurance when you become eligible for Medicare, is it worth the monthly premium cost to sign up for Medicare medical insurance?
The answer varies with each person and the kind of other health insurance you may have. Although we cannot give you “yes” or “no” answers, we can offer information that may be helpful when you make your decision.
If you have a private insurance plan
Get in touch with your insurance agent to see how your private plan fits with Medicare medical insurance. This is especially important if you have family members who are covered under the same policy. And remember, just as Medicare does not cover all health services, most private plans do not either. In planning your health insurance coverage, keep in mind that most nursing home care is not covered by Medicare or private health insurance policies. One important word of caution: for your own protection, do not cancel any health insurance you now have until your Medicare coverage actually begins.
If you have insurance from an employer-provided group health plan
Group health plans of employers with 20 or more employees are required by law to offer workers and their spouses who are age 65 (or older) the same health benefits that are provided to younger employees.
If you are currently covered under an employer-provided group health plan, you should talk to your personnel office before you sign up for Medicare medical insurance.
If you have health care protection from other plans
If you have coverage under a program from the Department of Defense, your health benefits may change or end when you become eligible for Medicare. You should contact the Department of Defense or a military health benefits advisor for information before you decide whether to enroll in Medicare medical insurance.
If you have health care protection from the Indian Health Service, Department of Veterans Affairs or a state medical assistance program, contact the people in those offices to help you decide whether it is to your advantage to have Medicare medical insurance.