Medicare Information for Customers

Are you new to Medicare or interested in finding answers to your Medicare-related questions? Read on to learn more about Medicare, how it works, what it covers if you are eligible, and how you can enroll. Medicare information for customers that speak with us will get the A-Z info about this insurance.

What is Medicare?

Medicare is the federal health insurance program created for Americans who are 65 or older, younger people with disabilities, and people living with End-Stage Renal Disease, including permanent kidney failure requiring dialysis for a transplant. There are different parts of Medicare, as you will find out later.

Medicare History and Statistics

President Lyndon B. Johnson signed the Medicare bill into law in July 1965, allowing people who are 65 and older to access a national healthcare program designed specifically for them.

Medicare started with only Parts A and B, but the coverage has been expanded over the years to include more people. For instance, in 1972, it started covering younger Americans with permanent disabilities. It currently has four parts – Parts A, B, C, and D.

Over 61 million Americans are now included under Medicare.  About 12% of the Medicare population is aged 85 or older, while 17% are currently under 65. Medicare took up about 14% of the Federal Spending in 2018 – it is expected to increase to 17.5% by 2027.

Medicare Parts and Coverage

As mentioned above, the Medicare Program has four parts:

Medicare Part A

Part A Medicare is also called “hospital insurance” because it caters to inpatient care. Beneficiaries do not have to pay for inpatient hospital, home health care, hospice care, and skilled nursing facility stays of at least one night. 

Part A is free for most people at age 65 since they have paid taxes during their working years to pre-fund the premiums.

Read more about Medicare Information for Customers

Medicare Part B

Medicare Part B focuses on outpatient medical coverage. It covers sick visits or trips to your doctor for a checkup or any outpatient care you might get. It also covers specific preventive care, for instance, the annual Wellness exam and preventive care.

It also covers kidney dialysis and cancer therapy, which would be otherwise expensive without supplemental coverage. Part B is not free, and the exact cost is not fixed – it depends on Social Security.

Read more on Medicare Part B Medicare Information for Customers

Medicare Part C

Medicare Part C is the Medicare Advantage program. It is not free, and the cost differs across carriers, countries of residence, and the type of plan. This part offers Medicare-covered benefits via private health plans. This may also include additional benefits like prescription drug coverage.

Unlike Parts A and B, you do not have to enroll in Medicare Part C at Social Security. Prior enrollment in Parts A and B is a prerequisite for enrollment in Part C. However, on enrolling, the coverage comes from the Advantage plan and not from the government.

Read more on Medicare Part C here.

Medicare Part D

This part of Medicare is designed to cover prescription medicines, so it is often called a Pharmacy Card. People aged 65 and above, through Medicare Part D, can enjoy free retail prescription drugs when they choose a preferred carrier and enroll in their drug plan.

There are up to 30 drug plans to choose from – you can determine the best option by asking your agent. You can either have a stand alone or Medicare Part D coverage in your Medicare Advantage Plan or enroll as a stand-alone plan.

Read more on Medicare Part D here.

Medicare vs. Medicaid vs. Medigap Insurance

While Medicare is health insurance targeted at the elderly, Medicaid is a financial and/or healthcare program designed to offer low-income individuals assistance. Both options are for people age 65 and older, and if anyone enrolls in both, Medicaid will be their secondary plan while Medicare will be the primary plan.

Medigap Insurance, on the other hand, is under Medicare as a supplement package. Beneficiaries of Medicare can purchase Medigap to cover out-of-pocket expenses that they would ordinarily pay themselves. Medigap Insurance is only open to people enrolled in Original Medicare – they cannot combine it with a Medicare Advantage Plan.

Medigap beneficiaries will pay a monthly premium plus their normal monthly Part B Medicare premium. The premium for Medigap goes directly to the private insurance company providing the Insurance, while the Part B premium goes to Social Security.

What Medicare does not cover

A few health services and costs are not included under Original Medicare. These include Massage therapy, Long-term care, Dentures, Routine foot care, Acupuncture, Cosmetic surgery, Routine foot care, Dental care (with a few exceptions), Vision exams required for a glasses prescription, and Hearing aids, and related exams.

Medicare also does not cover medical care outside the United States.

Eligibility for Medicare

Anyone who meets one of the following criteria is eligible for Medicare.

–      65 years old legal permanent resident in the United States for at least five consecutive years.

–      Under the age of 65 but with amyotrophic lateral sclerosis (ALS) or Lou Gehrig’s Disease, and/or end-stage renal disease (ESRD).

–      Under the age of 65 but eligible for the Social Security Disability benefits over at least two years.

Likewise, becoming eligible for Medicare Part A with no premium requires previous payment into the Medicare system, either personally or through a spouse or parent (for a disabled child) who has worked for at least ten years before enrolling in Medicare.

People without a 10-year work history are also eligible for Medicare, but they will have to pay a Medicare Part A premium.

Enrolling in Medicare

Enrollment in Medicare is either automatic or manual.

Automatic enrollments are for people who are already getting Social Security or Railroad Retirement Board benefits (for at least four months before the start date). It is also automatic for people under the age of 65 with a Social Security disability for 24 months and anyone with Amyotrophic Lateral Sclerosis (ALS) or end-stage renal disease.

Manual enrollments are recommended for people who are about to turn 65 or already 65 without getting Social Security benefits.  To enroll manually, visit the Social Security website and fill out the online application. Alternatively, you can register at your local Social Security office.

Talk to the Experts

Do you have any questions on Medicare or professional help in choosing the best coverage options for you? Reach out to us today, and we will guide you on the right supplement plan for you.

Disclaimer: This video and blog post are for entertainment purposes only.  If you want advice on Medicare or any of its plans, please speak to a licensed agent, whether it is me or another licensed agent. No advice should be taken from this video or blog post.  If you don’t speak to me about your individual concerns, I can’t give you my 100% opinion. Brian Monahan and Medicare 365 are not responsible for any actions that you take without consulting with a licensed insurance agent.

Medicare Sign Up

Are you approaching age 65 and wondering how you can sign up for Medicare? This page discusses all you need to learn about enrollment for the different Medicare programs.

Medicare Automatic Enrollment

Enrollment into the Medicare program is automatic in some situations, as we have identified below:

Americans getting retirement benefits

Americans who are receiving Social Security benefits or Railroad Retirement Board retirement benefits are automatically enrolled into Medicare once they turn 65. However, the enrollment is only for Medicare Part A and Part B. For Part B, the beneficiary must have signed up for Medicare Part B alongside their retirement benefits. People living outside America will enjoy automatic enrollment for Medicare Part A but must enroll manually for Medicare Part B.

Americans getting disability benefits

Younger people who enjoy Social Security disability benefits are also enrolled in Original Medicare, Part A, and Part B automatically after 24 months of receiving such benefits. For people with Lou Gehrig’s disease or ALS, Medicare enrollment and coverage become active right from the first month of their disability check. People living with end-stage renal disease (ESRD) and who have undergone a kidney transplant or require regular kidney dialysis are eligible to apply for Medicare.

NB – A beneficiary who is automatically enrolled in Medicare Part B can drop the coverage if they so wish.  All you have to do is send the Medicare coverage card back by following the instructions on the card.  However, this is only possible if the coverage is not yet effective – if the coverage has started, kindly contact the Social Security office and request to be exempted.

Considering that Medicare enrollment is not a one-off process, beneficiaries may have to sign up for each part of the plan at different points after their eligibility. But not to worry, signing up for different parts of this United States federal government health insurance program is easy.

When can you enroll for Medicare?

For qualified potential beneficiaries who are not automatically enrolled, they are expected to enroll for Medicare before their 65th birthday.

Initial Enrollment Period

People who are new to Medicare can enroll in Parts A, B, and/or D within the Initial Enrollment Period. This enrollment period lasts seven months, starting from three months before their 65th birthday and ending three months after their birthday month.

The Initial Enrollment Period does not cover Medicare Part C – it has a different enrollment period, which is called the Initial Coverage Election Period. Similarly, the Medicare Advantage plan has a different enrollment period. People looking to enroll in a Medicare Advantage plan can only do so within three months before their Medicare Part B enrollment is due to start, until three months after their 65th birthday.

General Enrollment Period

People who failed to enroll during the Initial Enrollment Period get another enrollment window during the General Enrollment Period. This enrollment period starts from January 1 to March 31 every year. However, signing up during the General Enrollment Period may attract a late enrollment penalty.

Special Enrollment Period

Eligible beneficiaries may decide not to enroll in Medicare Part B due to their coverage by a group medical insurance (through a union or company). If such beneficiaries decide to switch from such group coverage to Medicare, they can sign up for Part B without exiting their current coverage.

For such beneficiaries, their Special Enrollment period starts either when their group health coverage ends or when their employment ends.

Enrolling for Medicare Advantage Plan

Enrollment in a Medicare Advantage Plan is usually through a private insurance company. The condition includes an existing Original Medicare, Part A, and Part B coverage. Every Medicare Advantage plan provides the same Medicare Part A and Part B benefits as Original Medicare. However, beneficiaries may get additional benefits like prescription drug coverage with certain private insurers.

When does your Medicare coverage start?

The coverage for each part of Medicare starts on a different date. The Part A coverage becomes active on the first day of the 65th birthday month. On the other hand, the Part B coverage starts on the first day of the 65th birthday month, provided the beneficiary has signed up within three months before their birthday or in their birthday month.

How can you enroll for Medicare?

If you are not automatically enrolled for Medicare, you can do so manually using one of the three mediums below:

  • Physical enrollment at a local Social Security office.
  • Online application via Social Security website.
  • A phone call to Social Security at   1 (800) 772-1213

The easiest and fastest option is the online application; you can be done in about 10 minutes.  For physical enrollment at the Social Security closest to you, kindly make an appointment in advance either by calling or the website.

Whichever option you decide to go for, we recommend that you pay attention to the specific enrollment deadlines for the Medicare plans you are joining. This is the best way to ensure that your benefits are properly arranged.

Are there penalties for late enrollment?

Yes, beneficiaries may pay penalties for Parts A, B, and D of Medicare if they fail to sign up at first eligibility.  The exact penalty is estimated according to the duration of non-enrollment and non-payment of the Medicare base premium price. The penalties are then added to the monthly premium.

For Part A, the penalty for late enrollment is 10% higher premium, to be paid for 2x the number of years of non-enrollment.

For Part B, the penalty for late enrollment is a 10% higher premium, to be paid for every 12 months of non-enrollment after becoming eligible. This will continue for as long as the plan is active.

For Part D, the penalty for late enrollment is 30% of the base beneficiary premium, to be paid every 63 days of non-enrollment after becoming eligible. This will continue for as long as the plan is active.

Talk to the Experts

Do you qualify for Medicare but are not sure of how or where to start? Or do you want to know how best to approach your Medicare penalties? Feel free to reach out to us via phone or the contact us page.  We will be happy to speak to you and help you get started with your Medicare enrollment process.

Medicare Cost

While Medicare is not free of charge, placing a price tag can be difficult considering the nature of the program. The four parts of Medicare – Medicare A, B, C, and D, and the supplement plan – Medigap – are designed for different uses. Despite the numerous discount and assistance programs open to beneficiaries, the final cost depends on which plans a beneficiary enrolls in.

What determines Medicare Costs?

The cost of Medicare is determined by your state of residence, your income, and the kind of supplemental coverage you chose. The best approach to understanding the costs of Medicare is to treat the parts separately.

Medicare Cost – Part A

Medicare Part A is free for most people. The only condition for eligibility is to have worked for over ten years in the United States. The government pays the Medicare Part A premiums for beneficiaries who fulfill this condition through their payroll taxes. This is why almost every Medicare beneficiary qualifies for Part A at zero cost.

However, if you do not meet this condition, you may have to pay for your Part A, which costs around $471 per month.  A pro-rated premium is available at $259/month, open to people with over 30 quarters of work experience but less than 40 quarters. However, such potential buyers must have stayed in the United States as legal residents for at least five years.

Medicare Cost – Part B

Medicare Part B is not free. Beneficiaries are expected to pay premiums according to their adjusted household gross (MAGI) income. The Social Security office determines the exact premium payable on Medicare Part B by checking the beneficiary’s tax return over the previous two years.

The MAGI is influenced by the money earned through investment dividends, interest, and wages. Other contributors include tax-deferred pensions and Social Security benefits. In the case of beneficiaries who filed jointly with a spouse, the premiums will be estimated per spouse, according to their married income. However, each spouse is treated as an individual beneficiary and expected to pay their Part B premium.

The notification for the annual premium comes in December or early January through mail from Social Security.

Medicare Cost – Part C

Only private health insurance companies can provide Medicare Advantage or Part C plans. Hence, beneficiaries can only buy from them. The exact cost will vary, depending on the requirements of the private health insurance provider you are working with. However, there is a limit to how much a beneficiary can spend on out-of-pocket expenses.

Centers for Medicare and Medicaid Services (CMS) puts the average monthly premium at a possible $21 for 2021.

Medicare Cost – Part D

Medicare Part D is designed to cover prescription drugs and can only be purchased through Medicare-approved private insurance companies.  The costs for Medicare Part D differ according to the income of the beneficiary and the chosen plan. There are several plans to choose from – up to 20 in some states. An average Medicare Part D plan costs around $15 per month for most states. Part D’s base premium is payable by every beneficiary, except people with higher incomes – who pay higher.

What is the cost of Medigap?

Medigap or Medicare supplement insurance are plans designed to cover the costs that are not included in the original Medicare coverage.  Only private providers offer this set of plans, and they determine the exact premium payable based on the age, needs, and locations of the beneficiaries.

On average, you can spend between $20 and $500 on your Medigap premiums every month.  We recommend that you compare the plans and prices of multiple Medigap providers before settling for the most favorable option.

How do you make Medicare payments?

Beneficiaries on federal retirement benefits will have their Medicare Part B premiums deducted from their Social Security checks.  The Part D premiums can also be deducted from the benefit checks, depending on the insurer’s preferences.

Beneficiaries who are not on federal retirement benefits will be served a monthly Medicare Premium Bill for the parts of Medicare they are subscribed to. The bills are payable through the online service of your bank. Alternatively, you can mail back a check or money order payment, as well as use debit and credit cards.

Medicare Easy Pay is a dedicated payment method for Medicare Premium Bills.  It is designed to remove the payments automatically from a bank account linked by the beneficiary. The copays and deductibles go to the healthcare providers directly.

Are Medicare Premiums taxed?

Medicare premiums are tax-deductible as part of the medical expenses of the beneficiary. For instance, if the beneficiary’s annual total medical expenses are more than 10% of their Adjusted Gross Income, it becomes tax-deductible. This arrangement also excludes some part of their income from being tax-deductible.

If you are not sure about your Medicare premiums and taxation, please speak to a tax professional for proper guidance.

How can you minimize your Medicare costs?

There are a few ways to lower your Medicare costs, including Medicare Savings Program and the Medicare Extra Help Program.

The Medicare Savings Program is targeted at low-income Medicare beneficiaries, so they can conveniently pay their original Medicare premiums, deductibles, and copays. The Medicare Extra Help program is designed to help low-income beneficiaries with their prescription drug coverage.

There is also Medicaid, which is a government-funded health insurance program established for low-income Americans. The eligibility for Medicaid differs across states – not all states are eligible.

Overall, the best way to lower your Medicare costs is to go for the best plan and program structure. But it is also important to note that the benefits and coverage are more robust in some plans than others

Talk to the Experts

Do you have any questions on Medicare costs or professional help in understanding the best coverage for you?  Reach out to us today.  Our Medicare experts are always available to discuss your needs and answer your questions.

Medicare Eligibility

Not everyone is eligible for Medicare. As we will find out together on this page, there are certain conditions an individual can meet before they can be considered eligible for Medicare.

Medicare Eligibility Age

Contrary to popular belief, the retirement age does not count for Medicare eligibility. Anyone who is 65 years old qualifies for Medicare, whether they are still working or not when they turn 65.

What are the requirements for Medicare eligibility?

For people aged 65 or older.

Any U.S. citizen or a permanent legal resident who has been in the country for not less than five years will be eligible for Medicare, provided:

–           they are receiving Railroad Retirement or Social Security benefits; or

–           they have worked for the number of years required for such benefits without receiving them.

Likewise, U. S. citizens, or permanent legal residents who have lived in the country for at least five years, will qualify for full Medicare benefits if they (or their spouses) are government retirees or employees.  However, such government employees or retirees must have paid Medicare payroll taxes during service.

For people below the age of 65.

American citizens who are younger than 65 will be eligible for full Medicare benefits if:

They are permanently disabled.

Permanently disabled Americans who have been entitled to or receiving Social Security disability benefits for not less than 24 months, not necessarily consecutive, are eligible for Medicare. Such individuals are automatically enrolled in Medicare Parts A and B on the 25th month of their disability benefits.

They are receiving a disability pension.

Americans below age 65 who have been receiving beneficiaries of disability pension from the Railroad Retirement Board and meet other important requirements are eligible for Medicare.

They have Lou Gehrig’s disease.

People under age 65 but living with Lou Gehrig’s disease or amyotrophic lateral sclerosis (ALS) are eligible for Medicare Parts A and B. Such potential beneficiaries are automatically enrolled on the first day of the month they start receiving disability benefits – the enrollment is immediate.

They have permanent kidney failure.

Americans with end-stage renal diseases (ESRD), which needs regular dialysis or kidney transplant, are eligible for Medicare. However, they (or their spouse) must be eligible for, or already getting, the Railroad Retirement Board or Social Security benefits or worked under the Railroad Retirement Board, Social Security, or the government.

They are also qualified if they are a spouse or dependent of an eligible beneficiary for Railroad Retirement or Social Security benefits.

Now, let’s discuss eligibility for each Medicare Parts

Medicare Eligibility By Parts

Who is eligible for Medicare Part A?

If anyone (or their spouse) has worked legally for at least ten years in the United States and is aged 65, they are eligible for Medicare Part A. Such potential beneficiaries must have paid taxes towards their Part A hospital benefits, which exempts them from paying premiums on eligibility.

Americans age 65, but yet to meet the 10-year working period requirement, can buy Medicare Part A for around $400 every month. The premium may be lower if they have worked over 30 but less than 40 quarters.

Enrollment is automatic after the 65th birthday, provided the potential beneficiary is enrolled in Social Security home benefits.

Who is eligible for Medicare Part B?

Americans age 65 are eligible for Medicare Part B. However, Part B is not free – it attracts a monthly premium. If the potential beneficiary still has active health insurance through their employer, they can maintain that and postpone their Part B enrollment.

Who is eligible for Medicare Part C?

Medicare Part C or Medicare Advantage program is open to Americans who want their benefits to come through a private insurance company rather than Original Medicare. This may come with Part D coverage as an add-on in some cases.

The prerequisite for Medicare Part C is an existing enrollment in both Parts A and B and being a resident in the plan’s service area.

NB – Enrolling in Medicare Advantage does not exempt beneficiaries from Medicare Part B premiums. The enrollment in Medicare Parts A and B must be maintained to keep the Medicare Advantage plan active.

Who is eligible for Medicare Part D?

Anyone who is actively enrolled in either Medicare Part A or Part B is automatically eligible for Part D, provided they live in the plan’s service area.  Unlike Medicare Part A, Part D is not compulsory. However, it is best to enroll if there is no drug coverage in place to prevent paying expensive medication costs out of your pocket.

Enrolling in Medicare Part D or having a creditable substitute coverage will also exempt you from the late enrollments that come with future enrollment.

When can an eligible beneficiary enroll in Medicare?

Eligible beneficiaries are automatically enrolled at age 65 or enroll manually within the 7-month Initial Enrollment Period. For details, visit our Medicare Enrollment page.

What is the right age to apply for Medicare?

Anyone who meets every other requirement but age can apply for Medicare when they are age 64. The enrollment period is three months before their 65th birthday month.

Is Medicare enrollment compulsory?

While it is not compulsory to sign up for Medicare at age 65, there will be penalties for delaying enrollment if the potentially eligible beneficiary does not have creditable health coverage.

NB – An enrollment into Social Security income benefits automatically enrolls you into Medicare Part A.

Have any more questions on Medicare eligibility?

Ask the experts

Are you struggling to determine your eligibility for Medicare? Or you have questions on Medicare eligibility that need adequate answers? Contact us today via phone or email. Our experts are always willing and ready to discuss your Medicare needs and concerns. We are here to help.

Enrollment Periods

 When should you join Medicare?

After you have confirmed your eligibility and identified what Medicare plans you want to enroll in, the next is knowing when to enroll. Knowing when to join your chosen Medicare plans can help you plan effectively ahead, register on time, and avoid the penalties that come with late registration.

Medicare Enrollment Is Not Open All Year

One of the common mistakes people make is assuming they can enroll for Medicare any time of the year, provided they are eligible. There are usually official registration periods for potential eligible beneficiaries to join their desired Medicare plans. These periods are called Enrollment Periods.

What happens during enrollment periods includes enrollment into plans, switching plans, and dropping plans.

Key Medicare Enrollment Periods

Here are the most important enrollment periods for various Medicare Parts:

    Initial Enrollment Period

If you are enrolling for Medicare because you are turning 65, the initial enrollment period is the official time to join. It lasts for seven months – starting from three months before your 65th birthday, through your birthday month, and continues for three months after you have turned 65.

A potential eligible beneficiary can enroll in the following plans during the Initial Enrollment Period:

–           Medicare Parts A and B

–           Medicare Part D or a stand-alone Medicare prescription drug plan

–           Medicare Part C or Medicare Advantage Plan

Not signing up for these Medicare Parts during this period attracts penalties, so you will end up paying higher premiums than usual.  Note that enrollment into Medicare Parts A and B is automatic for potential eligible beneficiaries who are already receiving Social Security benefits.

   General Enrollment Period

If you failed to register for Medicare Parts A and B during the Initial Enrollment Period, your next chance comes during the General Enrollment Period.  This may be due to personal reasons or your ineligibility for the special enrollment period.

The General Enrollment Period starts from January 1 through March 31 every year. If you register during the general enrollment period, your coverage starts July 1 and may attract late enrollment penalties.

NB – The General Enrollment Period is only open for Original Medicare. You cannot enroll for Medicare Part D coverage or a Medicare Advantage Plan during this period.

    Special Enrollment Periods

The Special Enrollment Period is another window for eligible beneficiaries who missed the 7-month Initial Enrollment Period. It lasts for two months and allows beneficiaries to change their coverage due to a special circumstance or qualifying event.

For instance, delaying your Medicare enrollment past age 65 to get creditable coverage via active employment means you can apply for Medicare A and B during the special enrollment period. You can also enroll for or switch between different Medicare Advantage and Part D Medicare Plans during their Special Election Periods (SEP).

During a Special Enrollment Period, I haven’t witnessed many enrollment penalties for being late signing up.  The timing for the SEP varies based on the qualifying situation.

    Annual Enrollment Period

The Annual Enrollment Period presents a perfect opportunity to make changes to your coverage or enroll in a new Medicare plan. It runs from October 15 through December 7 every year. You can take advantage of the annual enrollment period if:

NB – All successful changes made during the Annual Enrollment Period will not be effective until January 1, which is when the coverage officially begins.

    Medicare Advantage Open Enrollment Period

The Medicare Advantage Open Enrollment Period (MAOEP) is designed for Medicare beneficiaries with an existing Medicare Advantage plan. You can switch between Medicare Advantage plans during this period or drop the plan altogether and enroll in Original Medicare with a Part D plan.

You cannot move from Original Medicare to a Medicare Advantage plan during this enrollment period. Likewise, you cannot enroll for a Medicare prescription drug plan if you are not enrolled in Original Medicare. You cannot also move from a stand-alone Medicare prescription drug plan to another.

The Medicare Advantage Open Enrollment Period starts from January 1 through March 31 every year. Whether you switched Medicare Advantage plans or transitioned from Medicare Advantage to Original Medicare, your new coverage starts on the first day of the month after the month you made the change.

NB – You can only buy Medicare Advantage plans from private insurers. It is best to go for one with prescription drug coverage.

    Medigap Open Enrollment Period

After joining Medicare Part B for the first time, you can enroll in a Medigap plan B without answering health questions if you do so within six months before and six months after your Part B effective date. Missing this period without any qualifying event means you will answer health questions to join a Medigap plan.

Note that the Medigap Open Enrollment Period comes once for most eligible beneficiaries. This enrollment period is beyond serious, so don’t wait and miss it.

What happens when you miss the Enrollment Period?

Not enrolling within the official registration period may delay your coverage. There may also be penalties in some cases, which means paying more than the regular amount.

Let’s help you make the right enrollment decisions

The Medicare enrollment process can be tricky – from knowing what to do and when best to do it. Navigating the process on your own makes it error-prone and costs you extra money in the form of higher premiums.

Save yourself the extra money and stress by getting help with your Medicare choices from professionals. We are always available to discuss your enrollment needs and decisions. We also ensure you do not miss any enrollment deadline, so you don’t have to pay extra,

 Reach out today on the phone or send us an email.

Choosing A Plan

How To Pick The Right Medicare Plans For You

Being eligible for a Medicare Plan is only half the job – the other half is knowing the right plans to choose. The ideal Medicare plans should suit your way of life and align with your health goals.

Deciding on which Medicare coverage to go for does not have to be a problem. This page tells you all you need to know about choosing a Medicare Plan.


Do you know how Medicare works?

Most people who are eligible for Medicare tend to make the avoidable mistake of rushing to choose a plan without understanding the basics of Original Medicare. Do not make a similar mistake. Take your time to learn about Original Medicare – it is the first step on your journey to choosing the right Medicare Plans and additional coverage.

We have compiled all you need to know about Medicare on our Medicare page here, including the various parts and how they fit together to give you the perfect coverage. You can also check out our other Medicare pages for more information.


Do you understand your health needs?

First, it is essential to note that a “one size fits all” approach does not work with Medicare. This is because healthcare needs differ across individuals. As a rule of thumb, each eligible beneficiary must assess their needs and structure their Medicare coverage around such needs.

Start with your medications – what medications are you on, and for how long would they last? Assess the types of medical care you have been receiving – are you maintaining the exact needs or making adjustments?

While no one knows what their health would certainly look like, it is best to make projections and anticipate the help we need. You may consult your physician for specific information and guidance in these regards.


Medicare Supplement vs. Medicare Advantage Plan

Once you know what your healthcare needs are, you can search for suitable Medicare Supplemental Insurance. It is common to see people confuse Medicare Supplement (Medigap) plans with Medicare Advantage plans. Although both are types of Medicare plans, they differ considerably.

Medigap or Medicare supplement insurance are plans designed to cover the costs that are not included in the original Medicare coverage. Only private providers offer this set of plans, and they determine the exact premium payable based on the age, needs, and locations of the beneficiaries.

On the other hand, Medicare Advantage plans (Medicare Part C) are not free, and the cost differs across carriers, countries of residence, and the type of plan. This part offers Medicare-covered benefits via private health plans. This may also include additional benefits like prescription drug coverage.

We have highlighted a few questions to help you decide the more suitable plan:

–           Are your important physicians a party to any Medicare Advantage plans, or do they accept only Original Medicare?

–           What insurance do your preferred hospitals recognize?

–           Do you travel out of the area regularly? If yes, you should go for a combination of Original Medicare and a Medicare Supplement – it is acceptable in all hospitals that accept Medicare nationwide.

–           Can you handle a year of heavy health spending? This may not be a problem if you have sufficient saving to foot the highest possible out-of-pocket expenses that may come with your Medicare Advantage plan.

–           What works for you best? Do you prefer to pay for your services as you go or want some additional insurance against unexpected expenses? Medicare Advantage plan is good for the former with its low premiums and Medicare Supplement for the latter because it tells you your exact medical expected expenditures irrespective of your health state.

Based on your answers to the above questions, you can determine which is more suitable for you between Medicare Supplement plans and Medicare Advantage plans.

Let’s look at how you can choose the right provider and/or coverage in both cases.


Choosing the right Medical Supplement Plan

The standardization of the Medial Supplement Plans in 1990 has made comparison easier. There are tons of resources online to help you compare the best Medicare Supplement Plans.

If you are going with a Medigap Plan, you can use the internet to search for the list of plans in your area. After creating a list, compare the prices and offers to see which works best for you.

NB – The premiums payable for your Medicare Supplement plan are determined by a couple of factors, including gender, age, zip code, tobacco usage, and your eligibility for discounts (if applicable).


Choosing the right Medicare Advantage Plan

The Medicare Advantage or Part C Medicare is a combination of both Part A and B coverage into a single plan. Most of these plans come with prescription drug coverage automatically. You can either go for such or plans without drug coverage – the latter allows you to choose a separate standalone Part D plan.

You need Medicare Part D for Prescription Drug Coverage because it helps to reduce the cost of prescription drugs while delivering a standard level of coverage as outlined by Medicare.  You can only get a Part D Medicare plan from approved private insurers, although they are part of the government’s Medicare program.


Get Professional Help

Choosing the right Medicare plan can be a complicated process to navigate. Despite using online resources, you may struggle to sieve through the vast information to identify the best plans available in your area.

You can save yourself this stress by getting personalized help from Medicare experts. At Medicare 365, we are always ready to help. You can trust us to tell you more about Medicare plans and how they work. We will be delighted to speak to you one-on-one on this or any other Medicare topics. Feel free to call us today on 1-844-55-27426 or send an email.

Medicare Part A

As the name suggests, Part A is a part of original Medicare, a Government-sponsored health insurance program for those at the age of 65 or receiving the benefits of disability. People who qualify for Medicare are automatically enrolled in the program.

If you’re enrolled in part A, you can go to any hospital that accepts Medicare, including all acute hospitals. If you have paid social security benefits via an employer for about 10 years. You will not have to purchase a monthly premium for Part A.

If you or your spouse is a Government employee or retire and has paid Medicare payroll taxes while working. You can get premium-free part A. Though there is no monthly premium, you will have to pay a deductible to receive hospital care.

Now let’s come to the point of enrolling in Medicare Part A. If you’re already enjoying social security benefits, you will be automatically enrolled. Conversely, if you’re not receiving security benefits, contact social security before you reach 65.

What does Medicare Part A cover?

Are you ready to get Part A hospital benefits? Here is what you need to know about Part A. Medicare Part A is hospital insurance, and its coverage helps pay for things like;

  • Inpatient hospital stays
  • Skilled Nursing facility
  • Home health care
  • Hospice care

Let’s discuss these benefits one by one.

Inpatient Hospital coverage

It covers hospital expenses, including a semi-private room, nursing services, meals, and other services from the hospital. However, Medicare part A does not cover the costs of a private room, private-duty nursing, and other personal care items, including razors, shampoo, and more.

Blood costs don’t fall under part A. However, you don’t need to pay if the hospital gets it free from the blood bank. Otherwise, you will have to pay. Medicare Part A cover inpatient care through

  • Inpatient rehabilitation facilities
  • Acute care hospitals
  • Long-term care hospitals
  • Mental health care
  • Critical access hospitals

Skilled Nursing Facility (SNF)

After qualifying for the inpatient hospital stay, you will be eligible for SNF. However, home nursing must be related to your illness or diagnosis during an inpatient hospital stays for at least 72 hours. You will not get SNF unless your doctor determines that SNF is necessary for your recovery. Medicare Part A SNF covers the costs of;

  • Medications in SNF care
  • Ambulance transportation
  • Medical Equipment
  • Semi-private room
  • Meals
  • Dietary counselling

But part A does not cover long-term care and personal care.

Home Health Service

Medicare Part A covers the following home health services;

  • Part-time care services like intermittent nursing skill
  • Physical therapy or continued occupational therapy
  • Speech-language pathology services
  • Home health aide service

One thing more, part A does not coverer 1-day home care and other personal care services.

Hospice Care

You will be eligible only for Hospice care if your doctor certifies that you are terminally ill and have six months or less to live. The patient will receive the benefits of Hospice care in their home, and services include;

  • Pain relief and symptom-control prescription drugs
  • Medical, support, doctor, and nursing services
  • Grief counselling services
  • Short-term respite care
  • Physical and occupational therapy

Medicare Part B

This part of original Medicare provides medical insurance and covers all medically necessary services and supplies that you might need for effective treatment. Medicare part B covers a wide range of services, including outpatient and preventive care. Both Medicare Part A and Part B combine to form Original Medicare.

Unlike Part A, you will have to pay for premium Medicare Part B. In 2021, monthly premium Part B starts at $148.50. This article aims to help you understand what Part B covers and what it does not. It also aims to define Part B eligibility criteria, enrollment period, and more.

What does Medicare Part B cover?

Part B covers the following services;

  • Doctor visits
  • Outpatient and inpatient care services
  • Preventive care services
  • Clinical research
  • Ambulance services
  • Durable medical equipment such as wheelchairs, oxygen, etc.
  • Part-time or intermittent home health
  • Rehabilitative services
  • Blood

What does Medicare Part B not Cover?

Part B does not cover the following services;

  • Dental care dentures
  • Cosmetic surgery
  • Nonmedical long-term care
  • Vision care and eye exams for prescription glasses
  • Acupuncture
  • Exams for hearing aids
  • Skilled nursing facility services

Who is eligible for Medicare Part B?

People, who are the beneficiary of Medicare Part A, are eligible for Part B. Like Medicare Part A, you will be automatically enrolled in Medicare part B if they have already received social security advantages.

After the enrolment, you will get a red, white, and blue Medicare card about three months before you reach the age of 65. As a Medicare Part B beneficiary, you can go to any doctor who accepts Medicare, including an acute affiliated doctor.

If you’re not receiving social security benefits and are not eligible for premium-free part A Medicare. You will have to qualify for the following requirements to get your Medicare Part B.

  • Your age must be at least 65
  • You must be a US citizen

People under 65 and receiving social security or Railroad Retirement Board disability benefits may also qualify for automatic Medicare Part B enrollment.

When to Enroll?

As earlier mentioned, if you’re already receiving social security and retirement benefits through disability. You will be automatically enrolled in Medicare Part A and Part B; however, you’re at 65 and did not sign up for Medicare’s initial enrollment. You can sign-up for General Enrollment Period from January 1 to March 1.

If you’re not eligible for Medicare through automatic enrollment, you can apply through social security at a local security office or via their website. One thing more, once you have Medicare Part B at 65, your 6-month Medigap enrollment period begins. I highly recommend, don’t miss this initial guaranteed-issue enrolment period for a Medigap plan.

Delaying Part B Coverage

Some people do not sign-up for initial enrollment. This is because they’re still working and receiving health insurance coverage through their company or from where they work. Or maybe they’re using their spouse’s health insurance plan.

If you’re also working, don’t worry, you can sign-up later for the Medicare program. After retirement from your workplace, you will be given some time for a special enrolment period where you can sign-up for Part B without paying any penalty.

Medicare Part C (Medicare Advantage Plans)

Medicare Advantage plans are an alternative way to receive Medicare coverage. There are managed care plans administrated by private insurance companies that Medicare has approved. These plans bundle in the benefits of Medicare Part A, and B, and even Part D.

Medicare Advantage plans aka Medicare part C cover the exact same thing as Original Medicare, Part A, and Part B, covers. They may provide extra coverage, such as hearing, dental, vision, wellness, and health programs. If you’re a beneficiary of Part A and Part B, you can enroll for Medicare Advantage plans.

However, you have to remain enrolled in Original Medicare, and you will have to pay your Medicare part B premium. So, you will have to keep paying for Part B even if you enroll in Medicare Part C.

What does Medicare Part C Cover?

Medical Advantage plans cover the following services

  • Inpatient care
  • Outpatient care
  • Home health service

Types of Medicare Advantage Plans

Here are different types of Medicare Part C

Health Maintenance Organization Plan (HMO)

In HMO plans, you could use only in-network doctors and hospitals. There is no Medicare coverage out of network unless you need an emergency. This plan requires you to build a primary care physician to get referrals from it when you see a specialist. HMO plan could be a great option for you if your doctor is already in the network because you’re going to pay less from your pocket.

Preferred Provider Organization Plan (PPO)

Using a PPO plan, you will get coverage both in and out of the network. On a PPO plan, you can choose any hospital and doctors that accept Medicare. Unlike HMO, this plan does not require you to establish a primary care physician. So, there is no need for any referrals to see a specialist.

Private Fee for Service Plan (PFFS)

PFFS plan may be a great option for you if;

  • It’s available in your area
  • If your physician and Hospital accept the PFFS plan’s terms and condition

If your doctor and Hospital don’t accept the plan’s payment terms, your PFFS plan will not provide coverage through that physician and doctor.

Special Needs Plan (SNP)

SNP is for those who qualified for special health care needs. You can be eligible for SNP if you meet the following requirements;

  • You’re eligible for Medicare and Medicaid
  • If you have a condition that is considered severe or disabling
  • You’re institutionalized, such as in a long-term skilled nursing facility

HMO- Point of Service (HMO-POS)

This plan offers both in-network and out-network Medicare coverage at different rates. Moreover, you will pay less when you visit in-network physicians, labs, and hospitals.

Who is eligible for Medicare Part C?

If you’re a beneficiary of Part A and Part B, you’re also eligible for Medical Advantage plans.

When to enroll for Medicare Part C?

There are specific enrollment periods

Initial coverage election Period

This is a seven-month period that starts three months before you reach 65.

Annual election period

The AEP period runs from October 25 to December 7.

Open Enrollment Period (OEP)  

OEP period runs from January 1 to March 31.

Medicare Part D

Part D prescription drug coverage plans are administrated by private insurance companies that Medicare has approved. These plans aim to help people in Medicare pay for prescription drugs. Medicare Part D is optional, and it is up to you whether you enroll in a Prescription drug coverage plan or not.

Part D is also considered as part of Medicare. If you\’re willing to opt into the program, you will have to purchase their insurance from approved and registered private companies. Like the other parts of Medicare, Part D includes a monthly premium that may vary depending on your plan and drugs. In 2021, the basic Part D Premium plan is about $30.50/month.

What does Medicare Part D cover?

Part D covers all the drugs of the following six classes;

  • Antineoplastics, for cancer
  • Anticonvulsants, to treat epilepsy and health conditions
  • Antipsychotics
  • Antidepressants
  • Immunosuppressant
  • Antiretrovirals used to treat HIV/AIDS

Stages of Medicare Part D

There are four stages of the Medicare prescription drug plan.


The deductible is the amount that you pay out of pocket each year on your medical services before the copays begin. Medicare sets the maximum number of deductibles each year, and insurance companies must keep their plan deductible at or below that number. So, you will have to pay the full charges of your prescription drug costs to meet the deductible.

Initial Coverage Level

After meeting the annual deductible, you will enter into the initial coverage phase. During this phase, you will have to pay a copay or co-insurance for each medication, depending on the tier type. The drugs are broken down into five different tiers.

  • Preferred Generics
  • Non-Preferred Generics
  • Preferred Brand
  • Non-Preferred Brand
  • Specialty Medications

Each tier will have a copay or co-insurance associated. If we come to preferred generics, they will have the lowest copays. For example, you might find a drug that has a copay of $5 for preferred generics, $10 for non-preferred generics, $30 for preferred brands, and so on. The copay amount listed for that tier is what you pay for your medical services when you pick them at the pharmacy.

Coverage Gap or Donut Hole

During this stage, your plan can charge you as much as 25% of your brand name drugs\’ cost and a bit higher percentage of your generic drugs. For example, you have a Part D plan where one of your tier 3 brand name medications costs $400, and your copay for tier costs $50.

During the initial level, you will pay $50. However, when you reach the coverage gap, many plans will charge you the full 25%. It means when you hit the gap, you would go from spending $50 to $100 on that same medication.

Catastrophic Coverage

This stage protects you from catastrophic drug spending on your medications. When you reach catastrophic coverage, Part D carrier must pay 95% of all your covered medications costs for the remainder of the year. This stage is only the single best reason to sign-up for Medicare part D.

Who is eligible for Medicare part D?

If you are a beneficiary of Original Medicare, you can sign-up for a Part D prescription drug plan. However, if you’re looking for a Medicare Advantage prescription drug plan, you should have both Part A and Part B?