- Know Your Eligibility
If you are “new to Medicare” – 65 years of age or older and a citizen or permanent resident of the United States, you are eligible for all Medicare coverage options. You can initially apply for Medicare during this 7 month “Initial Enrollment Period (IEP) starting 3 months before the month of your 65th birthday and for three months after. If you are drawing a Social Security benefit already, you will automatically be enrolled. Others younger than 65 may also be Medicare eligible due to a disability or qualifying illness.
- Three Enrollment Periods
IEP = Initial Enrollment Period – 3 months before the month of your 65th birthday and for three months after. You only get an IEP once in your lifetime so it’s important to understand what you should do during this time period.
GEP = General Enrollment Period – January 1 thru March 31 each year; Medicare coverage starts July 1 of the same year. If you are still working, you may be advised by Social Security to enroll during this period when in fact, you should not if you have employer group insurance.
SEP = Special Enrollment Period – a special enrollment may be granted anytime for those who have other qualified coverage and can allowably delay taking Medicare because they are on a large employer group policy, for example.
- Pick Your Coverage
There are 4 primary parts to Medicare: Hospital (Part A), Medical (Part B), Medicare Advantage Plans (Part C), and Prescription Drug (Part D) coverage benefits. Once you are eligible, you should familiarize yourself with these parts of Medicare and the various options available.
Most individuals receive Part A coverage at no cost if they or their spouse has paid Medicare taxes thru payroll deduction for at least 40 quarters while working. There is a premium for Medicare Part B which is determined based on previous tax returns. Higher earners pay a higher Part B premium. You may be able to delay enrollment in Part B without a penalty but you must understand how these rules apply to you to avoid paying higher premiums once you do enroll.
Medicare Part C plans are available in many areas but may not work well in all areas of the country. People with Medicare Parts A and B can choose to “assign” their benefits to a private insurance company approved by Medicare to provide Medicare coverage. This can include prescription coverage or Part D. While many people see benefits to Medicare Advantage Plans, they may not work for everyone. Part C plans require you to use strong plan provider networks like an HMO or PPO (preferred provider organization). You must determine if you providers take these plans in your area. If you travel, you could easily be out of network and face higher costs. Discuss with an unbiased insurance consultant who does not sell insurance to determine if these plans are for you. Some Part C plans provide extra coverage like hearing or dental and may lower your out-of-pocket costs. However, if you choose a Medicare Advantage Plan you may not be able to move back to original Medicare and/or have a Medicare supplement. This can create issues and high out of pocket expenses if your health needs change.
You are eligible for Medicare Part D at the same time you become eligible for Part A and/or Part B OR if you lose other creditable prescription drug coverage. There is a separate premium for Part D (prescription) coverage plus a co-pay for your medications. Costs between plans can vary widely so it’s important to have someone who understands the important cost considerations that you should understand including formulary coverage and pharmacy partnerships. If you don’t sign up for coverage when you are first eligible and don’t have other qualifying coverage – you could face late enrollment penalties and delays in getting coverage started. You should review your Part D plan annually to be sure you’re getting the best coverage at the lowest cost.
- Completing an Application
Most Medicare eligible applicants can apply for benefits online at the Social Security Administration Web Site (https://www.ssa.gov/medicare/) or at the closest Social Security Administration office in person. Social Security can also provide general information about the Medicare program. They will also accept and submit your application.
If you need assistance with this process or are feeling overwhelmed, contact SENIORx Patient Advocates to schedule an “Initial Needs Assessment” appointment to evaluate your individual situation more specifically. This appointment will help you establish enrollment timelines, requirements, coverage options, and the best coverage for your individual needs. SENIORx Patient Advocates can also help you complete and submit your application. Their consultants are licensed and do NOT sell insurance or financial products.