Are you approaching the age of 65 and are looking at your options for healthcare coverage? No problem, you are in the right place to get the information you need to make a decisive decision about your healthcare. The first question people approaching Medicare age ask is when am I eligible? Usually, Americans are automatically enrolled in Medicare Part A (medical insurance) 3-months before they turn 65. Nevertheless, you may still be at risk if don't understand all the parts of Original Medicare and when to enroll in selected parts.
One of the most prominent questions out there for individuals soon to turn 65 is, "What is Original Medicare?" The question itself sounds like a simple one. But when it comes to your health and your finances you quickly learn that certain actions have corresponding consequences. Trying to understand all of this information on your own can cause some to get overwhelmed because they are overcome by questions that have popped into their heads but they don't know where to go for answers.
Building a relationship with a qualified licensed health insurance broker can help answer specific questions pertaining to your individual situation, as opposed to getting a one-size-fits-all answer. Talking to a broker can give you detailed information that allows you to take control of what your health insurance plan can do for you and allows you to structure a sound plan that protects your retirement financial outlook with supplemental benefits.
So without any further ado let's get started.
What is Original Medicare? What's important?
Signing up for Medicare is simple and in most cases automatic depending on your situation. But for more clarity, if your situation is different and you want to know when you can sign up for Medicare, you have what is called your Initial Enrollment Period.
The Initial Enrollment Period (IEP) includes a total of 7 months in which you can enroll in Original Medicare. The IEP is the three months before your 65th birthday month, the month of your 65th birthday, and three months after your 65th birthday month.
If you are already getting benefits from Social Security or the Railroad Retirement Board (RRB), you will automatically get Medicare Part A and Part B starting the first day of the month you turn 65. If your birthday is on the first day of the month, Part A and Part B start the first day of the prior month.
​If you live in Puerto Rico, you'll automatically get Part A the first day of the month you turn 65 or after you get disability benefits for 24 months. However, you must sign up for Part B (form CMS-40B) coverage this is not automatic. You can visit Medicare.gov/basics/forms-publications-mailings/forms/enrollment, to get Form CMS-40B in English or Spanish. |
If you automatically get Medicare, you'll get your red, white, and blue Medicare card in the mail three (3) months before your 65th birthday. You will get Original Medicare coverage, Part A ("premium-free Part A"), and Part B unless you choose not to keep the coverage due to current employer coverage. If you didn't automatically get Original Medicare because you're still working, and not getting Social Security or Railroad Retirement Board benefits, you can sign up for it within 90 days of leaving your employer-sponsored coverage. To apply visit ssa.gov/benefits/medicare to apply if you work for the railroad, contact the Railroad Retirement Board.
Important: If you choose not to keep Part B, but decide you want it later, you may have a delay in getting Medicare Part B coverage, and you may have to pay a late enrollment penalty for as long as you have Part B, if you don't have credible coverage as good as Medicare during this time of non-Part B coverage. There is also a penalty for not getting Medicare Part A (if you have to pay for it) when first eligible.
For individuals under the age of 65 who have a disability, you'll automatically get Part A and Part B after you get disability benefits from Social Security or certain disability benefits from the RRB for 24 months. You get your red, white, and blue Medicare card for the 25th month of disability benefits, and you don't need to pay a premium for Part A. If you have amyotrophic lateral sclerosis (ALS) also called Lou Gehrig's disease, you will get Part A and Part B automatically the month your Social Security benefits begin.
Special Enrollment Period
After your IEP is over, you may have a chance to sign up for Medicare without incurring a penalty.
Anytime you are still covered under a group health plan
During the 8-month period that begins the month after the employment ends or the coverage ends, whichever happens first.
This period does not apply if you are eligible for Medicare based on End Stage Renal Disease (ESRD), or if you still have your Initial Enrollment Period available.
Remember to always contact your current employer when you are considering Medicare and Medicare Insurance Plans to find out how your employer's coverage works with Medicare.
Original Medicare
Original Medicare is one of your Medicare health coverage choices, and you also have a choice of a Medicare Advantage Plan or other type of Medicare health plan.
With Original Medicare you can go to any Medicare-enrolled doctor, other healthcare provider, hospital, or other facility that accepts Medicare patients anywhere in the United States. However, it does not cover most drugs or drugs outside of what may be administered in a doctor's office. This means that you will need a prescription drug plan (PDP) if you take medications prescribed by your primary care physician.
Many diagnostic and treatment services are covered under Medicare by Medicare-participating hospitals. You generally pay 20% of the Medicare-approved amount for services. Original Medicare doesn't cover medical care outside the US unless certain exceptions are met.
What is Medicare Part A?
Original Medicare usually covers most medically necessary services and supplies in hospitals. Part A (Hospital Insurance) helps cover inpatient care in hospitals, skilled nursing facility care, hospice care, and home health care. It is possible to pay more for services you get in a hospital outpatient setting than you'll pay for the same care in a doctor's office, usually paying the hospital copayment for each service you get in a hospital outpatient setting.
Part A Penalty
If you are not entitled to Medicare Part A, and you don't buy it when you're first eligible, your monthly premium may go up 10%. You'll have to pay the higher premium for twice the number of years you could have had Part A but didn't sign up.
What is Part B?
Part B (Medical Insurance) helps cover services from doctors and other health care providers or Outpatient care. Part B can also assist in giving recipients access to Durable medical equipment, like wheelchairs, walkers, hospital beds, and other equipment.
Part B has a monthly premium, and for covered services, you usually pay 20% of the Medicare-approved amount after you meet your deductible (often referred to as a coinsurance). It is also important to know that there is no year limit on what you pay out of pocket unless you have enrolled in Medicare Supplement Insurance or a Medicare Advantage plan. The Part B deductible applies, except for certain preventive services.
A good start to understand Medicare is to visit Medicare.gov or call 1-800-MEDICARE. You can also contact Social Security at 1-800-772-1213 for more information about your Medicare eligibility and to sign up for Part A and/or Part B. TTY users can call 1-800-325-0778. If you worked for a railroad or get RRB benefits call RRB at 1-877-772-5772 ( TTY users can call 1-312-751-4701. Get personalized health insurance counseling from your State Health Insurance Assistance Program (SHIP).
What Original Medicare doesn't cover
Prescription drug coverage is not covered under Original Medicare if you have to go to a pharmacy and pick up your medicines. It is important that you understand that regardless of whether you take medications or not you need to enroll in a qualified prescription drug plan, or a plan that includes prescription drug coverage. Not enrolling into a plan when you are eligible holds a penalty. Therefore, look for a Medicare Advantage with Prescription Drugs (MAPD) plan or a stand-alone Prescription Drug Plan (PDP) plan to ensure that you are covered.
Looking for coverage from private insurance carriers talk to a local licensed broker to get detailed information about the plan(s) that you are interested in. Whether it is a Medicare Supplement plan, Medicare Advantage, or a stand-alone Prescription drug plan, a broker is an excellent resource to allow you to take care of your healthcare on your terms and that fits your lifestyle.
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