Find your way through the complex choices and options of Medicare, with our simple and useful guide on how coverage works.
Medicare is a program that helps millions of Americans get the healthcare they need. It can help you tremendously because it offers you choices on how you can obtain your benefits. However, sometimes finding the solution you need is tricky. So make sure you spend time exploring your options, because, in the end, you can find a solution that’s right for you. Our comprehensive guide to Medicare introduces you to the choices that are available and will explain the important differences.
This guide will help you construct a rock-solid plan for understanding what’s important when it comes to your Medicare. Healthcare costs are a big part of your finances. It’s something we all have to acknowledge now— even when it comes with a big price tag. Medicare offers a helping hand with these costs. Making the right choice for you will take some thoughtful and extensive planning, so let’s get started!
Who is eligible for Medicare?
Americans 65 years and older are eligible for Medicare. Medicare also serves as health insurance for people under 65 with certain disabilities. People of any age with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant) are also eligible for Medicare. You must be a U.S. citizen or a legal resident who has lived in the country for at least five consecutive years.
What are my coverage choices?
There are two main ways to get your Medicare coverage—Original Medicare (Part A and Part B provided by the federal government) or a Medicare Advantage Plan (Part C offered through private insurance). Explore your options to help you decide which way to get your coverage.
What are the different parts of Medicare?
Medicare Part A (Hospital Insurance) helps cover:
- Inpatient care in hospitals
- Skilled nursing facility care
- Hospice care
- Home health care
- Original Medicare doesn’t pay for everything. You still pay a share of the cost in monthly premiums and copays
Medicare Part B (Medical Insurance) helps cover:
- Services from doctors and other health care providers
- Outpatient care
- Home health care
- Durable medical equipment
- Some preventive services
- Original Medicare, Parts A & B, are the same across the United States
Medicare Part C (Medicare Advantage):
- Includes all benefits and services covered under Part A and Part B
- Run by Medicare-approved private insurance companies
- Usually includes Medicare prescription drug coverage (Part D) as part of the plan
- May include extra benefits and services for an extra cost
Medicare Part D (Medicare prescription drug coverage):
- Helps cover the cost of prescription drugs
- Run by Medicare-approved private insurance companies
May help lower your prescription drug costs and help protect against higher costs in the future
When to ENROLL
The Initial Enrollment Period (IEP) is your first chance to enroll in Medicare. It’s the three months before your 65th birthday month, the month of your birthday, and the three months after your birthday month.
- If you enroll before the month you turn 65, coverage starts on the first day of your birthday month
- If you enroll during your birthday month or later, coverage starts on the first day of the month following the date you enroll
Tip: If you don’t sign up for Part D coverage when you enroll in Medicare, you may pay a penalty if you enroll later unless you qualify for an exception.
Evaluate your choices once a year
After you choose your Medicare coverage, it’s important to know that you can make changes to your coverage during the Medicare Open Enrollment Period (OEP), Oct 15th– Dec 7th. Make sure you review your coverage thoroughly so you can find something that suits you best.
Special Election Period (SEP)
In some cases, you can enroll or switch plans outside of IEP and OEP. This includes changes to your life situation which include:
- You’re in retirement and choose a healthcare plan through your employer or union.
- You move out of your healthcare plan’s service area.
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You must begin the enrollment process with Social Security. Go online or call/visit your local Social Security office to get started with your Medicare coverage. The Social Security Administration takes care of the paperwork for joining Medicare. The first letter you get in the mail about Medicare will come from Social Security. If you’re drawing Social Security benefits when you turn 65, Social Security should automatically enroll you in Medicare Part A and Part B, but check with your local Social Security office if you suspect there is a problem. Social Security can also help you find out if you’re eligible for Extra Help with the cost of Medicare coverage.
Who’s eligible for assistance?
It depends on your income. Your income includes money you get from retirement benefits or other money that you report for tax purposes. It also includes your assets (for example, property other than your house). The income eligibility levels vary by state and program. The income eligibility limit for 2021 is $19,140 a year for an individual or $25,860 for a couple. Go online, call, or visit your local Social Security office to determine if you are eligible for extra help.
Here are some things Medicare doesn’t cover.
As mentioned above, Medicare does cover a skilled nursing facility, but that is not the same thing as long-term care. Medicare only covers up to 100 days in a skilled nursing facility and that can come with a $185.50 daily copayment for days 21 through 100. In order to be covered, the hospital stay must follow a qualifying inpatient stay, and you must need a higher level of care than just assistance with daily living.
Healthcare statistics tell us that 70 percent of people turning 65 this year will need long-term care at some point in their remaining years.
Medicare does not cover eye exams, glasses, or contact lenses. If you are diagnosed with cataracts, Medicare will pay for surgery and one pair of corrective lenses, but further routine vision care is not covered.
Regular eye exams are even more important as you reach your senior years. The American Optometric Association recommends annual eye examinations for everyone over age 60.
With retirement comes the freedom to travel more. When traveling abroad or across seas, you will not have Medicare, even for emergency care. Exceptions to this rule are when traveling to Alaska through Canada or if you are near a border and a foreign hospital is closer than one based in the U.S.
For many frequent flyers, this can be very alarming. One serious emergency could leave you with hundreds of thousands in crazy medical bills.
Routine Dental Care
Unfortunately, Medicare Part A and B do not cover routine dental care visits. Medicare only covers “medically necessary” dental services such as if you have oral cancer and need surgery as a part of your treatment. Routine dental care is only covered if deemed necessary for clearance for heart surgery.
According to the CDC (Centers for Disease Control and Prevention), 96 percent of adults 65 years or older have had one cavity. Two out of three older adults suffer from gum disease. Nearly one in five adults 65 years or older have lost all of their teeth. Dentures are also not covered by Medicare.
Very few insurance plans cover hearing aids, let alone routine hearing care. This means that 100 percent of the cost of hearing exams, hearing aid fitting, and the hearing aids themselves is out of pocket.
According to the National Institute of Deafness and Other Communication Disorders (NIDCD), one-third of seniors between ages 65 and 74 have hearing loss, and half of those age 75 and over are hard of hearing. Few insurance plans cover hearing aids; the average person spends about $2,700 out-of-pocket for a pair.
Lastly, Original Medicare does not cover drugs that you pick up yourself at a retail pharmacy.
Though costs for generic medications have dropped by nearly 40 percent over the past five years, costs for brand-name and specialty drugs increased by almost 60 percent. Over 90 percent of seniors take at least one prescription and 54 percent report taking four or more daily medications.
Even if you supplement your Medicare with Medigap (or Medicare Supplement Plan), you’re on your own for prescription medications. Medigap doesn’t cover your out-of-pocket costs for prescription drugs unless they’re covered under Part A or Part B.
Assess your current coverage
If you have coverage from your current job or insurance from the job you retired from, you’ll want to find all the information you can and how it works with your Medicare plan. Always remember that help is available, even financial help. For additional information and resources, make sure you visit us at medicareworld.com.
Additional Medicare information
Call your local State Health Insurance Assistance Program (SHIP) to see if you qualify for any financial assistance
- Medicaid: helps pay for health care costs not covered by Medicare for people and families with limited incomes. It may also offer extra benefits that Medicare doesn’t cover, but each state creates its own program, so contact your state office for more information.
- Medicare Savings Program helps you pay your Part A and B premiums, deductibles, and coinsurance.
- The Program of All-Inclusive Care for the Elderly (PACE) combines medical, social, and long-term care services for frail elderly people who live in the community, not a nursing home. It’s not available in all states.
- Other programs may be available in your state.