Medicare doesn’t have to be scary; you just have to be informed.
The Basics: Medicare is the health insurance program administered by the Centers for Medicare & Medicaid Services (CMS). And when one approaches age 65, a decision must be made—shall I enroll in Medicare? The answer depends on your individual situation. But first you must understand how this government healthcare program is designed.
Medicare Has Parts!
Part A is the insurance that covers “in-patient” hospital, skilled nursing home (rehabilitation) care following an in-patient hospital stay of at least three days, and skilled home health care following the in-patient hospital stay.
Part B is the insurance that covers “out-patient” care, including physicians, laboratory services, and other medically needed services, such as x-rays, MRIs, home healthcare, etc.
Important: Medicare doesn’t cover long term care, such as care in an assisted living facility OR in a skilled nursing facility.
Part D is the prescription drug benefit. You can enroll in a stand-alone plan, or be part of a Medicare Advantage Plan, like an HMO or PPO.
Eligibility & Enrollment Timeframes
If you are receiving Social Security (SSA) retirement income before age 65, Medicare enrollment is automatic at your 65th birthday month.
If you are NOT receiving SSA income, then you MUST make a decision. Your enrollment time frame is seven months—it begins three months before your 65th birthday month and ends three months after your 65th birthday month. Delaying enrollment in this case will lock you out until the following January-March General Enrollment Period, and you may be subject to a late enrollment penalty.
If you are still working and covered by an “employer group health plan” or covered by your spouse’s healthcare coverage AND s/he is still working, you can delay Medicare enrollment. About two months before you (or your spouse) stop working, contact the Social Security office to enroll. The easiest way is to establish a login and password on SSA.GOV and do it all online.
If you delay Medicare enrollment because you are covered by active employment healthcare, you have eight months to enroll in Medicare once you stop working. But don’t delay, because you may be subject to a late enrollment penalty if you miss the opportunity to enroll during those eight months.
Costs
Part A is usually free for those who have worked at least 10 years and have accumulated 40 Social Security quarters. You could also become eligible based on your spouse’s work history.
Part B has a monthly premium. In 2024, the standard monthly premium for Medicare Part B will be $174.70, but it is based on your income. It could be much higher based on your Modified Adjusted Gross Income.
Both Part A and Part B have deductibles. Part B is like an 80/20 plan—it pays 80% of approved claims, and most of the balance could be covered by a Medicare Supplementary policy. For more on costs go to: https://www.medicare.gov/basics/costs/medicare-costs.
Two Ways of Getting Your Medicare Coverage
- Original Medicare: Medical providers submit claims to Medicare directly.
- Purchase a Medicare Supplement (aka Medigap) to cover all or most of the Medicare cost sharing. You can see providers ANYWHERE in the country. There are usually no Prior Authorization requirements.
- You can also enroll in a stand-alone Part D plan for your prescription drugs.
- Medicare Advantage Plans (aka Part C): These are plans like a Kaiser HMO or an Anthem Blue Cross PPO. You have to be enrolled in both Part A & Part B to enroll in a Medicare Advantage (MA) plan. Many of these plans offer prescription drug coverage, and more benefits. But they have to cover all the healthcare benefits that are covered under Original Medicare. Availability and plan options vary among counties, cities, or zip codes. These plans have provider networks. Going outside of the network may cost you a lot!
More Enrollment Opportunities
Every year, Medicare has an Annual Enrollment Period (AEP), also known as Medicare’s Open Enrollment. It is from October 15 to December 7. It is ONLY for those who already have Medicare Part A and Part B. During this period, you can explore coverage options for the following year. It is recommended that all Medicare beneficiaries review their coverage options for the following year.
Other Coverage Options
If you or your spouse are covered by an employer’s retirement group health plan, like CalPERS, PG&E, Federal Government plan, etc, you must read all the material they send you during their unique open enrollment and make a decision accordingly.
Help Is Available!
All this information can be confusing and challenging to navigate. But the good news is, help is available. To receive unbiased information and personalized counseling, contact your local State Health Insurance Assistance Program (SHIP) for local help navigating Medicare. To find a SHIP in your area go to www.shiphelp.org or call 877-839-2675. You can also call 1-800-Medicare.
Beware of Scams!
Finally, beware of cold calls, mail promotions, and TV advertising—you will NOT get all the facts. Never give out your Social Security or Medicare number to anyone who calls you. Social Security or Medicare will NOT call you. Only speak with your trusted financial planner or insurance broker that you have been dealing with in the past. If you come across any suspected healthcare fraud, report it to the Senior Medicare Patrol (SMP) at 877-808-2468 or visit www.smpresource.org to find your local SMP in your state. Remember: If it sounds too good to be true, or fishy, then it is!
This article was written by Tatiana Fassieux, Education & Training Specialist for California Health Advocates. Tatiana Fassieux is a Training & Education Specialist for California Health Advocates (CHA), an organization dedicated to Medicare advocacy and education for Californians. She has served various terms as Board Chair and has been affiliated with this organization for over 25 years. She conducts many training sessions for California’s Health Insurance Counseling & Advocacy Program (HICAP) volunteers and other organizations. HICAP is California’s State Health Insurance Assistance Program (SHIP). California Health Advocates also focuses on California’s Tribal Nations Elder’s access to Medicare health benefits.