Medicare 101 & Intro

●Medicare eligibility typically begins the first day of the month in which you turn 65 years old.One exception is if you were born on the first day of a month, you will actually become eligible for Medicare on the first day of the prior month.

●If you are under age 65, you can become eligible for Medicare if you have been on SocialSecurity Disability Insurance for 24 months or if you have medical conditions such as EndStage Renal Disease or ALS.

●You must also be a U.S. citizen or permanent resident.

Automatic Enrollment - As long as you are eligible to receive Social Security benefits when you turn 65, you will automatically be enrolled in Medicare Part A (Zero Premium) which covers hospital costs, and Medicare Part B (Paid Premium), which covers your visits to the doctor. You don’t need to do anything to enroll in these programs.

Non-Automatic Enrollment - if you are not automatically enrolled, you will need to take steps to get properly enrolled in Original Medicare.  This is typically done in the 3-month period immediately before the month your turn 65.  By enrolling during this 3-month period you Medicare coverage will begin on time (the first of the month you turn 65).  If not enrolling in Medicare during this 3-month period, you will have a delayed start date for Medicare. *Keep in Mind your IOEP (Initial Open Enrollment Period) will also run 3 months following your birthday month. (This allows a 7 month total window.) By signing up in the remaining months following your birth month, coverage will start the month following enrollment.

*Typically, it is advantageous to sign up for Medicare Part A & B when you are first eligible; however, if you are working and currently covered by a group health plan, you may wish to delay enrollment in Medicare Part B until such time that you are ready to leave the group plan. 

*Failure to Enroll in Plan B without retaining Credible Coverage during that time will result in a 10% Annual Penalty Cost Increase. For example, if you wait 2 full years, your penalty is a 20% markup on the Part B premium.

Annual Election Period (AEP)

The AEP is October 15th through December 7th each year.  This is the time period where you can change your Medicare Advantage plan or your Medicare Part D drug plan.  Plan changes made during this period will take effect on January 1st.

Open Enrollment Period (OEP)

The OEP will run January 1st through March 31st each year.  This is another opportunity for Medicare Advantage plan members to make a plan change.  During this time MA-eligible beneficiaries will be able to change their MA plan or elect Original Medicare and coverage under Part D.  Plan changes made during this period take effect on the first of the month following submission of the new application.

Special Enrollment Periods (SEP)

There are special qualifying events that can occur throughout the year that will allow you to enroll in or change your Medicare Advantage plan or Medicare Part D drug plan.  Examples are moving to a new area, losing employer group coverage or moving into a skilled nursing facility.

●INPATIENT HOSPITAL CARE

●SKILLED NURSING CARE IN A SKILLED NURSING FACILITY

●HOME HEALTH CARE

●HOSPICE CARE SERVICES.

Medicare Part A is your hospital insurance. It covers expenses that occur in a hospital setting, such as inpatient care, as well as skilled nursing facility care, hospice care, and home health care.

Keep in mind that Part A doesn’t cover you indefinitely, and there are some eligibility hoops to jump through in order to qualify for the coverage that you do get.

Part A covers inpatient care if these 3 items are true:

1. You’re admitted to the hospital as an inpatient after an official doctor’s order, which says you need inpatient hospital care to treat your illness or injury.
2. The hospital accepts Medicare.
3. In certain cases, the Utilization Review Committee of the hospital approves your stay while you’re in the hospital.

For skilled nursing facility care, you also have a slew of requirements to meet, and Part A only covers the first 20 days. Days 21-100 are partially covered, and you are responsible for the full cost after Day 101. Medicare Part A does not cover long-term care stays.

Part A is usually $0 premium for most people because you (or your spouse) worked and paid Medicare taxes for 40 or more quarters.

Part A also has segments of Co-Insurance and Deductibles required. 

For Example : Part A Hospital Deductible 2023

•$1600 per benefit period

•This is the amount you must pay for hospital/inpatient services before Part A will begin to pay.

•A benefit period begins when you are admitted to the hospital as an inpatient and ends when you’ve received no hospital or skilled nursing care for a full 60 days in a row.

•Note:  It is possible to have 6 benefits periods in one year.

● SERVICES FROM DOCTORS AND OTHER HEALTHCARE PROVIDERS

● MENTAL HEALTH CARE

● PREVENTIVE & SCREENING SERVICES

● DURABLE MEDICAL EQUIPMENT

● OUTPATIENT CARE

● AMBULANCE

Part B is your outpatient medical insurance, covering medically necessary and preventive services. Part B covers things like clinical research, ambulance services, durable medical equipment, mental health, and limited outpatient prescription drugs. Rest assured that if Part B does not cover a service or supply you need, you’ll be asked to sign a form stating that you’re responsible for the cost. You should never be blindsided by an unexpected medical bill.

Premiums for Part B are calculated based on the income you report in your taxes. The standard Part B premium is $164.90 in 2023, and this applies to individuals with an income of less than $88,000 and married couples reporting less than $176,000. If you make more than $88,000 or $176,000 as a couple, you will pay an Income Related Medicare Adjustment Amount (IRMAA) each month. This added charge raises your premiums based on how much higher your income is.

The Part B deductible is $226 in 2023. Like most health insurance, this deductible is only paid once per year. Once you meet the deductible, you will pay 20% of the Medicare-approved amount for covered services as coinsurance.

** There is NO limit on Part A & Part B Out of Pocket Cost.**

● Outpatient prescription drugs

● Routine dental care and dentures

● Routine vision exams and eyeglasses

● Routine hearing exams and hearing aids

● Routine preventive physical exams

● Over the counter items

● Gym memberships

● Transportation

** Medicare Advantage (C) can aid in these benefits at zero to low cost.