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Medicare Explained: Your Guide to Coveragemedicare diagram

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What is Medicare?

Medicare is the U.S. government’s tax-supported health insurance program for qualifying individuals. During your working years, you’ll pay into the Medicare system. When you qualify for benefits, you can receive your health insurance coverage from the Medicare pool. Those who can claim Medicare include:

  • Adults aged 65 and older
  • People of any age with certain health disabilities
  • Individuals of any age with End-Stage Renal Disease (ESRD)

Almost everyone will qualify for Medicare at some point in their life. If you think you’re eligible, speak to our agents.

Please note: Medicare is not the same as Medicaid. Medicaid is health insurance for qualifying individuals, like low-income adults and children.

How can Medicare benefit you?

Medicare is a great safety net. It provides health insurance when you might not be able to get it otherwise. That way, you’ll be able to receive essential affordable health care coverage, often during a time in life when your needs are great.

Look at it this way: During your working years, you might receive your health coverage from an employer or spouse's plan. Or, you might buy privately-managed policies. Still, upon retirement, you might no longer qualify for those options. Shrinking incomes might even make affording certain plans difficult. Rather than wonder where you’ll get coverage, consider your eligibility for Medicare. You’ll often find it one of the best ways to get affordable health protection later in life.

How Many Parts of Medicare are there?

There are 4 parts to Medicare: Medicare Part A, Medicare Part B, Medicare Part C and Medicare Part D.

What is Original Medicare?

Original Medicare only covers the first 2 parts of Medicare. Medicare Parts A and B

What does Medicare Part A Cover?

Medicare Part A: Pays for hospital stays and related costs. Coverage might also insure home health care or hospice care. Most people will pay no premiums for this coverage.

What does Medicare Part B Cover?

Medicare Part B: Covers standard doctors services, like office visits. It will also cover preventive services. Think of this as the coverage you’ll use for all medical care outside of inpatient hospitalizations. Coverage includes:

  • Office visits
  • Mental health care
  • Lab testing and x-ray services
  • Outpatient hospital care
  • Medical equipment
  • Preventive care like vaccination
  • Certain ambulance services
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What Original Medicare doesn't cover?

Expanding Your Original Coverage
Original Medicare won’t cover everything. It won’t cover prescriptions and other procedures like dental care, hearing aids, routine eye care, acupuncture and long-term care don’t have protection under the basic Part A & Part B package. Even so, you have options to expand on your Original Medicare. By doing so, you’ll be able to get more covered care that will include prescriptions, dental, eye-care, etc. 

Senior Market Agents Network can assist you in finding coverage for prescriptions, dental, eye-care.

What cost are not covered by Medicare Part A and B?

Medicare Part A and Part B only covers 80% of all Medicare approved services. So, you would be responsible for the other 20%. Senior Market Agents Network can help you find affordable coverage that will pay for the other 20%.

How do I enroll in Medicare Part A and Part B?

Medicare Part A is automatic when you turn 65. There is no cost for Part A if you paid into the tax system throughout your employment years.

Medicare Part B is voluntary, so you would have to activate your part B with social security. There is a monthly premium for Part B based on your income unless you qualify for Extra help - Low Income Status (LIS) which subsidizes your Part B premium. You can check with Social Security to apply for LIS.

What is Medicare Part C?

Medicare Part C/Medicare Advantage Plans: These are private health insurance policies offered by major insurers. They must offer all the same benefits as Original Parts A & B.

However, they also include many benefits not offered by original Medicare which infused Part D prescriptions, dental, vision, hearing and a free gym membership. Therefore, if you need to see your dentist or buy new glasses, your plan will help pay for them.

What is Medicare Part D?

Part D Prescription Coverage: Most people will need to take prescription medication at some point. Part D is a prescription plan offered through private insurance companies. Original Medicare Part A and Part B does not include prescription coverage. You would have to purchase a Part D plan as a standalone policy. One other way to purchase Part D is through enrolling in a Medicare Advantage Plan, Medicare Part C which includes all parts of Medicare.

Senior Market Agents Network can assist you in Finding a Part D plan that is right for you.

How Much Does Medicare Cost?

Almost every Medicare customer will pay certain costs for their policies and covered care.

Premiums: How much you pay for your coverage will vary.

  • Most people pay nothing for their Part A premium because they’ve paid into the system through payroll taxes. If you do have to pay, it’s around $421/month in 2018. Some people can get lower premiums of $232/month.
  • The 2018 Part B premium is $134/month. If you receive social security, your premium will be deducted from your check monthly. You’ll receive a bill quarterly if you do not draw social security.

Deductibles: You must pay the deductible before Medicare pays for other care costs. The current Part A deductible is $1,340 and the Part B deductible is $183/year.

Coinsurance: For many services, you’ll pay for a percentage of the procedure, while your insurance will pay the rest. Both Parts A & B will pay 80 percent of care costs. You’ll be responsible for the other 20 percent of costs in most cases.

Co-payments: For most care, you’ll pay a small fee up front to see your provider.
If you want supplementary coverage for some of these costs, consider enrolling in Medigap Insurance. These plans help pick up some of the costs that remain after Original Medicare pays.

When Can You Enroll in Medicare?

Most people qualify for Medicare upon turning 65. You have a seven-month period to initially enroll. You can start:

  • Three months before your birthday
  • The month you turn 65
  • Three months after the month of your birth date

Those who qualify due to disabilities or ESRD will face other enrollment periods. Talk to your caseworker and insurance agent to determine what your filing period is. It’s important to note that you might face a financial penalty if you do not enroll in Part B within your eligibility time frame.

How do I apply?

The Medicare application might seem tricky. If you’re ever in doubt, call Senior Market Agents Network. We’re here to help you determine the right course of action.

  • If you currently receive Social Security, you will automatically be enrolled in Medicare upon qualification.
  • If you are not enrolled in Social Security, or if you still work full-time, you might not be automatically enrolled. If that’s the case, you’ll need to follow the steps below. Contact your local Social Security office for assistance.
  • Automatic enrollees will receive their new Medicare cards about three months prior to their benefits start date. Non-automatic enrollees will receive their cards after completing the enrollment process.

Don’t wait to sign up. If you do, you might face coverage delays and enrollment penalties. Instead, let one of the agents at Senior Market Agents Network help you find the coverage that’s right for you. We’ll take your needs into account to help you determine what type of Medicare coverage is right for you.

The Enrollment Process

If your enrollment doesn’t occur automatically, you’ll need to follow a certain process. Your particular rules might vary.

To Enroll in Parts A & B

  • Apply in-person at your local Social Security office
  • Start an Application online at www.SocialSecurity.gov
  • Call 1-800-772-1213, Monday – Friday, 7AM – 7PM
  • TTY users call 1-800-325-0778

For Those with Railroad Retirement Benefits

If you worked for a railroad or receive assistance from the Railroad Retirement Board (RRB), your Medicare enrollment period is as follows.

  • If you already collect RRB benefits or Social Security upon turning 65, you’ll be automatically enrolled in Parts A & B if you signed up for Part B when you enrolled in retirement benefits.
  • Contact the RRB at 1-877-772-5772
  • TTY Users call: 1-312-751-4701

For those Receiving Social Security

If you receive Social Security upon turning 65, enrollment will occur automatically. However, you will need to indicate that you want Part B coverage at the time that you enroll in the benefits.

For those Receiving Disability Benefits

If you receive Social Security or Railroad Retirement disability benefits, you can qualify for Parts A & B after 24 months of disability benefits. Certain exceptions exist for this rule, however.

  • End-stage Renal Disease and Kidney Transplant Patients: Those with ESRD, transplant recipients and those receiving regular dialysis can apply for Medicare.
  • ALS Patients: Those with Amyotrophic Lateral Sclerosis (Lou Gehrig’s disease) will be automatically enrolled when their disability benefits start.

Enrollment Periods

Some people qualify for special enrollment periods which include retiring. However, those without these exceptions must enroll in Medicare Part B between January 1 and March 31 for benefits starting July 1.

Residents Outside the U.S.

Residents of U.S. territories and other areas, like Puerto Rico, will automatically enroll in Part A coverage only. However, you’ll need to contact the Medicare program to enroll in Part B.

Medicare Part B Enrollment Rules

Part B has multiple rules for enrollment. Talk to one of our agents about your specific course to take.

  • If you do not want to keep Part B (even after automatic enrollment) you can cancel the coverage. You must return your Medicare card if you receive it, however. If you signed up through Social Security, you will need to contact them to drop coverage.
  • Those who receive health coverage through an employer or private health insurance plan might decide to keep or drop Part B coverage. If you keep the coverage, you’ll need to see whether Medicare will pay secondary to your current insurance. You’ll also need to check to see if you’ll face penalties by dropping Part B. Talk to your health benefits administrator to learn more.
  • Part B does have a late enrollment penalty. If you don’t sign up when first eligible, you might face up to 10% higher premiums to get covered. Enrollment periods exist throughout the year to help you meet this goal. Keep in mind, certain exceptions exist for this rule.

We know Medicare can prove frustrating. That’s why you shouldn’t wait to talk to Senior Market Agents Network about your eligibility for coverage. Contact us today at 1-877-209-4949! We’re ready to help. 

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Senior Market Agents Network is not connected with or endorsed by the United States government or the federal Medicare program. Senior Market Agents Network is an Independent Insurance Agency Licensed in New Jersey, New York, Pennsylvania, Maryland, Virginia, West Virginia, South Carolina, North Carolina, Georgia, Florida, Ohio, Texas, Arizona and Michigan.