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Medicare has a lot of different coverage options, but you must qualify to enroll in each benefit
Medicare’s health insurance benefits help millions of Americans qualify for medical care at low costs. Therefore, at some point in their lives, most people wonder if they qualify for the program?
Medicare doesn’t just offer one coverage option. It offers multiple types of plans—some required, some optional. Each plan will have different eligibility rules. When it’s time to get Medicare, contact Senior Market Agents Network. We’ll help you get the perfect coverage for your needs.
Types of Medicare Insurance
Medicare is health insurance supported by the U.S. government, states and private insurers. It helps senior citizens and those with special medical needs obtain affordable health insurance. It mixes publicly-funded and private insurance options to allow policyholders choices of coverage.
The best-known options are:
Original Medicare: This was the first Medicare coverage. It consists of Medicare Part A and Medicare Part B coverage. The original Medicare program is supported by the federal Medicare tax.
- Part A coverage pays for hospital services. Generally, it will cover surgeries, inpatient stays, IV drug treatments and other costs related to a hospitalization.
- Part B coverage insures medical costs not related to hospitalizations. For example, this coverage might pay for physician visits, vaccinations, lab tests, x-rays and other outpatient costs.
Medicare Advantage Plans: Medicare Advantage plans, also known as Medicare Part C, are private health insurance policies. They offer an alternative to Original Medicare. They will include all the coverage offered by Parts A & B coverage, except for hospice care coverage. However, they will also include coverage for services not covered by Original Medicare. Extra insured costs might include:
Advantage plans come in a variety of shapes and sizes, including:
- HMO Point-of-Service Plans (HMOPOS)
- Private Fee-for-Service (PFFS) Coverage
- MSAs (Medical Savings Accounts)
- Special Needs Plans (SNPs)*
Depending on the plan you choose, the covered care and costs of services might vary.
*If you want an Medicare Advantage Special Needs Plan (SNP), you must meet all enrollment requirements for that plan. You must also continue to meet those requirements every time you renew your plan.
Medicare Prescription Drug Insurance: Original Medicare (Parts A & B) does not include coverage for most standard prescription drugs. While certain inpatient drugs during hospitalizations often have coverage, those you get from your pharmacy usually don’t. To cover these costs through Medicare, policyholders have the option to choose Medicare Part D Prescription Coverage.
Part D insurance plans are private policies that you obtain from a major insurer. Plans will generally cover both generic and name-brand medications, while you will pay only a few dollars out-of-pocket.
Who is eligible for Medicare Part A?
As part of Original Medicare, Part A insurance allows a wide variety of individuals to enroll in coverage. You can usually get a plan if:
- You are aged 65 or older
- You are disabled. You will have to receive verification that you do have a qualifying disability.
- You have End-stage Renal Disease (ESRD). ESRD usually leads to kidney failure, dialysis and kidney transplants. Applicants often qualify for temporary or permanent Medicare services.
In most cases, you will pay no premium for your Part A coverage. If you have paid taxes into the Medicare system for a certain number of qualifying periods, and if you have filed for Social Security or Railroad Retirement Benefits (RRB), you often will qualify for premium-free coverage..
Who is eligible for Medicare Part B?
Medicare Part B is part of Original Medicare. However, it is an optional choice. Still, it is very important because it pays for many of your standard medical costs. You will pay a premium for this coverage. Your eligibility for Medicare Part B will vary.
If you have premium-free Part A coverage, you become eligible for Part B at the same time you become eligible for Part A. The enrollment qualifications are the same as those listed above.
If you want Part B coverage, but you pay a Part A premium, you must meet the following qualifications:
- You are age 65 or older
- You are a U.S. resident; AND
- Either a U.S. citizen, OR
- An alien who has been lawfully admitted for permanent residence. You have lived in the U.S. for 5 continuous years prior to the month of filing an application for Medicare.
Enrolling in Original Medicare
Individuals qualifying for Medicare at age 65 can enroll in Parts A & B coverage during their Medicare Initial Enrollment Period (IEP). This is a 7-month timeline encompassing:
- Three months before your 65th birthday
- The month of your 65th birthday
- Three months after your 65th birthday
If you don’t enroll in coverage during the IEP, you might have to pay a late enrollment fee. However, at times, you might qualify for an additional special enrollment period (SEP). Talk to your agent about your own qualifications.
Who is eligible for Medicare Part C?
Medicare Advantage plans are a bit different from the coverage offered in Original Medicare. They are private policies. Major insurers offer them, and their availability will vary depending on whether an insurer offers a plan in your area.
You usually qualify for a Medicare Advantage plan if:
- You are over 65 years old
- You have Original Medicare Parts A & B. You must already have Original Parts A & B to qualify for a Medicare Advantage plan.
- You do not have end-stage renal disease (ESRD)
- You live in the Medicare Advantage plan’s service area.
Depending on the plan you select, the covered services and providers will vary.
You can enroll in Advantage coverage during certain periods. These include:
- The 7-month IEP during which you qualify for Original Medicare Parts A & B. You must establish your Parts A & B coverage before getting a Medicare Advantage plan.
- The annual Medicare Advantage election period, also called Open Enrollment. This time occurs annually from October 15 to December 7. Individuals who wish to switch plans or drop coverage can do so during Open Enrollment.
- Various people qualify for special election periods. If you move, qualify for Part B coverage or lose existing coverage, you often can get an Advantage SEP.
Who is eligible for Medicare Part D?
Original Medicare holders can turn to Part D coverage to pay medication costs. To get this coverage:
- You must qualify for, and enroll in, Medicare Parts A & B insurance.
- You must live within the service area of the Part D plan.
- You cannot have an existing Medicare Advantage plan.**
The timeline for enrolling in coverage is as follows:
- You can enroll during your 7-month IEP
- You can enroll in, drop or change Part D plans during Open Enrollment
- If you qualify for a SEP, you can enroll in Part D coverage then.
Those with disabilities and End-stage Renal Disease can qualify for Part D coverage. If you already have Medicare because of a disability, you might already pay a premium penalty for your Part D coverage. However, upon turning 65, you usually qualify for a new enrollment. You therefore won’t have to pay the penalty any longer.
** Some prescription drug coverage comes within Medicare Advantage plans. If you switch from a Medicare Advantage plan back to Original coverage, you must enroll in Part D coverage to keep this protection.
Can I get Medicare if I am under 65?
The answer: Yes. However, such qualifications are restricted those who have a disability or have end-stage renal disease (ESRD).
To qualify for Medicare disability coverage, you usually must already receive Social Security Disability Insurance (SSDI). You will usually face a two-year waiting period before you are automatically enrolled in Medicare. Those with Amyotrophic Lateral Sclerosis (ALS, Lou Gehrig’s Disease) do not have a two-year waiting period. Coverage will start the first month they draw SSDI benefits.
If you have End-stage Renal Disease, or kidney failure, you qualify for Medicare if:
- You are eligible for Railroad Retirement Benefits (RRB)
- You, a spouse or parent have paid Medicare taxes for a defined time limit.
- You have an official diagnosis of ESRD, and you qualify for SSDI
You must directly apply for Medicare if you have ESRD. There is no automatic enrollment, and you can apply up to 12 months retroactively. Your coverage will take effect based on a variety of factors, such as when you apply, or if you receive dialysis or a kidney transplant.
Is Medicare mandatory at age 65?
As you approach 65, you might wonder if you should enroll in Medicare. The answer might depend on your employment status.
- If you are about to turn 65, and have retired, it is best to enroll in Medicare during your 7-month initial enrollment. If you don’t, you might not qualify for a special enrollment period. You might have to pay a late enrollment fee and could face other penalties.
- Even if you have retiree health insurance, enrolling in Medicare might let both plans work together to provide benefits.
- If you have health insurance from your employer, you might decide to go ahead and enroll in Medicare. Or, you might decide to delay your enrollment. If you delay, your employer coverage can cover you until retirement and you won’t have to pay an enrollment penalty. Some people delay Part B enrollment and still get Part A during their original initial enrollment period.
- If you still work and receive employer-provided health insurance, but your business has less than 20 employees, you will need to sign up for Medicare as soon as you become eligible.
- Even if you still have employer-provided coverage, you might want to still enroll during initial enrollment. By doing so, you might be able to let your employer coverage be your primary insurer while Medicare provides secondary assistance.
The longer you go without enrolling in coverage, the harder it might be to get Medicare. Also, you might put yourself at-risk of facing coverage lapses and ineligibility for benefits.
Will the Medicare age ever change?
Changing the Medicare age will depend on whether changes to the federal Medicare law occur. There are some indicators that the Medicare age might increase to keep the program solvent and address the fact that many people now work (and live) longer. However, this change has not happened yet.
Here at Senior Market Agents Network, we understand all eligibility requirements for those interested in the Medicare program. Contact us at 877-209-4949 or request policy assistance online today.