Frequently Asked Medicare Questions and Their Answers
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I am a federal retiree with federal employee health benefits (FEHB). Why should I enroll in Part B?
Federal retirees with FEHB have the option to enroll in Part B or not when they are first eligible for Medicare. Like others newly eligible for Medicare, they have to weigh their options based on their particular situation, including their health and financial needs.
Most enroll in Part A, since they paid for it while still working. In most cases, Part A (covers hospital services) will pay first, and FEHB will pay second.
This decision needs careful review. Let’s look at your options.
- Reasons to enroll in Part B: There are a number of reasons to enroll. First, some FEHB plans will cover copays, coinsurance and deductibles if you enroll in Part B, so it might be in your financial favor to enroll. Also, you get a one-time chance to change FEHB plans up to 30 days before your Medicare begins. So you could enroll in an FEHB plan with a lower monthly premium and lower copays. If you do not enroll in Part B when you are first eligible, you could have a penalty later if you decide to enroll. And you have to wait for Medicare general open enrollment period (January 1- March 31) with coverage not starting on July 1 of that year. Lastly, you may find better coverage under Part B than FEHB for certain services, such as durable medical equipment and rehabilitation services.
- Reasons to not enroll in Part B: FEHB coverage is known to be very good coverage, and unless Congress changes it, many federal retirees find they do not need both FEHB and Part B. Also, many federal retirees find that they can save money by not having to pay two monthly premiums: one for their Part B ($104.90, for most, in 2013) and for their FEHB plan (amount varies by plans available). And Medicare beneficiaries with higher incomes ($85,000 single, $170,000 married) have to pay higher Part B premiums (ranging from $146.90 – $335.70 in 2013).
So it is worth your time to review the financial considerations of paying both premiums and potentially getting your deductibles and copayments waived by your FEHB plan versus paying all cost-sharing for the FEHB plan and paying a late-enrollment penalty should you decide to enroll in Part B at a later time.
I am turning 65 and live permanently outside the country. Do I need to enroll in Medicare?
Medicare does not provide coverage for services outside the United States, except in very limited circumstances. However, living overseas does not exempt you from the Part B penalty.
Most newly eligible people enroll in Part A when they turn 65. Some people can delay enrolling in Medicare B when first eligible and not face a penalty. These include people who are working and have employer-related health insurance (or get health insurance through an actively working spouse). Those who are newly eligible for Medicare and do not have employer-related health coverage can face a 10% penalty premium surcharge for each 12 months they were eligible for and not enrolled in Medicare Part B.
If you are living overseas and actively working with health insurance through a group health plan (including a foreign national health plan), you can delay Part B until you retire or lose your employer-related health insurance. You will have an 8-month Special Enrollment Period to enroll in Part B, if and when you return to the states.
If you are retired and live overseas and do not have health insurance through active employment (either through your own or a spouse), there are a few things to consider about enrolling in the various parts of Medicare during your 7-month Initial Enrollment Period when you turn 65:
- Part A: For most people, Part A is free, so you should enroll during your 7-month IEP. Medicare benefits are generally not available outside the United States. But you can use your benefits when you return to the states and avoid a late-enrollment penalty. (The Part A penalty premium is 10% of the current Part A premium. You would continue to pay the penalty premium for twice the number of years you were eligible for Part A but did not enroll.)
- Part B: Here you will need to weigh the pros and cons of cost. That is, paying the monthly premium for Part B while overseas (without having access to Medicare Part B benefits until you return to the states) versus the cost of paying a (likely hefty) lifetime penalty for not enrolling in Part B when first eligible. Also, after your IEP, you can only enroll in Part B during a certain time of year (between Jan 1 – March 31) with coverage not starting until July 1, so enrolling during your IEP can help you avoid a potential future gap in health coverage.
- Part C and Part D: To enroll in a private Medicare Advantage Health Plan or a Medicare Part D Prescription Drug Plan, you must live in the plan’s service area. Since you are living overseas and do not have a U.S. primary address, you cannot enroll in a C or D plan. When you return to the states, you will have a Special Enrollment Period to enroll in a health or drug plan, if you decide to do so.
- Medigap: Like Parts C and D, you cannot purchase a Medigap policy if you do not have a primary address in the United States. If you live overseas and enroll in Part B, you will trigger your Medigap Open Enrollment Period. This is the 6-month period after you enroll in Part B (remember, you need Parts A and B to purchase a Medigap policy) during which insurance companies must sell or “issue” you a Medigap policy even if you have health problems. Because of this protection, it is generally the best time to buy a Medigap policy. There is no guarantee when you return to the states that an insurance company must sell you a Medigap policy outside the Open Enrollment Period.
Since more baby boomers may be retiring and living part of the year overseas or traveling overseas, there are some other options to consider for health coverage. Learn more.
Remember, Medicare does not generally cover services outside the U.S., except for certain and rare emergency situations.
My husband is over age 65 and I am retiring next month. When should he sign up for Medicare Part A and B?
Your husband should sign up for Part B during the last month of your employment, so he will be covered on the first day/month after you retire. This way, he will not have a gap in health coverage.
Also, if he waits too long, he may get charged a penalty. Your husband has 8 months (called a Special Enrollment Period) after you retire or your employer health insurance ends – whichever comes first – to sign up for Part B. If he enrolls in Part B after the 8 months, he may get a late enrollment penalty for Part B. This penalty can be expensive. And he would have to wait until the next General Enrollment Period (Jan. 1-Mar. 31) to enroll, with coverage not starting until July 1 of that year, which means possibly an even longer time without coverage.
In addition to enrolling in Part B, your husband should also consider his other health coverage options:
- Medigap: He may want to consider buying a Medigap policy to supplement his Medicare Parts A and B. Medigap pays for some of the out-of-pocket costs in Medicare, such as deductibles and coinsurance. He should shop around and buy a Medigap policy during the first 6 months after he takes his Part B. It is important to buy during the first 6 months after he enrolls in Part B because he can buy any Medigap policy that is sold in your state regardless of his health. Learn more about Medigap.
- Medicare Advantage: He might want to shop around and compare available Medicare Advantage (MA) options to Original Medicare. Learn more about Medicare Advantage.
- Part D: Regardless of whether he decides on Original Medicare or Medicare Advantage, he will need to decide about joining a Medicare Part D drug plan. If he chooses Original Medicare he will need to pick a Prescription Drug Plan (PDP). If he joins a Medicare Advantage plan, he should be sure to pick one that includes Medicare Part D drug coverage. Learn more about Part D.
- COBRA: COBRA is the federal law that allows certain people to continue their employer group health insurance once they are no longer actively employed by the company. COBRA protects dependents such as spouses too when employer health insurance ends, for example because of a job loss, retirement, divorce or death. COBRA coverage is generally expensive. People who get COBRA must pay the full cost, or premium, themselves; their company no longer helps with the premiums for their coverage. The important thing to know is that people who enroll in COBRA are not protected by the late-enrollment penalty for Part B. They do not get an 8-month period to enroll in Part B after their COBRA ends, and they would have to pay a lifetime penalty for Part B when they do enroll. In addition, they would have to wait to enroll in Part B during the next General Enrollment Period, which runs each year from Jan. 1-Mar. 31, with Part B coverage not starting until July 1 of that year. The other option is to enroll in both Part B and COBRA, but that can be very expensive. Either way, it is usually a good idea to call your job’s benefits administrator to find out more about your specific COBRA options, especially if you have high medical and prescription costs. You will want to find out how much COBRA will cost, what type of coverage it will provide and if it offers creditable drug coverage.
I am not taking any medications right now. Does it make sense for someone like me to delay enrolling in Part D and accept the penalty?
Generally, we encourage anyone who is eligible for Part D to join. The exception is limited to whether you have creditable coverage, or coverage “as good as” Medicare Part D. If so, be sure to ask your employer for a certificate or letter of creditable coverage to prove it.
That said, Part D is a voluntary program, and you are right that one option is to delay enrollment and pay the penalty later on when you decide to enroll. However, it’s hard to say that you should delay enrolling now because you currently take no prescription drugs. That’s because no one can predict the future. And Part D is insurance to help you should you need help with your prescription drug costs.
Here are some important things to keep in mind when you are making this decision:
- Your health may change: As you age and your health status changes, your need for prescription drugs may grow. The cost of those drugs may also increase over time. Consider signing up for one of the least expensive Part D plans in your area now (some areas even offer plans with $0 monthly premium), especially if you have a chronic health condition that could worsen with age.
- Penalty costs may go up: The cost of the Medicare Part D penalty depends on how long you went without creditable prescription drug coverage. So what may be a small penalty amount, say if you only delayed Part D for a year, could become costly if you waited 5 years. And this is a lifetime penalty — meaning as long as you have Part D you may have to pay the penalty, and it can increase every year. To view a sample penalty calculation visit the Penalties and Risks page.
- You can enroll only at certain times: If your health suddenly changes, and you need prescription coverage, you may have to wait to enroll during the Open Enrolment Period, which runs each year from Oct. 15 to Dec. 7, with coverage taking effect the following January 1. If you don’t enroll when you’re first eligible, you may end up in a situation where you need coverage, but you don’t have a special enrollment period and must wait until the next annual enrollment period to get it.
I am over age 65 and still working. I have health insurance through my job. Do I still need to enroll in Part D?
It is always your decision whether to join a Part D plan. If you are 65 or older and still working, here is the first question you should ask yourself to help you decide if you should enroll in Part D: Does your job-related health insurance cover your prescription drugs?
If YES: Ask your employer whether your current health insurance plan is considered “creditable” by Medicare. In other words, does the employer health insurance give you the same coverage for drugs that you would have if you were in a basic Medicare Part D plan? Your employer is required to tell you this.
Your employer is required to tell you this in writing in a letter or certificate of creditable coverage you should keep to share with Medicare later to avoid late enrollment penalties.
If your job’s health insurance plan is not considered “creditable” coverage, you may want to consider enrolling in a Part D plan as soon as possible, so that you do not have to pay a penalty.
If NO: If you don’t have health insurance from your employer, or your job-related health insurance does not cover prescriptions, or your employer’s insurance plan is not “creditable,” then you may have to pay a penalty to enroll in a Part D plan. The longer you wait to enroll in a Part D plan without having “creditable” coverage, the higher this penalty could be.
I lost my Medicare card. How do I get a new one?
If you lose your Medicare card, you can ask for a new one from Social Security.
Once you join Medicare, Social Security will send you a red, white and blue Medicare card in the mail. Your Medicare card will show:
- Your Medicare number (just adds a letter to the end of your Social Security number or the number of your family member),
- When your coverage starts, and
- What parts of Medicare you have (Parts A and/or B).
Important: Your Medicare card will not show if you have Part C or D coverage with a private plan. If you sign up for a private Medicare Advantage plan (Part C) or a drug plan (Part D), the plan will mail you a separate membership card.
Keep your Medicare card safe and bring it (along with any Part C or Part D card) with you to the doctor or the pharmacy. You will need to let them know what coverage you have.
If you lose your Medicare card, you can ask for a new card either online or by telephone:
- Visit the Medicare Replacement Card section of Social Security’s website, or
- Call the Social Security hotline at 1-800-772-1213
(TTY users, call 1-800-325-0778).
Social Security will mail you a new card in about 30 days. The card will be mailed to the address that Social Security has on record, so be sure they have your current address.
Note: If you need proof right away that you have Medicare, you can get a paper verification letter in these ways: log into your mymedicare.gov account and print a letter or visit your local Social Security Office.
I just got my Medicare card in the mail. How do I know how to use my Medicare? What does Medicare cover?
Medicare covers important medical care and many preventive services and screening tests, but there are rules about what services are covered and when and how to get coverage.
Here are 4 important resources to help you learn more about your Medicare, the coverage rules and benefits:
- Medicare & You handbook: Everyone who is new to Medicare gets a Medicare handbook, called Medicare & You, in the mail when they enroll. You get an updated handbook each year in the fall from Medicare. If you want, you can sign up to get this handbook electronically. Sign up at www.mymedicare.gov. Use your handbook as a general reference for what Medicare offers.
- Medicare websites: Medicare’s official website, www.Medicare.gov, offers general info about Medicare’s benefits. You can find publications on specific benefits to help you better understand Medicare’s coverage limits. You can also find information on how to read a Medicare Summary Notice that lists all the charges Medicare received for you. Medicare’s other site, www.MyMedicare.gov, is a personalized online site where you can get detailed information about your current benefits. You can easily sign up for an online account, you can access and download your recent Medicare Summary Notices, keep track of your preventive benefits, view the status of claims/bills, keep a medication list, and more. The online service is free and secure.
- MyMedicareMatters.org: Learn about Medicare’s coverage and benefits, including information on enrollment, types of coverage, costs, preventive services and more. You can take a free Medicare Questionnaire to help you compare plans and find the right one for you
- Get personal help: Get help in your local area through your State Health Insurance Assistance Program (SHIP). This service is free to people with Medicare and their families. A counselor can help you review your options, review Medicare’s rules with you and help you get the benefits you are entitled to. SHIP may have a different name in your state, to find contact information visit www.shiptacenter.org.
I changed to different Part D plans for the new year. Do I need to notify my prior year's plan about the change?
You do not need to contact your old plan. Your coverage automatically switched as of January 1. You should have received materials, including your new plan’s identification card and a booklet explaining your plan’s coverage information, in the mail by the end of the prior year. You should be all set to fill prescriptions in January.
If you have not yet received your new plan’s insurance card, you should call your new plan immediately. Or you contact Medicare at 1-800-MEDICARE (1-800-633-4227).
How can I pay my monthly premium for Medicare?
Depending on which parts of Medicare you are referring to, there are a couple of different ways:
- Medicare Parts A & B: If you draw a Social Security Administration (SSA) check, then your monthly premium will be automatically withheld from your check. If you aren’t drawing a check, then you have to pay your premium directly. The Social Security Administration (SSA) is responsible for collecting your payments. You can pay quarterly or use one of the monthly options listed in the Medicare Easy Pay section at www.medicare.gov. Note: Most people do not have to pay a Part A premium since they paid into Part A while they were still working.)
- Medicare Advantage Plans: If you choose to get your Part A and B benefits through a private Medicare Advantage (MA) or Medicare Advantage-Prescription Drug (MA-PD) health plan, they require a monthly premium in addition to Part A and/or B premium. There are a few options on how to pay your MA or MA-PD plan premium, such as; (1) mailing a check, (2) paying by credit card, or (3) having the payment taken directly out of your checking or savings account. You should contact your plan directly to find out the payment options, locate the number on your insurance card.
- Medicare Part D: As for Medicare Part D (drug coverage), this is a separate premium that is paid to the drug plan. Contact your plan directly to find out the payment options. Keep in mind you may have the option to have your Part D premium taken from your monthly Social Security benefit. However, this option can be frustrating when switching plans from year-to-year. If too much premium is withheld, it will be paid back to you but may take 30-90 days. Note: If you cannot afford your Part D premium or if you need help with your drug copayments, you may be able to get Extra Help.
I need to see my doctor for a specific test, item, or service. How can I find out if Medicare will cover it or not?
Medicare has very strict rules about what it covers and does not cover. That said, there are many places where you can find general information about your Medicare benefits. Here are some ways to find out:
- Check out the Medicare & You handbook: This handbook is mailed to people with Medicare every year, usually in September. It gives you a broad overview of what Medicare covers and provides. You can also find this handbook online at Medicare’s website.
- Use Medicare’s online coverage search tool:
- Go to Medicare’s homepage
- Enter the test, service or item you wish to search
- Select your state
- From this list you will see if Medicare covers it, how often and how much they will cover
- If you have Original Medicare (Medicare Parts A and/or B), call Medicare at 1-800-633-4227.
- If you get your Medicare through a private Medicare Advantage (MA) health plan such as an HMO or a PPO, call your MA plan directly. Locate their phone number on your insurance card.
Does Medicare cover an annual physical?
Medicare covers a complete physical examination only once within the first 12 months of joining Medicare Part B. This is known as the Welcome to Medicare visit. To get ready for the visit, you complete a Health Risk Assessment, which is a questionnaire about your health status. Your assessment responses, along with the measurements your doctor takes during your visit, help to inform the plan you and your doctor develop to keep you as healthy as possible and make sure you get the medical care, preventive and screening services, medicines and self-care support you need.
Starting 12 months after your Welcome to Medicare visit, you can schedule your first Annual Wellness Visit. After that, you can get an Annual Wellness Visit every 12 months. During the Annual Wellness Visit, your doctor will check your blood pressure, weight and height and assess your body-mass index. You and your doctor review your health, your medicines and any treatments you receive. You and the doctor create a plan to keep you healthy, including any screenings and shots you may need over the next year, and look ahead to your needs in the next 5 to 10 years. If your doctor finds it necessary, he/she may refer you to other doctors or may give you a vision test, an Electrocardiogram (EKG) or any other needed test.
You will not be charged for your Welcome to Medicare visit and Annual Wellness Visits; these services are fully covered by Medicare so there are no deductible charges or coinsurance paid by you. Sometimes one of these visits may be combined with other Medicare services for which cost-sharing does apply. For example, if your doctor takes your blood pressure during the Welcome to Medicare visit and it’s really high, the doctor should determine a treatment plan to bring your pressure down. That service is not considered a part of the visit, so you could be charged the regular Medicare Part B 20% coinsurance amount for that part of your interaction with the doctor. It’s not unusual for doctor visits to include more than one service. For Medicare, some may be free of cost-sharing, while others might cost you.
If you want to learn more about the Welcome to Medicare visit, Annual Wellness visit and other services, see the Preventive Services page.
My loved one is incontinent. Will Medicare help pay for the cost of adult diapers?
Original (fee-for-service) Medicare does not cover “absorbent” products, such as adult diapers, because they are not considered durable medical equipment. Medicare does offer limited coverage of “urine collection devices,” such as catheters. Some Medicare Advantage plans do cover adult diapers or liners.
To find help with the cost, talk with your county Social Services (Medicaid) department. They may be aware of some resources to help with this expense. In addition, if your loved one is eligible, some state Medicaid plans pay for adult diapers.
And if you are having trouble affording your health supplies, use a web-based screening tool called BenefitsCheckUp to see if you may be eligible for programs that can help pay for healthcare, housing, food and more. This tool is completely free and confidential; you can use it at www.BenefitsCheckUp.org.
I need the shingles shot. Does Medicare pay for all or part of this cost?
All Medicare Part D drug plans are required to cover the shingles vaccine. Part D plans have very specific rules about where you need to get the shot in order for the plan to cover both the injection (the vaccine itself) and the administration of it, that is to say, giving you the shot. You should call your Part D plan to learn more about their rules to get the shot paid and how much you have to pay.
Ask your plan:
- How much do they charge you (your copayment or coinsurance) for the vaccine?
- Do you need to get the shot at your doctor’s office in order to get coverage?
- Can you get the shot at a pharmacy or drugstore and get reimbursed by your plan?
The shingles vaccine can help you avoid a very painful and often lifelong condition that could limit your activities. Let Medicare help you stay healthy by getting the vaccine if you have not had it yet.
And if you have limited income and resources, you may be eligible for Part D Extra Help. This program helps you pay for certain Part D costs, such as the coinsurance and copayments, making the cost of your vaccine much more affordable.
Does Medicare help pay for caregiver services?
Medicare has very specific coverage rules, and generally Medicare does not provide coverage for personal care (also known as “custodial care,” such as needing help with meals, supervision). If a person is homebound, has a provider’s prescription or order, and also requires skilled care services provided by a Medicare home health agency, then Medicare will pay for home health care. Skilled care is care from a licensed nurse or therapist, which has been ordered by a doctor.
Medicare does provide short-term respite to give caregivers a break, but only under the hospice benefit, when your loved one has a life-threatening illness and has elected to receive hospice care.
There may be other options in your area (other than Medicare) that can help you and your family with taking care of your loved one. Here are some resources to help support your efforts:
- Medicaid programs: Many states offer programs through Medicaid to allow direct federal payments to family caregivers for their services. To see what’s available in your community, use the Eldercare Locator at www.eldercare.gov. The Eldercare Locator can connect you to your local aging and disability agencies that can assist you in applying for assistance.
- Caregiver respite and support programs: There are also a number of caregiver support programs that can provide respite care, so you can take an occasional break from your caregiving responsibilities. Check out Family Caregiver Alliance at www.caregiver.org, and select “Family Care Navigator: State-by-State Guide” under the “Caregiver Info & Advice” tab to help find local respite providers and support services in your area.
- BenefitsCheckUp.org: BenefitsCheckUp is a free confidential screening service from the National Council on Aging that helps identify thousands of programs to help seniors and adults with disabilities pay for health care, prescriptions, food, home energy costs, transportation and more. To learn more, visit www.benefitscheckup.org.
What kind of in-home care will Medicare pay for?
If you wish to see whether home health services may be appropriate, you might want to start by speaking with their primary care provider. To receive in-home help paid by Medicare you must meet all of the following conditions:
- Have a doctor’s order for home health services.
- The services must be provided to a Medicare-certified home health agency. You can find one on your own, or the doctor’s office may recommend a provider.
- The doctor will need to reorder the care as needed and must see the patient periodically.
- The patient must be homebound. Generally this means that leaving home is difficult and doesn’t happen frequently.
- The patient must need skilled care like physical therapy or speech and language services or intermittent (meaning not continuous) nursing care. The doctor’s order must specify what services are needed.
Medicare will only cover part-time or “intermittent” skilled nursing care, which is defined as care that’s needed for fewer than 7 days every week or fewer than 8 hours each day over a period of 21 days. There are a few exceptions to this rule. You can learn more about this benefit with the Medicare and Home Health Care Booklet.
Medicare does not pay for any of the following:
- 24-hour care at home
- Meals delivered to your home
- Homemaker services like shopping, cleaning and laundry
- Personal care given by home health aides like bathing, dressing and using the bathroom when this is the only care needed
If you wish to find help with the above services Medicare doesn’t pay for, contact the Eldercare Locator at www.eldercare.gov or 1-800-677-1116 to find what assistance may be available in your area.
I’ve just been prescribed a new drug and was told Medicare won’t cover it. What can I do?
Medicare covers most outpatient drugs through the Part D drug benefit. To get coverage, you must join a Medicare drug plan.
There a few reasons Medicare may not cover your drug:
- The drug is excluded by law from coverage,
- The drug is not on your plan’s list of covered drugs, also called the formulary, or
- The plan may have special rules or set limits on how you get your drugs.
If your current plan does not cover a drug you are taking, there a few things you can do:
- Ask your pharmacy: Your pharmacy should give you a notice that explains why your prescription could not be filled and how to contact your plan.
- Ask your plan why the drug is not covered: Call your plan and ask for a coverage determination. Do this to get an explanation of why your drug isn’t covered. Look at your plan membership card or other materials for your plan’s toll-free number.
- Talk with your doctor: See if your doctor (or other prescriber) can switch you to a similar drug on your plan’s drug list known as a formulary. You may need to take your plan’s drug list to your doctor’s office to find a suitable drug on the drug list. If not, ask your doctor to give you free samples of the drug.
- Request an “exception”: If the drug is covered by Medicare but not by your plan, ask your plan to cover it. This is called an “exception.” You will need your doctor who prescribed the drug to tell the plan why you need the specific drug. Contact your doctor and ask if he can help you request an “exception” from your drug plan.
- Prescription Assistance Programs: See if any local prescription assistance programs in your area may offer this drug at a discount.
- Review other drug plans: If you cannot get an exception from your plan and there is not an alternative drug, review other drug plans available in your area. Medicare’s coverage of prescription drugs varies from plan to plan. There may be another drug plan that does cover it. Take the Medicare Questionnaire to get help to compare plans.
My drug plan cost too much. What can I do?
Shop around because plans change their costs and the drugs they pay for each year. What you should do is take advantage of the annual Open Enrollment Period. This is the time of year when you can make changes in your Medicare coverage. The period starts on October 15 and ends on December 7. Your new coverage will start January 1 of the new year.
This enrollment period is very important. Why? Because unless you are new to Medicare, have Extra Help to pay your Medicare drug plan costs or have a special circumstance, you will not be allowed to change your Medicare coverage for another year. So, if you need better coverage, now is the time to review your options.
During this time, you should review your plan options and consider joining a different Medicare drug plan. Remember, you only have until December 7 to switch to a plan that may better meet your needs in the new year, so don’t delay.
Find out how to explore your Part D options, what to consider in a plan, and how to enroll in a new plan.
What’s the best way to review my plan options? And where can I find the information I need?
The Medicare Open Enrollment Period is from October 15 to December 7, and is when you can make changes in your current coverage or to enroll in a Part D drug plan or a Medicare Advantage plan. Any changes you make during this time take effect January 1.
First, try taking our Medicare Questionnaire. The Questionnaire is a quick, easy-to-use assessment tool (created by the nonprofit National Council on Aging) that provides access to free Medicare advice from a licensed benefits advisor. Or contact your local State Health Insurance Assistance Program (SHIP). SHIP provides free, federally-funded Medicare counseling from trained staff members. You can find your local SHIP office at www.shiptacenter.org.
I think I am about to go into the Part D coverage gap. How will I know if I do? And if I do, how will I afford my prescriptions?
Each month that you fill any prescriptions using your Medicare Part D plan, you receive an Explanation of Benefit (EOB) summary in the mail. This summary shows the amount that you have paid for prescriptions drugs to date. It also shows how much your plan has paid to date. The EOB also shows you if you have reached the coverage gap for the year.
If you need help paying for drugs during the coverage gap, check these resources:
- Learn about Extra Help and apply if your income and assets are within the allowed range.
- Check the www.medicare.gov website to see if there is a State Prescription Assistance Program in your state to help with drug costs.
If you have the Extra Help/Low-Income Subsidy, you do not have a coverage gap.
How do I go paperless?
If you’d like to receive your Explanation of Benefits (EOB) online or by email from your Medigap, Medicare Advantage Part C Plan or Medicare Part D Drug Plan, then call your plan directly to learn how to opt-out of paper statements. Their customer service toll-free number appears on your insurance card.
I’m turning 65 and still working. Can I keep my employer coverage or should I join Medicare?
If you are eligible for an Employer Group Health Plan (EGHP) based on your current employment (working and not retired) and your employer has more than 20 employees, then you can delay enrolling in Medicare Parts A, B & D. When you stop working or lose coverage, you will get a Special Enrollment Period (SEP) to join Medicare. The same applies if you are turning 65 and you have EGHP because your spouse is working. To view this in writing, visit the Medicare Who Pays First publication for more information about Coordination of Benefits.
Using this SEP means you won’t incur late enrollment penalties since you have an EGHP and are currently working. When you retire or lose employer coverage, the SEP to enroll in Medicare allows you to join:
- Parts A and/or B within 8 months of retirement and loss of employer coverage
- Part C or Part D within 63 days of retirement and loss of employer coverage
- Medicare Supplement Insurance (Medigap) within 6 months of retirement and loss of employer coverage (applies only if joining Part B for the first time at age 65 or older). You can buy a Medigap policy outside this 6 month period but the insurance company can turn you down for medical reasons after the 6 month period.
Because most people pay no monthly premium for Part A, they often join Part A when they turn 65. However, Medicare Part A won’t likely pay anything on your behalf because it is the secondary coverage (pays after employer insurance). The main reason to consider delaying Part A relates to Health Savings Accounts (HSA). First, you cannot contribute to an HSA after joining Part A (and/or B). Second, you may face an IRS penalty if you don’t time your final HSA contribution carefully. The Social Security Administration will automatically enroll anyone 65.5 years or older in Part A retroactively for 6 months prior to signing up for Part A or claiming their Social Security cash benefits.
Which plan I should get? Can someone help me?
Review the My Medicare Matters chart comparing the basic coverage details among Medicare Part A & B, Medicare + Medigap, Medicare Advantage, and Medicare Part D. For help comparing the details of your choices, we’d suggest one of these sources:
- Complete our Medicare Questionnaire for access to free, trustworthy Medicare advice from a licensed benefits advisor.
- Contact your local State Health Insurance Assistance Program (SHIP). SHIP is a federally funded service that provides free, unbiased Medicare counseling.
If you’d like to compare plans on your own, we’d suggest using these sources:
- Compare Medicare Advantage Part C and Prescription Drug Part D plans on the Medicare Plan Finder at Medicare.gov. Enter a personalized search, your drug information, and your pharmacy preference. The plan finder will list details like which plans cover your medications on their formulary (list of drugs), which pharmacies are in the network, and which offer preferred cost-sharing.
- Compare Medigap policies with your State Insurance Commission Medigap Shoppers booklet. Click the hyperlink and then the state in which you live for contact information. Normally, the comparison booklet listing the prices and coverage is available in .pdf online at the website too.
What if I can’t afford the costs of Medicare like premiums, deductibles, and coinsurance?
Use the NCOA BenefitsCheckUp tool to see if you qualify for programs to help with some of your costs. Set aside 20-40 minutes to complete the checkup because you must complete it once you start vs. saving and returning to the site.
If you’d prefer to talk with someone, we suggest your local State Health Insurance and Assistance Program (SHIP). Be sure to ask about these programs:
- Medicare Savings Programs help pay the Part B premium and possibly more depending on your income and asset levels.
- Extra Help with Medicare Part D prescription drug plans. If you get Extra Help you are allowed a continuous Special Enrollment Period and can change Part D plans any time during the year.
- Prescription Assistance Programs from drug manufacturers for your medications. NeedyMeds.org is a good resource to get information. Be careful when reviewing this information as there are a couple on online, discount pharmacies listed vs. foundations or drug manufacturers that will help pay a portion of the medication.
How much is the penalty for late enrollment?
There are late enrollment penalties for Medicare Parts A, B and D if you don’t sign up when you’re first eligible. The penalty calculations for each part of Medicare vary.
There are some circumstances in which a person does not receive a penalty, as follows:
- Still working and covered by an Employer Group Health Plan (EGHP) who joins in the appropriate timeframe after losing their EGHP. Review the response to the second question to learn more about how to avoid the penalties based on having employer coverage.
- The Part A and B penalties do not apply if you have a Medicare Savings Program.
- The Part D drug penalty does not apply if you have proof of creditable drug coverage or if you qualify for Extra Help to pay your Part D costs based on your income and assets.
When should I sign up for Medicare?
If you’re drawing a Social Security check before you turn 65, then at age 65 you’re automatically enrolled in Medicare Parts A & B. You will receive a Welcome to Medicare packet including your Medicare card in the mail three months before the month of your 65th birthday.
Note: If this situation describes you, then you can’t delay enrolling in Medicare Part A unless you’re willing to pay back the Social Security money you’ve drawn thus far. You can delay Part B and paying its monthly premium as described in the first question if you have employer coverage.
If you aren’t collecting Social Security yet, you can join Medicare during your Initial Enrollment Period (IEP) three months before or after the month of your 65th birthday. We advise signing up when you’re first eligible to avoid late enrollment penalties you may incur if you wait until the General Enrollment Period for Medicare Parts A & B.
Can I get Medicare before age 65?
I’m still working and have a payroll deduction for Medicare and pay a monthly Medicare premium. Do I have to pay both?
Yes. Medicare is funded three streams: general revenue (41%), payroll tax contributions (38%), and beneficiary premiums (13%). As you noted, you do pay a premium for Medicare Part B each month of around $109-$134 (for most enrollees in 2017) which is less than ¼ of the cost of the actual premium. The federal government pays the other ¾ of the monthly premium with general revenue, interest and other sources.
If you want to read more about Medicare spending and financing, then visit the Kaiser Family Foundation fact sheet about it.
I’m moving to another state in two months. Do I need to do anything?
Be sure to update your address by calling 1-800-Medicare (1-800-633-4227) and the Social Security Administration. If you move outside your plan’s service area, you can wait until you move or until you have a move date to make changes. The Centers for Medicare & Medicaid Services product no. 11219 details the options when you move outside your plan’s service area, among other Part C & D Enrollment Periods. Your timeframe to switch varies on when you notify your plan, detailed in the hyperlink on page 7 of the tip sheet.