Frequently Asked Questions About Medicare
Medicare is a federally-funded health insurance program. Medicare has four parts: Part A, Part B, Part C and Part D.
If you are aged 65 or older and are not disabled, getting benefits from Social Security or the RRB and have not been awarded SSDI benefits, you will need to contact the Social Security Administration (SSA) office to enroll.
If you are getting Social Security or RRB benefits, have been awarded SSDI benefits or have been diagnosed with ALS, you will be automatically enrolled in Medicare. If you have been diagnosed with ESRD, you will need to contact the SSA to enroll.
Once you’re enrolled in Medicare, you’ll have a variety of options to choose from to get complete coverage. You can either choose a single plan to cover all your needs or you can choose a combination of plans. But before you make a decision, you should assess your health and finances and compare these with the Medicare options available to you. Your Medicare options will generally fall under two main categories: Original Medicare (also known as traditional Medicare, which includes Part A and Part B) and Medicare Advantage plans. There also are other specialized Medicare plans available.
If you experience certain changes, you should have your Medicare options re-evaluated. Changes include:
Medicare plan prices and availability change every year. And so might your healthcare needs. So a plan that was relatively inexpensive this year may be more expensive next year. Some plans may be discontinued completely. While it’s not required that you review all your options every year, we strongly recommend that you do so to make sure you’re getting the coverage that is right for you.
BeginMedicare understands that no one type of Medicare plan will work for everyone. While one person might find that a Medicare Advantage plan most closely meets their stated needs, a spouse or friend might find that a Medicare Part D plan works better for them. If you would like to learn more about all the Medicare options that may be available to you, including Original Medicare, Medicare Advantage, Part D and Medigap you can contact us at 215-240-1263.
CMS stands for Centers for Medicare & Medicaid Services, the agency within the U.S. Department of Health and Human Services that oversees Medicare, Medicaid, the State Children’s Health Insurance Program and other programs.
No matter what kind of coverage you have, you have the right to:
Referrals and Prior Authorization
Referrals and Prior Authorization
Limited Network PFFS
No. Medigap plans are purchased to supplement original Medicare. Medigap plans pay for cost-sharing charges. Essentially, these plans “cover the gaps" in Original Medicare coverage.
Medicare Advantage plans actually replace Original Medicare. When a beneficiary opts to enroll in a Medicare Advantage plan, the privately administered plan provides their Medicare coverage. By law, Medicare Advantage plans must cover everything covered under Traditional Medicare Parts A and B. Medicare Advantage plans may also offer additional benefits, (such as dental or vision coverage), and prescription drug coverage.
No. When you enroll in a Medicare Advantage plan, Medigap will not cover Medicare benefits nor any health plan deductibles, coinsurance or co-pays for you.
When first eligible for Medicare at age 65 or after you have been receiving SSDI for 24 months:
Special enrollment periods (when certain criteria are met):
Your effective date will depend upon which enrollment period applies to you.
If you choose to enroll in a Medicare Advantage organization, you should ask them when your effective date will be.
Yes, all plans must cover all Medicare Parts A and B services, including emergency and urgently needed care.
Some plans, such as Medicare medical savings accounts and certain Medicare private fee-for-service (PFFS) plans, do not offer prescription drug coverage. Because the Medicare Advantage plans are administrated by private companies, they vary widely Check out Quote tool to compare different plans that are available.
If a Medicare Advantage plan does not offer drug coverage, you may be able to join a Medicare prescription drug plan (Part D).
The only exception is those members with Medicare and Medicaid who may be able to pay less or those who are eligible for low-income subsidy (LIS).
The only exception is those members with Medicare and Medicaid who may be able to pay less or those who are eligible for low-income subsidy (LIS).
You can join, switch or drop a Medicare Advantage plan:
In order to join a Medicare Advantage plan, you must have Medicare Parts A and B and live in the plan service area at least six months of the year.
Medicare Part A is hospital insurance and helps cover inpatient care in hospitals. Part A also helps cover skilled nursing facilities, hospice and home healthcare if certain conditions are met.
If you get benefits from Social Security or the Railroad Retirement Board, you will automatically get Part A on the first day of the month you turn age 65. If you are under age 65 and disabled, you will automatically get Part A after you get disability benefits from Social Security or Railroad Retirement Benefits for 24 months.
Medicare Part B is medical insurance and helps cover medically-necessary services such as doctors’ visits and outpatient care. Part B also covers many preventative services, such as flu shots, mammograms and Pap tests.
If you get benefits from Social Security or the Railroad Retirement Board, you will automatically get Part B on the first day of the month you turn age 65. If you are under age 65 and disabled, you will automatically get Part B after you get disability benefits from Social Security or Railroad Retirement Benefits for 24 months.
If you didn’t sign up for Part B when you first became eligible, you may be able to sign up during one of these times:
You may have to pay a late-enrollment penalty for not signing up for Part B benefits as soon as you became eligible. The premium may go up 10 percent for each full 12-month period that you could have had Part B but didn’t sign up for it.
The fee for Part B benefits varies according to income. The table below shows the 2015 Part B premiums.
|If Your Annual Income is…|
|File Individual Tax Return||File Joint Tax Return||You Pay|
|$85,000 or below||$170,000 or below||$104.90*|
|$85,001 – $107,000||$170,001 – $214,000||$146.90*|
|$107,001 – $160,000||$214,001 – $320,000||$209.80*|
|$160,001 – $214,000||$320,001 – $428,000||$272.70*|
|Above $214,000||Above $428,000||$335.70*|
Medicare Part C (also called Medicare Advantage) is another way to get Medicare benefits. Medicare Part C combines Part A, Part B and, sometimes, Part D (prescription drug coverage).
Medicare Part C is medical and hospital insurance. It includes everything that Medicare Parts A and B includes and often also provides prescription drug coverage under Part D and other benefits such as vision and dental coverage. Medicare Part C is also known as Medicare Advantage and is offered by private companies.
In general, most people who are eligible for Medicare Part A or Medicare Part B can enroll in a Medicare Advantage plan. However, people with certain disabilities or End Stage Renal Disease (ESRD) may not be able to participate in Medicare Advantage and may need to use Original Medicare instead.
Yes, you will still need to pay your Part B premium to Medicare. Most Medicare Advantage plans also charge a fee over and above what Medicare Part B charges because they provide extra coverage, such as prescription drug coverage, dental and vision.
Medicare Part D helps cover prescription drugs.
No. Although most prescription drugs are covered under Medicare Part D, there are certain medications, such as those administered in a doctor’s office, that are covered under Medicare Part B. If you’re interested in Part D coverage, you should contact the plan administrator to see if the drugs you take are covered.
If you are entitled to Medicare Part A or are enrolled in Part B, you can get prescription drug coverage under Medicare Part D.
Part D benefits can be purchased in two different ways. You have a choice of private drug plans that are either integrated with medical coverage (Medicare Advantage-Prescription Drug or MA-PD) or offered as a stand-alone prescription drug plan (PDP). Which one you are eligible to purchase can depend on how you are receiving your Medicare Part A and Part B benefits.
A stand-alone Medicare prescription drug plan (PDP) can be purchased to add coverage to Original Medicare, some Medicare private fee-for-service (PFFS) plans that do not offer integrated Medicare prescription drug coverage, some Medicare cost plans and Medicare medical savings account plans.
Most Medicare Advantage Plans (like an HMO or PPO) and other Medicare health plans include integrated coverage for prescription drugs. You then get all your healthcare and prescription drug coverage through one plan.
If you decide to get a stand-alone Medicare Part D plan, you will pay a monthly premium. Premiums differ from plan to plan. You should be aware that individuals with higher incomes will pay more for Medicare Part D. If you have to pay more for Medicare Part D, Social Security will deduct the extra amount from your Social Security check. Following is a table that provides you information on how much you will be charged if you have to pay extra for Medicare Part D in 2015. This charge will be in addition to what you pay for your Medicare Part D premium:
|If your annual income is…||Add the following amount to your Part D premium:|
|File Individual Tax Return||File Joint Tax Return|
|$85,000 or below||$170,000 or below||Your plan premium|
|More than $85,000 up to $107,000||More than $170,000 up to $214,000||Your plan premium + $12.30|
|More than $107,000 up to $160,000||More than $214,000 up to $320,000||Your plan premium + $31.80|
|More than $160,000 up to $214,000||More than $320,000 up to $428,000||Your plan premium + $51.30|
|More than $214,000||More than $428,000||Your plan premium + $70.80|
Some Medicare drug plans have a coverage gap, often called a “donut hole." Historically, this has meant that after you have spent a certain amount of money for covered drugs, you have to pay all costs for drugs until you’ve paid a total of $4,700 out of pocket, after which you’ll fall into catastrophic coverage where your plan will pick up most of the cost of your drugs. Starting in 2015, help will be available for people falling into the donut hole – if you reach the donut hole, you’ll get a 55 percent discount on brand-name drugs and a 35 percent discount on generics until you’ve reached catastrophic coverage. The discount will not affect how quickly you go through the donut hole; in other words, if you get the discount, that won’t mean that you’ll be in the donut hole longer.
To join a drug plan, you must be entitled to Medicare Part A or have Medicare Part B and live in the service area of the plan. Drug plans offer their benefit options in specific service areas. Beneficiaries are eligible to purchase only plans offered in the area where they reside.
You are eligible to enroll in a Medicare drug plan only during certain time periods depending on your situation:
If you do not join a drug plan when first eligible, you may have to pay a penalty for enrolling later. This means that you may pay a higher premium for as long as you have Medicare drug coverage.
In most cases, you will pay a penalty if you:
To estimate the penalty, take one percent of the national average benchmark premium for the coverage year. The national average benchmark premium for 2015 is $33.13.
Multiply it by the number of full months that you were eligible to join a Medicare drug plan and weren’t enrolled in one. The answer is the penalty amount. This penalty amount is added to the monthly premium of whichever Medicare drug plan you join for as long as you are in the plan. The penalty is recalculated each year there is a change in the national average premium. If you have to pay a penalty, the Medicare drug plan you joined will tell you the amount that must be paid.
If you are told that you need to pay a penalty but disagree with the plan, you can request that the plan reconsider the late enrollment penalty. To do so, you should contact your plan and they will provide you with the appropriate forms and instructions.
Traditional Medicare (Parts A/B) does not cover most outpatient prescription drugs. Medicare Part A bundled payments made to hospitals and skilled nursing facilities generally cover all drugs during an inpatient stay. Medicare Part B makes payments to physicians for drugs or biologicals that are not usually self-administered. Part D does not generally cover drugs that fall under Part A/B.
A covered Part D drug includes prescription drugs, biological products, insulin and certain vaccines. The definition also includes “medical supplies associated with the injection of insulin (as defined in regulations of the secretary)." These medical supplies include syringes, needles, alcohol swabs and gauze.
The definition of the Part D drug coverage does not include OTCs. Therefore, Part D plans cannot include OTCs in their drug benefit or supplemental coverage.
By law, there are certain types of drugs that Medicare must exclude from Part D. These include drugs used for anorexia, weight loss or weight gain; fertility drugs; drugs used for cosmetic purposes or hair growth; cough and cold medicines; prescription vitamins and minerals and over-the-counter drugs.
Medicare drug plans must cover prescription drugs in all prescribed categories and classes, but Medicare drug plans do not have to cover every drug in a given class or category.
Yes, but there are specific regulations the plan must follow. Prior to removing a covered Part D drug from its Part D plan’s formulary, or making any change in the preferred or tiered cost-sharing status of a covered Part D drug, a Part D plan must either:
If the Federal Drug Administration (FDA) has decided that a drug is unsafe, the plan must remove the drug from its formulary immediately and notify members as soon as possible, but within no less than three days of the drug’s removal from the formulary.
The term cost sharing refers to the costs participants will pay in addition to what Medicare pays for medical services.
Co-insurance is an amount you may be required to pay for services after you pay any plan deductible. Co-insurance is usually a percentage of the total cost of the service. In the original Medicare plan, this is a percentage (like 20 percent) of the Medicare-approved amount. You have to pay this amount after you pay the Part A and/or Part B deductible.
A copayment is a flat fee you pay in some Medicare health and prescription drug plans for each medical service, like a doctor’s visit, or prescription. Copayments may be different for services or prescriptions that are more expensive. For example, you may pay $10 to see your regular doctor, while your plan may require you to pay a $20 copayment to see a specialist such as a cardiologist or neurologist.
The deductible is the amount you must pay for healthcare or prescriptions before the original Medicare plan, your prescription drug plan or other insurance begins to pay. For example, in the original Medicare plan, you pay a new deductible for each benefit period for Part A and each year for Part B. These amounts can change every year.
Extra Help or Low Income Subsidy (LIS) refers to the program offered through Medicare that assists qualified beneficiaries with Part D premiums and overall drug costs. You must meet certain criteria to qualify for LIS. In 2015, you may qualify if you have up to $17,508 in annual income ($23,592 for a married couple) and up to $13,440 in resources ($26,860 for a married couple). The cost sharing amount for LIS depends on income and resources, but most people who qualify will pay no premiums, no deductibles and no more than $2.65 for generics and $6.60 for brand name prescriptions in 2015.
Certain Medicare beneficiaries will automatically qualify for the Extra Help (LIS) and don’t need to apply in the following circumstances:
CMS mails letters to beneficiaries to notify them of their LIS qualification.
When you have Medicare and Medicaid, CMS mails a letter on yellow paper to you as notification that Medicare is covering your prescriptions instead of Medicaid. The letter provides the name of the plan Medicare is enrolling you in and the date your coverage begins.
Beneficiaries who get help from their state to pay Medicare premiums (Medicare Savings Program), get Supplemental Security Income (SSI) benefits, or applied and qualified for the extra help, receive a letter from CMS on green paper. The letter provides the name of the plan Medicare has chosen for you and the date coverage begins.
If you’re not happy with the plan Medicare assigns you to, you may be eligible for a SEP. You also can make changes to your coverage during the annual enrollment period from Oct. 15 – Dec. 7 each year.
In determining your eligibility for LIS, both income and resources are counted. If you are married and living with a spouse, both of your incomes and resources are counted – even if only one is applying for Extra Help. If you are married, but not living with the spouse when applying, only your income and resources are counted.
Income is any cash, goods or services that can be used to meet needs for food or shelter. Examples include, but aren’t limited to, the following:
Income not counted:
Resources include cash and other things that normally can be converted to cash within 20 workdays. Examples include, but aren’t limited to the following:
It depends. If you have served on active duty in the armed forces and meet certain criteria, you may apply for VA healthcare coverage. Eligibility criteria include:
If the VA determines that you qualify for healthcare coverage, you will be assigned a priority level based on a scale of 1 to 8-1 being the highest priority and 8 being the lowest.
For example, if you are considered a priority level 8, you will get far less coverage and slower access to care than if you were a priority level 1 or 2. In general, the more you need healthcare coverage due to a combination of service-related disability and low income, the more coverage you will get from the VA.
For more information on eligibility and coverage or to apply for veterans health benefits, visit www.va.gov/healthbenefits.
Priority levels are an important part of VA coverage. Your priority level determines what type of health benefits you will receive. It also may determine when you will be scheduled for medical care or, if necessary, your placement in a VA long-term care facility.
If you qualify for VA health benefits, regardless of what priority level you are, you will get the VA’s Uniform Benefit Package, which includes:
Generally, yes. The VA usually suggests that you take Medicare Part A, which covers hospital care, and Part B, which covers medical services, if you are eligible. While there is some cost associated with Part B ($104.90 a month for most people in 2015), there are definite benefits to having Medicare. These include greater flexibility in healthcare options and greater overall cost savings. This is important if your VA health coverage gets reduced or denied at any point.
Funding for VA benefits and the priority groups is set by Congress each year and can be unpredictable. So you don’t want to suddenly find yourself having to make up unexpected, increased out-of-pocket medical costs, especially if you are in one of the lower-priority veterans groups.
Yes. If you have VA coverage, you automatically get Medicare Parts A and B when you become eligible for Medicare due to age or disability. When your date of eligibility approaches, you will receive a notice and an ID card from Social Security. You will also receive information about your Part B premium, which is deducted from your monthly Social Security check unless you choose to pay your premiums in some other way. If you are eligible for Medicare Part B, but decided not take it, you will have to pay a penalty later if you change your mind and add it to your Medicare coverage.
The penalty can be substantial as it adds an extra 10 percent to your monthly Part B premium ($104.90 per month for most people in 2015) for each full 12-month period that you could have had Part B but didn’t sign up for it. Plus, you will have to wait until the general enrollment period to sign up. This period lasts from January 1- March 31 each year, and coverage does not begin until July 1.
There are exceptions to the Part B enrollment penalty. The most common exception is having comparable coverage through a spouse’s employer, which can allow you to delay your enrollment in Part B until after you lose that coverage.
It is important to note that being part of the VA healthcare system is considered creditable coverage as far as Medicare Part D prescription drug coverage, so you don’t have to worry about facing a late-enrollment penalty if you don’t sign up for it right away.
The two plans are separate and seldom coordinate payments to give you extra cost savings. In other words, if you get care at a non-VA facility, Medicare generally pays the bills, unless you have received prior authorization from the VA. There are exceptions, of course. For example, an emergency may require you to go to the nearest medical provider which is a non-VA facility. In this case, the VA may pick up some of the cost until you can be moved to a VA facility for further care.
However, Medicare can still provide you with more options for care than VA health benefits Also, it can provide a secondary source of coverage if VA funding or facilities get scaled back.
No. The VA and Medicare do not coordinate benefits. This means that if you have a Medicare-approved outpatient procedure completed at a non-VA facility, only Medicare will cover that procedure. In addition, Medicare may not cover the full cost of the procedure, so you may have out-of-pocket costs.
That is a personal decision depending on your needs and budget. The VA package offers prescription drug coverage, and Medicare offers the same, which is known as Part D. If you get a Medicare Part D plan, generally, you will need to pay monthly premiums to keep it. Your costs may be less if you purchase a Medicare Advantage plan that includes prescription drug coverage.
The drug coverage you receive through the VA is considered as good as or better than that offered under a Part D plan and is premium-free, so you may not need both. However, you will be required to fill your prescriptions at a VA-approved pharmacy or by the Consolidated Mail Outpatient Pharmacy Program (CMOP). If you decide later you want a Medicare Part D plan for whatever reason, you are allowed to enroll in one without penalty.
Not necessarily. If you have VA benefits, but need medical services that the VA does not cover, you can simply use your Original Medicare benefits at the time of service. However, if you would like to have a Medicare Advantage plan, you can enroll in one. Medicare Advantage plans typically combine coverage provided by Medicare Parts A and B, and may include additional benefits and services. Some people find that having Medicare Advantage works best for them, even if they already have VA benefits.
It depends. Every VA office operates differently, and one facility may provide a different quality of care than another. Also, some facilities may have shorter wait times than others for access to specialists, certain medical procedures and more.
Since your VA coverage is free, if you are high on the priority list and there isn’t a long wait to get care, it may be wise to use your VA coverage instead of Medicare. VA coverage may be preferred, especially if you need inpatient hospital care or prescription drugs, because you are getting low- or no-cost health benefits in a timely manner.
However, if you face a long wait time for medical care (for example, you need to see a physical therapist or have an operation, but the VA waiting list is several months long), you might want to consider using your Medicare coverage outside the VA healthcare system. The same applies if you want to undergo a medical procedure or take a prescription drug that is not approved by the VA.
Because your healthcare situation is unique, you should carefully consider both your financial and healthcare needs when choosing what healthcare coverage will work best for you.