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12 of Your Biggest Medicare Questions Answered

There is a lot to understand about Medicare, and we know that getting all the information you need can feel like a monumental task. That’s why we set out to compile a list of the 12 most frequently asked questions we’ve received over the last decade in the Medicare business.

The 12 questions below were answered by one of our very own Medicare Supplement Insurance agents, Sherri Mack.

“The most rewarding part of my job is being able to make a difference in the lives of our customers. I love working with them to find a policy that will cover their needs at a price they can afford.”

— Sherri Mack, Medicare Supplement Insurance agent 

Don’t see your question answered below? Not a problem, give us a call. Our agents are dedicated to you and helping you make an informed decision about your Medicare coverage.

 

1. Who is eligible for Original Medicare?

If you’re a United States citizen or permanent legal resident for at least five consecutive years, you may be eligible for Medicare if you meet one or more of the following qualifications:

  • You are 65 or older and are eligible for retirement benefits through Social Security
  • You are 65 or older and are eligible for retirement benefits through the Railroad Retirement Board
  • You have a disability and have been receiving disability benefits for at least 24 months
  • You have ALS (Lou Gehrig’s disease)
  • You have end-stage renal disease and require dialysis treatment or a kidney transplant

There may be other circumstances that make you eligible for Medicare not listed here.

 

2. When can I sign up for Medicare?

The best time to enroll in Medicare is during your Medicare Initial Enrollment Period (IEP), which is the first time you become eligible for Medicare,

If you do not qualify for Medicare early because of a disability or medical condition, your IEP typically begins three months before your 65th birthday, includes your birthday month, and ends three months after your 65th birthday.

If you are younger than 65 and qualify for Medicare because of a disability, your Medicare coverage typically begins 24 months after your disability benefits are approved.

If you have ALS, your Medicare benefits begin the first month you have Social Security Disability Benefits. People with ALS are typically automatically enrolled.

If you have ESRD and on dialysis, your Medicare benefits typically start on the first day of the fourth month of your dialysis treatment. People with ESRD usually must manually enroll.

If you miss your Medicare Initial Enrollment period and don’t qualify for a Special Enrollment Period, you will have another chance to enroll during the Medicare General Enrollment Period, which runs from January 1 to March 31 each year. If you enroll during this time, however, your coverage won’t begin until July 1, and you may have to pay late enrollment penalties for as long as you have Medicare.

 

3. I’m still working and have group health insurance coverage through my employer. Do I still need to enroll in Medicare?

If you have health insurance through your or your spouse’s employer, you should qualify for a Special Enrollment Period. If you qualify for a Special Enrollment Period, you can enroll in Medicare outside of your IEP without having to pay late enrollment penalties.

Since most people do not pay a premium for Medicare Part A, you can remain enrolled in Part A and your group health insurance plan at the same time, and your group plan will help cover your health care expenses.

 

4. How do I sign up for Medicare?

Some people are automatically enrolled in Original Medicare (Medicare Part A and Part B), and others must enroll manually.

You may be automatically enrolled in Original Medicare if one or more of the following applies to you:

  • You’ve been getting benefits from Social Security or the Railroad Retirement Board for at least four months before you turn 65.
  • You’ve been getting disability benefits from Social Security for 24 months
  • You’ve been getting certain disability benefits from the Railroad Retirement Board for 24 months
  • You have ALS and receive disability benefits

If you are not automatically enrolled in Medicare and must manually enroll, you can do so by:

  • Calling Social Security at 1-800-772-1213 (TTY users 1-800-325-0778), Monday through Friday 7AM-7PM
  • Contacting the Railroad Retirement Board at 1-877-772-5772 (TTY users 1-312-751-4701), Monday through Friday 9AM-3:30PM (if you worked for a railroad)
  • Visiting the Social Security website at www.SocialSecurity.gov
  • Visiting your local Social Security office

 

5. Does Medicare cover my spouse?

No. There is no family coverage under Medicare, so each spouse must enroll in Medicare separately once they become eligible.

 

6. How much could I pay out of pocket for Medicare Part A and Part B?

Medicare Part A and Part B premiums and out-of-pocket costs1 are standardized by the government and include:

Medicare Part A premium

Premiums are what you pay each month for your Medicare coverage. Most people do not pay a premium for Part A, provided they paid sufficient Medicare taxes while working. If you must pay a premium, it could cost up to $437 a month in 2019.

Medicare Part B premium

In 2019, the standard Part B premium is $135.50 a month, but some people could pay more or less depending on their income and social security status.

Medicare Part A deductible

In 2019, the Medicare Part A deductible is $1,364 per benefit period. Benefit periods are based on how long you’ve been discharged from the hospital. A benefit period under Medicare Part A begins the day you’re admitted to the hospital and ends when you’ve been discharged for at least 60 days. If you’ve been out of the hospital for more than 60 days and are admitted again, a new benefit period begins.

Medicare Part B deductible

In 2019, the Part B deductible is $185 per year.

Medicare Part A coinsurance

Coinsurance is the percentage that you must pay for a covered health care service once your deductible is met. The Medicare Part A coinsurance structure is:

  • Days 1-60 spent in a hospital: $0 coinsurance for each benefit period
  • Days 61-90 spent in a hospital: $341 coinsurance per day of each benefit period
  • Days 91 and beyond spent in a hospital: $682 coinsurance per each “lifetime reserve day” after day 90 for each benefit period
  • Beyond lifetime reserve days: 100% of costs

Medicare Part B coinsurance

The Medicare Part B coinsurance is typically 20% of the Medicare-approved amount for most Part B services, once your deductible is met.

Part B excess charges

Healthcare providers choose whether or not to accept Medicare assignment. If they agree to accept assignment, it means they must accept the Medicare-approved amount for all services. If they don’t accept assignment, but still accept Medicare as health insurance, providers can charge up to 15% above the Medicare-approved amount. This is known as an excess charge.

Medicare Supplement Insurance

Medicare Supplement Insurance (also called Medigap) are private insurance plans that help cover some of the out-of-pocket costs of Medicare Part A and Part B.

You must pay a monthly premium for Medicare Supplement Insurance, which are determined by the insurance company. A licensed insurance agent can help you compare Medigap plans in your area.

There are 10 standardized Medigap plans to choose from in most states, labeled A, B, C, D, F, G, K, L, M and N.

All 10 of these standardized plans provide at least partial coverage for:

  • Medicare Part A coinsurance and hospital costs
  • Medicare Part B coinsurance or copayment
  • First 3 pints of blood
  • Medicare Part A hospice care coinsurance or copayment

Medigap plans may also offer different combinations of up to five additional benefits, which are illustrated in the following chart.

2019 Medigap Plan Comparison

Medicare Supplement benefits

A

B

C

D

F*

G

K**

L***

M

N****

Medicare Part A coinsurance and hospital costs

Medicare Part B coinsurance or copayment

50%

75%

First 3 pints of blood

50%

75%

Part A hospice care coinsurance or copayment

50%

75%

Coinsurance for skilled nursing facility

   

50%

75%

Medicare Part A deductible

 

50%

75%

50%

Medicare Part B deductible

   

 

         

Medicare Part B excess charges

       

       

Foreign travel emergency costs

   

80%

80%

80%

80%

   

80%

80%

* Plan F offers a high-deductible plan. This plan requires you to pay a $2,300 deductible (in 2019) before it covers anything.

** Plan K has an out-of-pocket yearly limit of $5,560 (in 2019). After you pay the out-of-pocket yearly limit and the yearly Part B deductible, it pays 100% of covered services for the rest of the calendar year. *** Plan L has an out-of-pocket yearly limit of $2,780 (in 2019). After you pay the out-of-pocket yearly limit and yearly part B deductible, it pays 100% of covered services for the rest of the calendar year.

**** Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that don’t result in an inpatient admission. Plan N has a Part B deductible of $185 (in 2019).

 

7. What does Original Medicare help cover?

Original Medicare is made up of two parts: Medicare Part A (hospital insurance and Medicare Part B (medical insurance), and each part covers different health care services.

Medicare Part A

Some examples of the types of services covered by Part A include:

  • Inpatient hospital care
  • Inpatient care in a skilled nursing facility
  • Hospice care
  • Home health care
  • Nursing home care (as long as custodial care is not the only care you need)

Medicare Part B

Some examples of the types of services covered by Medicare Part B include:

  • Medically necessary doctor’s services
  • Durable medical equipment
  • Outpatient care
  • Home health services
  • Mental health services (inpatient and outpatient)
  • Ambulance services
  • Preventive services and some other medical services

Important: Original Medicare does not typically cover prescription drugs or dental, vision or hearing care.

If you’re enrolled in Original Medicare and need coverage for prescription drugs, you may enroll in a Medicare Prescription Drug Plan (Medicare Part D).

 

8. Will every doctor accept my Medicare coverage?

People with Original Medicare can see almost any doctor in the U.S. (but be sure to ask if they accept Medicare assignment). Doctors who do not accept assignment can charge up to 15% more for health care services, which you could end up paying out of pocket.

Medicare Supplement Insurance plans are accepted by any doctor that accepts Medicare.

 

9. Is there help available to people with lower incomes?

Yes. Medicare Savings Programs help qualifying Medicare beneficiaries pay their Part A and Part B premiums and sometimes help pay for Part A and B deductibles, copays and coinsurance. Call your State Medicaid office to apply.

Additionally, Medicare’s Extra Help program helps people with limited incomes pay for prescription drugs. If you qualify for Extra Help, you will pay less for your Part D premiums, copayments and coinsurance. You’ll also be covered during the Coverage Gap (often referred to as the “donut hole”) and will not have to pay a late enrollment penalty. Contact your State Medicaid office or your State Health Insurance Assistance Programs to apply.

 

10. Can I make changes to my Medicare coverage once I’m enrolled?

You can generally make changes to your Medicare coverage once a year, during the Medicare Annual Election Period (AEP), which runs from October 15 to December 7. If you make changes during AEP, your coverage will begin January 1 of the following year.

During the Medicare Annual Election Period, you can typically:

  • Enroll or disenroll from a Medicare Advantage plan
  • Switch from Medicare Advantage back to Original Medicare
  • Join, drop or switch a Medicare Prescription Drug (Medicare Part D) plan
  • Switch from one Medicare Advantage plan to another Medicare Advantage plan

Important: If you qualify for a Special Enrollment Period, you may have the chance to make changes to your coverage outside of AEP. Examples of reasons you may qualify for an SEP include if you move or lose health coverage.

Can I make changes to my Medicare Supplement Insurance coverage?

You typically have one chance (known as your Medigap Open Enrollment Period) to enroll in Medicare Supplement Insurance without having to go through medical underwriting, which can raise your Medigap premiums.

Your Medigap Open Enrollment Period is a six-month period that begins the first day of the month in which you are 65 years or older and enrolled in Medicare Part B.

If you enroll in a Medicare Advantage plan for the first time and wish to disenroll from it to join a Medicare Supplement Insurance plan, this may qualify you for a guaranteed issue right, which means you may be able to switch to a Medigap plan without facing medical underwriting.

 

11. Who’s eligible for Medicare Supplement Insurance?

You must be enrolled in Medicare Part A and Part B to be eligible for Medicare Supplement Insurance.

If you’re younger than 65 and are eligible for Medicare because of a qualifying disability or medical condition, your Medigap eligibility will vary depending on the state in which you live.

The following states require that insurance companies offer at least one type of Medigap plan to people under 65 who receive Medicare benefits:

  • California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Kansas, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, New hampshire, New Jersey, New Mexico, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, South Dakota, Tennessee, Texas, Vermont and Wisconsin

California, Massachusetts and Vermont require that insurance companies offer at least one Medigap policy to people under 65 who are disabled. This requirement does not include those who are under 65 and have end-stage renal disease. Delaware requires that insurance carriers offer at least one Medigap policy to those under 65 who have ESRD. This requirement does not include those under 65 who are disabled.

 

12. How can I enroll in Medicare Supplement Insurance?

A licensed agent can help you find and compare Medigap plans in your area and get you enrolled in one that works for you.

 

Still have questions?

Agents like Sherri are available right now to help answer your Medicare questions, compare your options, and enroll in the right plan for you.


1 According to Medicare.gov “Medicare Costs at a Glance.” Published 2019 . https://www.medicare.gov/your-medicare-costs/medicare-costs-at-a-glance/

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