Medicare FAQs

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What is Medicare?

Medicare is a government health insurance program with different coverage options and enrollment guidelines. Unlike other health insurance you may have had, it has specific dates and guidelines you need to follow. We're here to help you understand it all.

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How Does Medicare Differ From Employer-Sponsored Health Insurance?

The distinctions between Medicare and other health insurance may surprise you. If you've had coverage through your employer, your plan probably included medical and prescription drug coverage, along with additional benefits. It may have also covered both you and your spouse.

Medicare provides coverage for one person at a time, requiring separate enrollment for you and your spouse. Moreover, it offers various options, allowing you to receive benefits in different ways based on your preferences.

You can:

• Receive hospital and medical coverage through the federal government (known as Original Medicare).
• Get prescription drug coverage from a private company (Medicare Part D).
• Purchase a supplemental insurance policy from a private insurer that can help cover costs (Medicare Supplement Plan or Medigap).
• Choose coverage from a managed-care organization that combines hospital, medical and often prescription drug coverage into one plan (Medicare Advantage).

Medicare offers the flexibility to select coverage that suits your needs, budget, and lifestyle. We are here to assist you in making the most of this freedom.

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Who is Eligible for Medicare?

• Age 65 +
• Under age 65with certain disabilities
• Have End-Stage Renal Disease (ESRD)

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When and How Do I Enroll?

Most people enroll in Medicare around their 65^thbirthdays. Your Initial Enrollment Period spans three months before, the month of, and three months after your birthday. If you did not qualify for Medicare for a disability or medical condition, this will be your first opportunity to enroll in Medicare.

This window is important, as missing it might entail late enrollment penalties for Medicare Part B or Part D. Beyond the financial considerations, delaying enrollment could mean foregoing essential coverage and benefits that play a pivotal role in safeguarding both your health and finances.

How you enroll generally depends on if you’re getting benefits from Social Security, the Railroad Retirement Board or the Office of Personnel Management.

If you’re receiving benefits from any of these sources at least four months before you turn 65:

• You’ll automatically get Medicare Part A and Part B starting the first day of the month you turn 65.
• If your birthday is on the first day of the month, Part A and Part B will start the first day of the prior month.

If you’re not receiving benefits from any of these sources at least four months before you turn 65:

• You’ll need to sign up with Social Security to get Medicare Part A and Part B.
• You can apply online at socialsecurity.gov, at your local Social Security office or by calling Social Security at 1-800-772-1213(TTY: 1-800-325-0778).
• If you worked for a railroad, call the RRB at1-877-772-5772.

If you’re under 65 and have a qualifying disability, you’ll automatically get Part A and Part B:

• At the beginning of the 25th month of receiving disability benefits from Social Security.
• At the beginning of the 25th month of receiving certain disability benefits from the RRB.
• The month your disability benefits begin if you have ALS (Amyotrophic Lateral Sclerosis, also called Lou Gehrig’s Disease).

If you have ESRD (End-Stage Renal Disease), you can choose to enroll in Part A and Part B:

• You’ll need both Part A and Part B to qualify for the full benefits that cover certain dialysis and kidney transplant services.
• You can apply online at ssa.gov, at your local Social Security office or by calling Social Security at 1-800-772-1213 (TTY:1-800-325-0778).

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Do I have deadlines to enroll?

There are five different periods during which you can enroll in or change your Medicare plan:

• Initial Enrollment Period is a seven-month window around your 65th birthday
• Special Enrollment Period allows you to make changes to your Medicare Advantage and/or Part D plan due to special circumstances, such as moving out of your plan's service area
• General Enrollment Period allows you to signup in case you missed your Initial Enrollment Period
• Annual Enrollment Period is a yearly opportunity to make changes to your Medicare Advantage and/or Part D coverage from October 15 to December 7
• Medicare Advantage Open Enrollment Period allows you to change your Medicare Advantage plan just once from January 1 to March 31 each year

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What If I Continue to Work Past the Age of 65?

Reaching the age of 65 doesn't necessarily mean an immediate obligation to sign up for Medicare, especially if you're still employed. However, if you delay enrollment in Medicare, you need to be wary that your coverage will qualify you for a Special Enrollment Period (SEP) when you do want to enroll in Medicare.

In most cases, maintaining employer-sponsored coverage means that you do not need to enroll in Medicare. However, if your employer has less than 20 employees, does not participate in a multi-employer welfare arrangement(MEWA), and the carrier elects to pay primary, you will need to enroll in Medicare, as it will be your primary coverage. In most other situations, Medicare would be the secondary payor, so enrollment is optional.

Another consideration is drug coverage. Creditable coverage is defined as prescription drug coverage that is determined to be as good or better than the basic Part D benefit. If the employer does not offer creditable drug coverage, you may want to enroll in a stand-alone Part D plan to avoid late-enrollment penalties if you decide to enroll in Part D later. Ask your company’s human resources’ contact for information on your plan’s creditability.

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Parts of Medicare

What Are the Parts of Medicare?

Medicare has four different parts that provide coverage for specific services. Learning what each part covers can help you better understand your options and feel more confident about your decisions.

Medicare Part A (Hospital Coverage)

Together, Medicare Part A and Medicare Part B are known as Original Medicare. Medicare Part A is hospital insurance that provides coverage for:

• Inpatient care
• Skilled nursing facility care
• Hospice care
• Some home health care

Most people don’t pay a monthly premium for Medicare Part A. It’s coverage that’s earned from Medicare taxes that you or a spouse have paid while working. If you don’t qualify for premium-free Part A, you can also buy Part A coverage. Our licensed insurance agents can help guide you through that process.

Medicare Part B (Medical Coverage)

Together, Medicare Part A and Medicare Part B are known as Original Medicare. Medicare Part B is medical insurance for medically necessary services and preventive services. It provides coverage for:

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-       Doctor's services

-       Outpatient care

-       Ambulance services

-       Clinical research

-       Durable medical equipment

-       Limited prescription drugs

-       Mental health

-       Early stage preventive services

Most people will pay a monthly premium for Medicare Part B. The standard amount is set each year and may increase based on your gross income as reported to the IRS.

If you receive benefits from Social Security, the Railroad Retirement Board or the Office of Personnel Management, your Part B premium is automatically deducted from Security benefit payment. Otherwise, you will receive a bill.

You’re not required to enroll in Medicare Part B during your Initial Enrollment Period. However, in many cases delaying enrollment means you’ll have to pay a late enrollment penalty for as long as you have Part B coverage. We can help you decide if enrolling in Part B is right for you.

Medicare Part C (Medicare Advantage)

Medicare Part C, commonly known as Medicare Advantage, is coverage offered by private insurance companies that have a contract with the federal government. Medicare Advantage combines your Part A hospital, Part B medical and often Part D prescription drug coverage into one plan.

• Provide all the benefits of Original Medicare (Parts A and B).
• Limit the amount of money you pay out-of-pocket for medical expenses each year.
• May require you to use providers within the plan’s network and charge you more when you use out-of-network providers.
• Must notify you of any changes to the plan before the next enrollment year.
• Are only available to you if you’re enrolled in both Medicare Part A and Medicare Part B.

With Medicare Advantage, you must continue to pay your Medicare Part B premium. You may also have to pay a monthly premium to the insurance company that provides your coverage.

Medicare Part D (Prescription Drugs)

Offered by private insurance companies, Medicare Part D coverage helps you pay for your prescription drugs. There are two basic ways to get Part D prescription drug coverage:

• ‍Purchase a standalone Medicare Part D Plan. You must have either Part A or Part B to join a part D plan. You’ll need both Part A and Part B to qualify for the full benefits that cover certain dialysis and kidney transplant services. If you choose to add a standalone Part D plan to your Original Medicare coverage, you will usually pay a monthly Part D plan premium to the insurance company.‍
• Join a Medicare Advantage (Medicare Part C) plan that includes Part D prescription drug coverage. If you choose to join a Medicare Advantage plan that has prescription drug coverage, you won’t pay an extra premium for Part D — those benefits are included in your plan.

All Part D plans — including Medicare Advantage plans with Part D benefits — cover a wide range of prescription drugs. However, coverage and cost vary from plan to plan:

• Each plan has a formulary — a list of the specific prescription drugs the plan covers.
• Many plan formularies also have tiers that place covered prescription drugs into different cost levels.
• Prescription drugs in a lower tier will generally cost you less than those in a higher tier.

Medicare Supplement (Medigap)

Original Medicare (Parts A and B) doesn’t cover everything. It only covers a portion of your costs for covered services — and it doesn’t limit what you pay out-of-pocket for health care expenses each year.

To help fill these coverage gaps, many private insurance companies offer Medicare Supplement, or “Medigap”, insurance policies that help pay for your health care costs. When you have a Medigap policy, Medicare continues to pay its share of the approved amount for covered services. Your Medigap policy then pays its share.

Here are some important things to know about Medigap policies:

• You must have Original Medicare (Parts A and B) to buy one.
• They have a monthly premium that you pay to the insurance company.
• You must also continue to pay your Medicare Part B premium.
• They don’t include prescription drug coverage — you must purchase a Part D plan separately.
• They generally don’t cover things like long-term care, vision, dental, hearing or private-duty nursing.
• They only cover one person — if you and your spouse want Medigap coverage, you’ll each need separate policies.

Coverage Options

Choosing Your Coverage

Choosing the right Medicare coverage begins by asking a simple question: What matters most to you? The providers you want to see, your prescription drugs, your budget and your lifestyle are all important factors to consider. We can help you understand your options and guide you to a plan that fits your needs.

Your Basic Coverage Options

Some of the most common ways for you to receive your Medicare benefits include:

• Original Medicare
• Original Medicare + Part D Prescription Drug Coverage
• Original Medicare + Medigap Coverage
• Original Medicare + Part D Prescription Drug Coverage+ Medigap
• Medicare Advantage Plan

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Coverage Combinations Explained

Original Medicare

Includes Part A Hospital and Part B Medical coverage.

This option might be good for you if:

• You only want basic Medicare coverage.
• You want to be able to see any provider that accepts Medicare.

Keep in mind

Original Medicare has coverage gaps — it only pays a portion of the costs for covered services.

Prescription drug coverage is not included.

• There’s no limit on what you pay out-of-pocket for medical expenses each year.
• There are no extra benefits like dental, vision, hearing.
• You must pay a monthly premium for Part B coverage.

Original Medicare + Part D Prescription Drug Coverage

Adds a Part D prescription drug coverage plan from a private insurer to the Original Medicare plan.

This option might be good for you if:

• You want prescription drug coverage to go with basic Medicare coverage.
• You want to be able to see any provider that accepts Medicare.

Keep in mind

• Original Medicare has coverage gaps — it only pays a portion of the costs for covered services.
• There’s no limit on what you pay out-of-pocket for medical expenses each year.
• There are no extra benefits like dental, vision, hearing and wellness.
• You will pay a separate premium to a private insurance company for your Part D coverage.

Original Medicare + Medigap Coverage

Adds supplemental coverage from a private insurer to Original Medicare.

This option might be good for you if:

• You want coverage to help fill the gaps in Original Medicare.
• You want to be able to see any provider that accepts Medicare.

Keep in mind

• Prescription drug coverage is not included.
• Depending on the Medigap plan, there may or may not be a limit on what you pay out-of-pocket for medical expenses each year.
• There are no extra benefits like dental, vision, hearing and wellness.
• You will pay a separate premium to a private insurance company for your Medigap coverage.

Original Medicare + Medigap + Part D Prescription Drug Coverage

Adds supplemental coverage and a Part D prescription drug plan from private insurers to Original Medicare.

This option might be good for you if:

• You want supplemental coverage that helps fill the gaps in Original Medicare.
• You want coverage for your prescription drugs.
• You want to be able to see any provider that accepts Medicare.

Keep in mind

• Depending on the Medigap plan, there may or may not be a limit on what you pay out-of-pocket for medical expenses each year.
• There are no extra benefits like dental, vision, hearing and wellness.
• You will pay separate private insurance plan premiums for both your Medigap and Part D coverage.

Medicare Advantage

An all-in-one option for receiving your Medicare benefits through a private insurer.

This option might be good for you if:

• You want to receive Part A hospital, Part B medical and often Part D prescription drug coverage together in one plan.
• You want predictable costs and a firm limit on what you pay out-of-pocket for medical expenses each year.

Keep in mind

• Medicare Advantage plans typically come with a network of contracted providers.
• Some plans may give you the ability to use out-of-network providers, but usually at a higher cost.
• You must continue to pay your Medicare Part B premium. Some plans may pay some or all of your Part B monthly premium.
• Depending on the plan, you may pay a separate premium to a private insurance company.

Can I change my coverage?

Your health care needs can change from year to year. So do health plans. Fortunately, Medicare gives you the ability to join a plan or change your coverage during certain times of the year. Medigap plans may ask medical questions and refuse to issue a policy if you are outside of Medigap open enrollment. For Medicare Advantage and Prescription Drug Plans, changes must typically be made with a qualifying election period, such as the Annual Election Period (AEP), or under special circumstances called a Special Enrollment Period(SEP).

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Enrollment

Medicare Annual Enrollment Dates

Beginning October 15th and ending December 7th, the Medicare Annual Enrollment Period (AEP) is generally the time when you can join or switch Medicare Advantage or Part D prescription drug plans.

Medicare Advantage Open Enrollment

There's also a Medicare Advantage Open Enrollment Period that begins January 1st and ends March 31st. During this time, if you're in a Medicare Advantage plan and want to change your coverage, you can switch to a different Medicare Advantage plan with or without prescription drug coverage. You can also go back to Original Medicare and, if needed, join a Part D prescription drug plan.

Special Enrollment Periods

Throughout the year, you may be able to sign up for Medicare during a Special Enrollment Period. These are typically reserved for times when certain events happen in your life — and each Special Enrollment Period can have different rules, depending on the circumstances.

Reasons for a Special Enrollment Period may include changing where you live, losing your current coverage or if your plan changes its contract with Medicare.

Coverage Changes

Your health care needs can change from year to year. So do health plans. Fortunately, Medicare gives you the ability to join a plan or change your coverage during certain times of the year. Note that Medigap plans may ask medical questions and refuse to issue a policy if you are outside of Medigap open enrollment.

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Not connected with or endorsed by any government or Federal Medicare Program. We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-Medicare to get information on all of your options. Currently we represent 10 organizations which offer 7,196 plans in the State of Ohio.