Medicare 101
Get the basics on how Medicare coverage works, the different plans and types of coverage, and whether you might be eligible for additional savings.
How Medicare Works
Medicare is health insurance provided by the federal government for eligible individuals, generally those age 65 and older or individuals under age 65 with certain disabilities or other medical conditions. Because Medicare is made up of several different plans—Parts A, B, C, and D—you have options to consider based on your personal needs. Here’s a closer look at the types of plans that make up Medicare.
Parts A and B
Often referred to as “Original Medicare,” Part A provides hospital insurance (for things like inpatient care, home health services, or hospice care) and Part B provides medical insurance (for doctor’s visit, outpatient care, and other medical supplies and equipment).
Part C: Medicare Advantage Plans
These plans are administered by private insurance carriers and offer alternative plan options to Original Medicare. Medicare Advantage Plans must provide all the same services as Part A and Part B, but many offer additional benefits like wellness programs or vision coverage. There may be different costs associated with Medicare Advantage Plans, and most have defined service areas, so be sure to review and compare these plans carefully. There are five different types of Medicare Advantage plans to consider, based on your needs:
- Health Maintenance Organizations (HMO)—With HMOs, you generally must get your care from in-network providers and your chosen primary care physician. Out-of-network emergency care will be covered.
- Preferred Provider Organizations (PPOs)—PPOs provide the flexibility to go out-of-network for care, but you pay less if you use in-network providers.
- Private Fee-for-Service (PFFS) Plans—PFF plans are offered by private insurance companies that set a predetermined payment for you and your insurance provider when you receive a medical service.
- Special Needs Plan (SNPs)—SNPs ensure in-network care for people with specific diseases or characteristics.
- Medical Savings Account (MSA)—MSAs are high deductible plans coupled with a savings account you can use to cover eligible health care expenses.
Part D: Prescription Drug
You can enroll in Part D if you are enrolled in Original Medicare or if you enroll in a Medicare Advantage Plan, that doesn’t already include prescription drug coverage. Note that most Part D plans require a monthly premium and/or a fixed copay when you fill prescriptions. If you meet certain requirements, you may be eligible for Extra Help.
Medicare Supplement Insurance
Also known as Medigap, Medicare Supplement Insurance plans help pay some of the health care costs that Original Medicare doesn’t cover. You must be enrolled in Original Medicare (Parts A and B) to enroll in a Medigap plan—these plans are not available to Medicare Advantage participants.
Medicare and Medicaid
Special rules apply for individuals who are eligible for both Medicare and Medicaid, also known as Dual Eligible Beneficiaries. To learn more, or if you are a Dual Eligible Beneficiary, you can find information on the Medicare or Medicaid websites.
Not sure which plan you need? We can help.
Eligibility and Enrollment
Many factors determine which Medicare plans you may be eligible for, as well as when you can enroll. For example, if you already receive Social Security benefits, you will automatically be enrolled in Medicare Parts A and B. Otherwise, you will need to apply for Medicare coverage when you become eligible (generally, when you turn 65).
The timeline below helps explain when you may become eligible for different Medicare plans and when you’ll need to take action to enroll.
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Seven months surrounding your 65th birthday: Initial Enrollment (IEP)
This seven-month period includes the three months before you turn 65, the month you turn 65, and three months after you turn 65. This is generally the first opportunity you’ll have to enroll in Medicare.
- If you join during one of the three months before you turn 65, your coverage begins the first day of the month you turn 65.
- If you join during the month you turn 65, your coverage begins the first day of the month after you ask to join the plan.
- If you join during one of the three months after you turn 65, your coverage begins the first day of the month after you ask to join the plan.
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Oct. 15 – Dec. 7: Medicare Annual Enrollment Period (AEP)
Anyone who has Medicare can join, switch or drop a Medicare Advantage Plan and/or Medicare Prescription Drug (Medicare Part D) plan between October 15 and December 7. If you make a change during this time, your new coverage will begin on January 1.
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Jan. 1 – March 31: Medicare Advantage Open Enrollment Period (OEP)
From January 1 through March 31 each year, if you are already enrolled in a Medicare Advantage Plan, you can switch to a different Medicare Advantage Plan, or switch from Medicare Advantage to Original Medicare and join a separate Medicare prescription drug plan. You may only make one election during the Medicare Advantage Open Enrollment Period. Your new coverage will start the first day of the month after your new plan gets your request for coverage.
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Throughout the year: Special Open Enrollment Period (SEP)
In most cases, you must stay in the plan for the calendar year when your coverage began. But you may be able to join, switch or drop a Medicare Advantage Plan or Prescription Drug Plan due to certain special circumstances. It’s important to check with your plan to find out if you can enroll outside of the typical enrollment periods. Some reasons you might qualify include:
- You moved out of a plan’s service area
- You qualify for low-income subsidy assistance (Extra Help)
- You are eligible for both Medicare and Medicaid
- You are leaving or losing your employer’s health plan
When you’re ready, get help determining which plans you’re eligible for and understanding your options.
Extra Help
You may be eligible for additional help with prescription drug (Medicare Part D) costs, including premiums, deductibles, and copayments. Valued at about $5,000 per year, Extra Help can offer significant savings to help offset out-of-pocket prescription drug costs for those who qualify.
Many people don’t realize that Extra Help is available, so you could be missing out on additional money to help manage your health care costs. Let a Choice Health licensed agent help determine if Extra Help may be an option for you and walk you through the process to qualify through the Social Security Administration. Then, a licensed agent will follow up with you to see if you have been approved for Extra Help and, when you’re ready, can help find the right Medicare coverage for you.
Ongoing Support
Get help understanding Medicare with these resources:
- Centers for Medicare and Medicaid Services (CMS)
- "Medicare and You Handbook"
- Social Security Administration
- Glossary
We Go Beyond Helping You Find a Plan
Choice Health is there to help support you every step of your Medicare journey. Once you enroll, your Member Advisor can help with questions about your benefits, coordinate your pharmacy options, identify routine and specialty health care providers, help you schedule appointments with your doctor, and much more. Your Member Advisor is there when you need support.
