There are specific requirements you must meet to be eligible for Medicare.
Veterans who are eligible to receive health care benefits like Tricare for Life (TFL) or Veterans Affairs are not required to enroll in Medicare. However, they might benefit by exploring their Medicare eligibility to receive more coverage, broader selections for physicians and treatment facilities, and supplemental benefits at little or no cost by adding on a Medicare Advantage (MA) Plan. Veterans who sign up for Medicare Advantage will continue to have access to their TFL and VA coverage. These plans work together to enhance the overall benefits.
The short answer: No. Your spouse is eligible for Medicare when he or she turns 65. However, if your spouse has a qualifying disability such as End-Stage Renal Disease or Lou Gehrig’s Disease, he or she may be able to enroll in Medicare sooner. Your eligibility for Medicare has no impact on the date that your spouse is eligible for Medicare. Medicare coverage is all individual, meaning you cannot have dependents on your plan. This includes your spouse and children.
Medicare Advantage (MA) and Medicare Advantage Prescription Drug (MAPD) plans include deductible and copay cost-sharing features, and typically have lower premiums than Medicare Supplement plans. In addition, individuals on an MA or MAPD plan may also receive additional benefits, such as vision, hearing, and some dental coverage.
Medicare Supplements, also referred to as Medigap plans, are exactly as they sound – they are designed to supplement and “fill the gaps” of original Medicare by paying the deductibles and coinsurance for Medicare-covered services. It is important to note that supplement coverage is secondary to Medicare and will only cover Medicare-approved services. In addition, Medicare Supplements do not provide prescription drug coverage so many individuals pair a stand-alone Prescription Drug Plan (PDP) with their Medicare Supplement to help cover the costs of prescription medications. If you travel frequently, this option might be a good fit for you as this plan goes wherever you go.
Doctors within a plan’s network vary from plan to plan, so the ability to keep your current doctors depends on which type of Medicare plan you choose (Supplement or Medicare Advantage) and the specific Medicare plan you choose. Regardless of the type of plan you decide upon, RetireMed’s advisors will work with you to ensure that you keep the doctors that are important to you.
Supplement Plans: If your doctor is contracted with Medicare, you will continue to have access to them on a Supplement Plan. Medicare Supplement plans are designed for people to have access to all Medicare providers, regardless of where they live within in the U.S.
Medicare Advantage Plans: First, it is important to know the different types of Medicare Advantage plans available to you. Medicare Advantage plans are network-based programs. There are two types of Medicare Advantage plans: HMO (health maintenance organization) and PPO (preferred provider organization). HMO plans provide you with a network of doctors to choose from. PPO plans allow you to choose doctors both in- and out- of your network.
Medicare Advantage Plans offer large and far-reaching networks. This means that both HMO and PPO networks often include providers in your city, as well as providers throughout your state. Should you spend your winters in another state, several of these plans include programs to cover providers in other areas.
The answer to this depends on what type of coverage you received while on your employer’s group plan and the type of coverage you’re looking for through Medicare. Enrolling in Original Medicare may not cover everything you’re used to having covered through your employer as it does not include a prescription drug plan or cover extras like, vision, dental, or hearing. However, if you choose to enroll in a Medicare Supplement (see below) or a Medicare Advantage (MA) plan, you can enjoy benefits that are similar to your employer’s health care plan and possibly even more! In fact, many Medicare Advantage plans now include allowances for eyewear, over-the-counter pharmacy, and rewards for healthy behaviors. These added benefits provide extra cost savings that aren’t necessarily included in an employer plan.
A Retiree Health Insurance Plan is health care coverage an employer may provide to its former employees after retirement. In most cases, retiree policies act as a secondary payer to Medicare, meaning the retiree policy will cover some – if not all – of the remaining medical expenses after the primary insurer (Medicare) has paid for the approved service.
Check with your employer’s benefits team to learn more about the coverage offered through their retiree health coverage program, and also contact an advisor to compare coverage types and discover which option would be the most cost-effective and beneficial for you.
Stand-alone Prescription Drug plans and Medicare Advantage plans outline their basic benefits in a booklet called the Summary of Benefits (SOB). This document presents an overview of the services your plan will cover. When you first enroll in a stand-alone Prescription Drug plan or Medicare Advantage plan, Medicare requires that you receive a copy of the SOB for that plan.
Insurance companies usually have a SOB and other plan documents available on their websites and give customers the ability to create an online account.
The ANOC is a 200+ page document that explains the changes that are coming to your Medicare Advantage or Prescription Drug plan in the following year. The plan benefits (including premium) for both the current and following year are compared side-by-side in an effort to make it easier to see the differences. Changes can include things like:
Starting in September, your insurance company sends you the ANOC, per government rules. Enrollees who receive these are typically either on a Medicare Advantage plan or a Prescription Drug plan. You will receive your ANOC in the mail or by email, depending on your insurance company.
Medicare’s Annual Enrollment Period (AEP) runs from October 15 through December 7, and it is your yearly opportunity to switch to a different Medicare plan if your current plan no longer meets your needs. The government requires your insurance company to mail the ANOC in advance of this period to make sure you have plenty of time to review changes to your plan and decide what action to take during the open enrollment period.
It is very important that you pay attention to your ANOC and review it carefully. Many people glance over this document and miss important details, like changes in the cost of prescriptions or increases in maximum out-of-pocket limits, that can result in unexpected health care expenses.
RetireMed offers support, one-on-one assistance, and plan comparison tools to help make your Medicare decisions easy and stress free.
Because of the close relationship between Medicare and Social Security, people often get these two programs confused. Although there are connections between Medicare and Social Security, they are actually two separate government programs. You can learn more in this video here.
Medicare: government-funded health coverage for people over the age of 65, those with certain chronic disabilities and individuals with End Stage Renal Disease.
Social Security: a government pension for people over the age of 62 and those with chronic disabilities.
Many recipients of Medicare are also eligible to receive Social Security benefits and vice versa. In addition to eligibility, there are a few other ways that Medicare and Social Security overlap.
Enrollment: Both programs require your initial enrollment to be done through the Social Security Administration. When you first enroll in a Medicare plan or if you need to defer your Medicare coverage (for example, to go back on an employer plan), you would do so through the Social Security Administration.
Premiums: Social Security pension amounts are factored into annual Medicare premium increases. The most common payment method for the Part B premium is through automatic deductions from a Social Security pension.
Eligibility: If an individual collects Social Security Disability (SSD) benefits, they become eligible for and are automatically enrolled in Medicare. Similarly, if a person is collecting Social Security when they turn 65, they are automatically enrolled onto Medicare (they have the option to defer Medicare if they have other coverage).
Additional Assistance: Medicare offers multiple levels of assistance to those on Medicare. These programs help cover expenses such as premiums and prescription costs. Applicants must contact the Social Security Administration in order to apply.
How and when you should enroll in Medicare is largely dependent on your personal situation. Your eligibility period and plan options can all be impacted by your employment status, benefits you may already receive such as Social Security, your health needs, and more. Keep in mind that you do not need to be retired to enroll into Medicare. Many times, Medicare is a more cost-effective solution.
Depending on your individual situation and health care needs, customized coverage can be established through a combination of Medicare Parts A, B, C and D. We know the different steps needed to apply and are here to provide assistance and instruction. If you want more comprehensive coverage with extra benefits, schedule an appointment. with one of our expert advisors to explore additional coverage options.
The short answer: No. You can enroll once you meet the age requirement for Medicare at age 65. In fact, your Medicare enrollment window begins three months before you turn 65. However, some individuals may qualify for benefits without meeting the age requirement for Medicare. For example, an End-Stage Renal Disease diagnosis may qualify you for Medicare at any age.
Working past age 65 is a common occurrence among Baby Boomers. Luckily, your working status has no impact on your Medicare eligibility once you turn 65. You can continue to work and enjoy the benefits of Medicare. Medicare may even be more cost-effective than your employer coverage. Plus, you can use the health savings account (HSA) funds you saved to pay for your health care costs even after you switch to Medicare.
If you work for a company with 20 or fewer employees, you’ll be required to enroll in Original Medicare (Parts A and B) once you become eligible.
The Part D Late Enrollment Penalty (LEP) occurs when someone who is eligible for Medicare goes without creditable prescription drug coverage for more than 63 days. When that person chooses to enroll onto a Medicare Prescription Drug plan they would have to pay a penalty for the number of months they went without creditable coverage. This penalty is added to the plan’s monthly premium and is calculated as 1 percent of the “national base beneficiary premium” times the number of months the individual has gone without prescription coverage. Once a penalty has been assigned, it has no expiration.
Creditable coverage is coverage as good as or better than Medicare’s minimum standards. All Medicare Prescription Drug plans are creditable but if you have prescription coverage outside of a Medicare plan and would like to know if it is creditable, we advise that you contact the administrator of your benefits to confirm.
RetireMed works with clients to ensure that you are on the right health plan. One of the most important parts of our process is ensuring that you also have a creditable drug plan that meets your needs.
The contributions made by both you and your former employer to your Health Savings Account (HSA) will not be affected. The money accrued during your employment is yours to use towards qualified expenses when needed. However, individuals who choose to enroll in Medicare Part A and continue to work after 65 can no longer receive HSA contributions from their employer. It is important to note that any individual who plans to enroll in Medicare Part A must stop contributing to their HSA six months before enrollment.
A deductible is the amount of money you pay for health care services before your health insurance begins to pay. Depending on the type of plan you have, deductibles are primarily understood as the amount of money you must spend out of pocket before your insurance kicks in. For instance, if your Medicare plan has a $1,500 deductible, you will likely pay 100 percent of the cost until your expenses reach $1,500. After you “hit your deductible,” you usually pay a flat rate (copayment) or percentage (coinsurance) of the cost of care.
An out-of-pocket maximum is a cap on your annual spending, but a deductible is a minimum you must pay before your health insurance plan covers your costs.
A deductible may or may not count towards your out-of-pocket maximum. In the case that it doesn’t, you are responsible for meeting both your deductible and your out-of-pocket limit before your health plan picks up any costs.
Medicare Savings Programs help individuals with low income or limited resources pay for their Medicare costs. Medicare beneficiaries can apply for these supportive benefits to save on premiums. Some programs even assist with deductibles, copays, and prescription drugs.
There are four types of Medicare Savings Programs:
If an individual qualifies for QMB, SLMB, or QI, they can also enroll in Extra Help. Extra Help regulates prescription drug expenses.
If you are considering working past 65, you likely have questions about whether you need to take Medicare even though you’re still working, including whether or not you should delay Medicare Part B, how Medicare works with your Health Savings Account, how Medicare works with your employer’s health insurance, and more.
If you are 65 and older and have been employed for at least 10 years under Medicare-covered employment while paying Medicare taxes, and you have been receiving Social Security benefit checks, you will automatically be enrolled in Part A & B, even if you choose to continue to work. If you only wanted Part A, you would need to take additional steps to enroll and refuse Part B. We can help walk you through these steps and options as they are dependent on your unique situation and could have penalty implications if not navigated appropriately.
If you plan to work past the age of 65, there are still several important Medicare items to consider around the time of your 65th birthday, including:
There are several individual health insurance plan options available to you, and the types of coverage and cost may vary. Call one of our expert advisors at 937.915.3563 for assistance in narrowing down these options to find the right health coverage plan for your individual needs. We’re ready to help.
If your spouse is not currently working or is not eligible to receive health care coverage through their employer, additional options for coverage include:
Your Medicare plan benefits are outlined in your Summary of Benefits, located in your plan booklet provided by your insurance company and available on your insurance company’s website. You can also call us at 877.222.1942 and we can walk through your plan’s benefit information with you. The Summary of Benefits gives you a general idea of costs for various procedures, but it is important to note that complicated medical services (such as surgeries) will only be estimates. The final costs will be based on the services billed by your provider and the allowed amounts by the plan.
No, an Explanation of Benefits is not a bill—it is simply a statement sent by a health insurance company to individuals explaining how medical treatments and/or services were paid for on their behalf. If you were to receive a bill for medical services, it would come from your provider or hospital, not from the insurance company. An insurance company will only bill you for plan premiums.
If you believe your bill is incorrect, call us for assistance. We can help guide you in the right direction and assist you in calling your insurance company or provider’s office if needed.
Once your enrollment has been processed, it can take up to two weeks for you to receive your ID card in the mail. In the meantime, we can provide you with your plan policy number that you can use until you receive the card in the mail. You can also create an online account with the insurance company and print a temporary ID card.
The fastest way to secure a new ID card is to call the insurance company or use your online member account to request a new one. When calling, many insurance companies have automated phone prompts through which you can request a duplicate ID card. It usually takes around five minutes to request a new one. You should receive the new ID card in 7-14 business days. Call our team if you need any assistance with this.
Ultimately, you must request a provider directory from your insurance company; however, we encourage clients to search online using the insurance company website which contains more current provider information than printed directories. Providers may leave or join a plan’s network at any time during the year. If you need assistance searching for a provider, call our team for assistance at 877.222.1942.
You must contact your insurance company to request plan materials such as the Evidence of Coverage, Summary of Benefits, or Formulary. You can also download the plan materials from your insurance company’s website. Contact us if you need assistance with reaching out to your insurance company.
Medicare plans grant coverage for urgent and emergency care within the United States. For all other non-emergency medical services while traveling, coverage depends on the kind of plan you have. For example, PPO plans offer some extended coverage while some HMO plans require you to stay within your plan’s service area. Please contact our team for details.
Coverage outside of the country varies depending on the plan. To confirm your travel benefits, you can refer to your plan’s Evidence of Coverage and Summary of Benefits or contact our team.
Medicare Advantage (MA) plans are based on the county you live in. If you are moving outside of your current county or to another state, please contact us to discuss your plan options. You may or may not need to change your plan depending on where you move. If you move within the same county, you only need to inform us of your new address.
The “donut hole” (or coverage gap) is a gap in prescription drug coverage. It occurs after the total cost of your medications during the year has exceeded a certain amount. Call us to discuss any questions you may have about your personal situation.
Your plan might require prior authorization for certain prescription drugs. Before your plan covers one of these drugs, your provider will need to contact your insurance company and explain why it is medically necessary for you. If a medication requires prior authorization, it will be noted on your plan’s Formulary.
A quantity limit is a cap on how much of a medication you can get in a certain timeframe. Insurance companies place quantity limits on certain drugs for safety and cost reasons. If you are prescribed more than the quantity limit, your provider will need to contact the insurance company to confirm that the additional amount is medically necessary.
In some situations, certain vaccinations may be covered. However, most provider offices are unable to bill these claims to your prescription drug plan. Typically, most have an easier time obtaining coverage by getting vaccines from a pharmacy instead of a provider’s office. If you have questions about the specifics of your plan’s benefits, call our team.
Step therapy is a type of prior authorization required by an insurance company. Specifically, it is the process of treating a medical condition with the most cost-effective medication before progressing and providing coverage for a more costly medication.
A prescription drug deductible is the amount you must pay annually before you start paying the fixed copays as outlined by your plan. Not all Medicare plans have a prescription drug deductible. You can refer to your Summary of Benefits to determine your deductible and copay amounts.
Generally speaking, Part B covered medications include those given by a doctor in a medical office or hospital setting; they are determined medically necessary by a provider. Part D medications are generally maintenance medications that you take yourself (the type you pick up from the pharmacy). Please visit Medicare’s website to learn more.
If you are having trouble paying for medication costs, you may have options. If the medication is not listed on your formulary, it is possible for your provider to request a formulary exception from the insurance company by providing medical necessity. Another option is to contact the Social Security Office to determine your eligibility for a federal program called Extra Help. For more tips on how to save on medication costs, watch this video. If you would like assistance or have further questions, contact our team.
During a hospital visit, any routine prescriptions you need that are given by the hospital are considered self-administered drugs. These medications are typically not covered in your hospital co-pay, unless they are required for the hospital services you are getting. You will most likely be billed for the full amount. Once you have paid your bill, you are able to request reimbursement from the Part D portion of your plan through a form called a Prescription Drug Reimbursement Claim Form. We recommend that you check the hospital’s policy on bringing in your own medications, which may allow you to avoid these types of bills. If you find yourself in this situation, contact our team to learn more.
A drug deductible is the amount of money you pay for certain medications before your plan begins to cover some of the cost. Deductibles are primarily understood as the amount of money you must spend out of pocket first before your insurance kicks in. After you reach your deductible, you usually pay a flat rate (copayment) or percentage (coinsurance) of the medication cost
If you’ve previously had drug coverage on your Medicare plan, you may be familiar with the concept of a drug deductible. Not all Medicare plans have a drug deductible but plans that do begin calculating it at the beginning of each calendar year. The deductible dollar amount may also change from year to year.
In some cases, the deductible will apply to all medications. But it’s very common for the deductible to apply only on certain drug tiers. In these situations, lower-cost medications will often be exempt from the deductible. The deductible usually applies to more expensive medications, such as tier 3, 4, or 5 medications.
A copay is a fixed dollar amount set by the insurance company that you are responsible for paying. In most cases you begin to pay copays after your plan’s deductible is met. It is important to keep in mind that deductibles do not always apply to all drug tier levels and some plans do not have drug deductibles.
Coinsurance is a percentage of the drug cost that you are responsible for paying. The full cost of medications fluctuates, which means this amount may differ throughout the year. Like copays, you may also have to satisfy your plan’s deductible before you begin paying your coinsurance on medications. Coinsurances are usually applied to higher tier levels, such as tiers 4 or 5. It is important to refer to your plan’s formulary and Summary of Benefits when estimating what you will be responsible for paying at the pharmacy.
Medicare plans with prescription drug coverage organize medications into different price categories called “tiers.” Medicare plans can have as many as 4 or 5 tiers and generally, drugs in the lower tiers have lower costs while drugs in higher tiers have higher costs. For example, a tier 1 drug will usually have lower copays than a tier 3 drug. But it is important to note that this is not always the case—it is up to the individual insurance company to determine the benefits of a given tier level. For this reason, we advise our clients to be aware of what tier their medications fall into and what the copay or coinsurance will be for that tier level.
It is important to know if your Medicare plan includes a Part D deductible. If a deductible is included, it is important to know which tiers are affected by the deductible. Your plan will list which tiers are affected by the deductible in your Evidence of Coverage. The deductible amount must be approved by the Centers for Medicare and Medicaid Services (CMS).
If your plan has a deductible, the deductible needs to be satisfied before your insurance company will pay anything toward your medications. Once the deductible is met, you will begin paying the copays or coinsurances that are associated with the tier level of your medication. On some plans, the deductible only applies to specific drug tier levels as opposed to all tiers.
During Medicare’s Open Enrollment Period (OEP), Jan. 1 – Mar. 31, anyone on a Medicare Advantage (MA) plan can enroll in a different MA plan or disenroll from their current MA plan and return to Original Medicare. Individuals can only make one change to their plan during OEP. If a plan change is made, the new plan will go in effect the first of the following month.
Medicare’s Annual Enrollment Period (AEP) is for all individuals on any type of Medicare plan. AEP is from Oct. 15 to Dec. 7 each year. During this time, you can review your current Medicare plan and explore others that may better fit your needs or budget. If you choose, you can enroll in a new plan for the upcoming year. It is important to note any needs that may require an adjustment in coverage throughout the year, that way we can assist you once AEP comes.
When certain life events happen, Special Enrollment Periods (SEPs) allow you to make changes to your medical or prescription drug coverage. Some examples of qualifying life events are moving to a different location or losing other insurance coverage. If you would like to know more about SEPs, please reach out to us.