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Medicare FAQ

Medicare Basics

Q. When does a person qualify for Medicare?

A. Most people "age-in" to Medicare when they turn 65 and qualify for premium-free Part A and for Part B of Medicare, for which they pay a monthly premium. Others will qualify for Medicare due to disability prior to age 65. To qualify for "premium free" Part A, a person must have worked and paid into the Social Security system for a minimum of 40 quarters (10 years). Otherwise they may either pay a premium to get Part A or not be eligible for it.

Q. What do I need before I can buy insurance?

A. You need to have both Medicare Part A and Part B before you can purchase a Medicare Advantage plan or Medicare Supplement insurance. You sign up for Part A and Part B by contacting the Social Security Administration (www.ssa.gov).

Medicare Supplement Insurance

Q. What does Standardized Medigap plan mean?

A. Standardized plans mean that the benefits of the insurance plan are the same no matter what company you purchase the plan from. So a Plan F from company A has exactly the same benefits as a Plan F from company B. That makes it very easy to shop and compare Medicare Supplement insurance plans. And it is important to shop because the cost of the insurance can vary greatly between companies - sometimes over twice as much from one company to another.

Medicare Advantage Plans

Q. What is a Medicare Advantage Plan?

A. Medicare Advantage is Part C of Medicare. Here are the different versions.

  • HMO's have a network of physicians and hospitals that you must use and are the most restrictive.
  • PPO's have a network, which you probably would use most of the time, but they allow you to access care outside of the network with additional costs involved.
  • PFFS plans (Private Fee For Service) offer more mobility as you can use any Medicare approved Doctor or Hospital that agrees to accept the plan's payments. This approval needs to be obtained prior to each use. There is no network.
  • SNP's (Special Need Plans) offer unique benefits to those whose medical conditions qualify them for these plans. Conditions such as Cardiovascular, Dementia, COPD, Diabetes and more. Dual Eligible (Medicare and Medicaid) plans are sometimes offered in this group as well.
  • HSA's (Health Savings Accounts) offer benefits in a similar way but with the opportunity to fund the HSA with personal contributions as well as Medicare contributions.

With any Medicare Advantage Plan, it is the plan that determines what it will pay and what you will pay for the Medicare covered services. It may be higher or it may be lower than you would pay under Original Medicare, but you may also receive some additional benefits that you wouldn't get with Original Medicare (i.e., dental, vision, hearing and wellness benefits). Medicare Advantage Plans can come as Medical only (MA) being similar to having Parts A & B only or they may come bundled together with Prescription Drug coverage (MAPD).

Q. When can I sign up for a Medicare Advantage Plan?

A. Each year during the Annual Enrollment Period, Oct. 15 - Dec. 7, you can choose to begin enrollment in one of these plans or choose to switch plans. You can also sign up during your Initial Election Period if you are new to Medicare or because of a Special Enrollment Period. It is wise to consult a health plan advisor who can review your options each year as the Medicare Advantage Plans are annual plans and can change dramatically in coverage and cost.

Part D Prescription Drug Insurance

Q. I don't take medications; do I have to have a Part D prescription drug plan?

A. You don't have to buy a Part D drug plan, it is an option. But, remember medication needs can change quickly. So, you might want a low cost plan to provide basic protection. There is also a financial penalty for not signing up when you are first eligible. If you buy later, Medicare can impose a one percent penalty for every month you didn't enroll. If you have VA and employer group plans that qualify as "creditable coverage", this penalty will most likely not be assessed.

Losing Employer Benefits

Q. I have been covered by an employer group health plan (EGHP), union plan, teachers plan, etc. for a number of years and now it is ending. What are my options?

A. One important point here is whether the "ending" is voluntary or involuntary. In some states it won't matter, but in others it will be the difference in getting a Special Enrollment Period (SEP) with guaranteed issue for certain Supplement plans or being subject to medical underwriting for any Supplement plan because it ended voluntarily. It is best to speak with an advisor if you are considering continuing your group health insurance through COBRA. There are serious timing and eligibility considerations regarding your ability to get certain plans after COBRA.

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