For those individuals who are approaching age 65 and for those who have delayed their Medicare Part B enrollment, this article is for you. Enrollment is automatic if you get Social Security. Otherwise, you need to apply for Medicare.
One of the interesting aspects of enrolling in Medicare is the fact that you apply for Medicare benefits through the Social Security Administration. The SSA processes each Medicare enrollment application because they have access to all of your personal information and it is more efficient for them to vet each prospective Medicare beneficiary first. Then, once your application has been approved, you will receive a letter confirming your enrollment and that you will be receiving your Medicare Card in the mail within the next two weeks.
Once your Medicare card has been issued, the majority of your contact concerning Medicare will be handled by Medicare. You will want to set up your own free Medicare Account on the Medicare website at www.medicare.gov. Here you can make a list of your medications and choose to receive information from Medicare.
It is also important to remind everyone that contrary to some long-held beliefs, Medicare is not entirely free. For 99% of Individuals applying, there is no cost for Medicare Part A, but everyone needs to pay for their Medicare Part B coverage each month. It does not matter whether you choose a Medicare Advantage plan or Original Medicare, everyone is responsible for paying the 2024 Medicare Part B monthly premium which is You can apply for Medicare directly using the www.ssa.gov website. Medicare by $174.70.
A QUICK REVIEW OF THE FOUR PARTS THAT MAKE UP MEDICARE
Medicare is the only National Insurance Program for Americans age 65 and older. Medicare consists of Medicare Part A, Medicare Part B, Medicare Part C, and Medicare Part D. Below is a brief synopsis of what each part of Medicare does and does not do for you.
MEDICARE PART A
The first part of Medicare is Medicare Part A. Simply put, Medicare Part A is what we receive for all of the years we have had Medicare and Social Security taxes deducted from our payroll checks during our working careers. And, some people who have not worked or have not accumulated 40 Quarters of work eligibility (10 Years of paying into Medicare) can easily qualify for their Part A benefits from their spouse's deductions.
Medicare Part A covers In-Patient Hospitalization. Part A pays for everything anytime you are admitted to the Hospital as an In-Patient. Occasionally, doctors may admit someone to the hospital for "Observation", which is not the same as being officially admitted as an In-Patient.
Medicare Part A pays for Hospital Room and Board, Meals, Medications, Surgery, and Anesthesia. Most typically this includes a semi-private room. If you have Original Medicare you can choose to go to any Hospital for care and if you are on a Medicare Advantage plan, you will need to go to a hospital facility in your plans network. If you go to a Hospital outside of your Medicare Advantage plans network, you will pay full price for all charges during your stay.
There is a $1,604 Deductible for Part A and most people will have that amount paid for if they choose Original Medicare with a Medicare Supplement or Medigap plan. Those choosing a Medicare Advantage plan will pay a daily Hospital Co-Insurance amount that varies from plan to plan. On average, this rate is between $295 - $395 per day for days 1-7 of any hospital stay.
MEDICARE PART B
Medicare Part B pretty much covers everything that is outside of a Hospital. These items are Doctor Office Visits, Imaging (X-rays, MRI's, CT Scans, etc., Blood Work, Lab Work, Preventative tests and procedures, all surgery and procedures in a Doctor's office or at an Out-Patient Surgical Center, and Durable Medical Equipment Crutches, Walker, Wheel Chairs, Oxygen, CPAP Machines, etc.
Some Injections are also covered under Medicare Part B but the majority of vaccines will be covered by Medicare Part D.
MEDICARE PART C
Medicare Part C refers to Medicare Advantage. If you choose to receive Medicare Benefits through a Medicare Advantage Plan, you have chosen Medicare Part C (Originally called Medicare Choice, hence Medicare Part C).
If you choose Medicare Part C, all of your Healthcare is controlled and your care is directed by your Insurance plan normally through your Primary Care Provider (PCP).
With Medicare Part C, you will choose either a Medicare Advantage HMO plan or a PPO plan. The biggest difference is HMO plans normally include Prescription Drug coverage (Medicare Part D), while most PPO plans do not. PPO plans are thought to be more flexible, allowing you to see any in-network doctor, without the need or hassle of getting a referral from your Primary Care Provider.
Most HMO plans have a $0 - Low Monthly Premium, while PPO plans are most often low-cost monthly premium options, but are rarely premium-free.
With Medicare Advantage plans (Medicare Part C), you will have Co-Insurance and C0-Pays for pretty much everything until you reach your plan MOOP Threshold. What in the heck is a MOOP? Good question, MOOP stands for Maximum-Out-Of-Pocket Expense. Meaning that you will pay your Co-Insurance and Co-Pays until you reach your annual MOOP, amount, which varies by plan. It is also important to note that everyone will have two MOOP amounts, one for In-Network and one for Out-Of-Network As a guideline, the lowest cost In-Network MOOP is around $2,800 per year while the national average is closer to $5,000, with the maximum being $9,600. So, once you meet your MOOP, your plan will pay for the remainder of the calendar year's costs, excluding your 20% Co-Insurance for Cancer Treatments (Chemotherapy and Radiation).
MEDICARE SUPPLEMENT/MEDIGAP PLANS
Original Medicare (Medicare Part A and Medicare Part B) is offered and managed by the government. With Original Medicare, the government pays 80% of your Healthcare Costs under Medicare Part A and Part B and you are responsible for the remaining 20%, which is where Medigap or Medicare Supplements as they are referred to come in. These plans (depending on which one you choose, 90% of people choose either Plan G or Plan N). This combination is the most comprehensive Healthcare Plan you can have. You can go to any Hospital and see any Doctor in the United States, and the Supplement will pay the Medicare Part A deductible for you. Adding a Medicare Plan G will cost the majority of 65-year-olds around $100-$140 per month. But, outside of the annual Part B deductible of $240, all of your Hospital and Outpatient costs will be $0. And a Plan N has a few restrictions and costs $30 less per month.
Medigap and Medicare Supplement plans are one and the same, it just depends on how you refer to them. And, these plans are all standardized, meaning that every Plan N is the same across the country and every Plan G is identical in all 50 states. The only difference is what each plan costs where you live.
Many people fall for the glitter and glamor of the Free, Extra, and/or Additional benefits that Medicare Advantage plans offer. But, I have to share with all of you that having Original Medicare, with a Medicare Supplement Plan G, and a $5,000 Dental/Vision/Hearing Insurance policy, will cost you in the neighborhood of $2,160 per year. Compare that with what your MOOP amounts are with any Medicare Advantage plan and I think you will quickly see that the most comprehensive and the most flexible healthcare plan, that keeps you in control of who you see and where you go and is without question is the best overall value with the lowest overall costs is having Original Medicare paired with Medicare Supplement Plan G.
The two best parts of choosing a Medicare Supplement policy are that #1. You never have to go through the headache of re-enrolling in Original Medicare or in a Medicare Supplement year after year. It is your plan and as long as A) you are happy with your plan and B) you are paying your premium, it is your plan forever. And #2, that all of your Medicare Plan Premiums, Medicare Supplement Plan Premiums, and All OTC Costs for Band-aids, Cough Medicine, Vitamins, and Aspirin are all 100% Tax Deductible, as long as you itemize your deductions. All of your Dental, Vision, and Hearing costs are also tax deductible. We always recommend shopping your Supplement every 3 years or so to compare prices to ensure you are not overpaying.
NOTE: Both Medicare Advantage Plans and Medicare Supplement Plans are offered by Private Insurance Companies, not the government.
MEDICARE PART D
The last part of Medicare is Medicare Part D. The easiest thing to associate with Part D is that D refers to Drugs. Part D of Medicare covers your Prescription Drug medications, much like you had with your employer's Group Health plan.
If you choose Original Medicare, you will need to enroll in a Medicare Part D Prescription Drug Plan within 63 Days of your Medicare Part B effective date or face a penalty for late enrollment, which you will have for the rest of your life. This penalty comes out to be about $.38 per month for each month you did not have a Part D Drug plan. That amount is then added to the monthly premium for your Medicare Part D Drug Plan premium once you choose one.
Plan choices vary where you live in the US. There are a few $0 to $10 monthly premium plans that are ideal for those with little or generic medications. For those individuals with more expensive and brand-name prescriptions, Medicare Part D Drug Plans can range from $22.90 - $169.00 a month. Note, this premium is just to join the plan, the cost of Medications will vary, most Generic medications will be $0 - $5.00 but many medications can cost hundreds or thousands of dollars depending on your plan and whether or not you have met your plans deductible for the year.
Every year in the fall from October 15th - December 7th, you should review your Prescription Drugs with your Medicare Broker/Agent and choose a new plan for the following calendar year, beginning on January 1st every year.
YOUR MEDICARE CARD
Your Red, White, and Blue Medicare Card will contain your own, individual and Unique Medicare Number. This is similar to your SSN except, it contains a combination of both Letters and Numbers.
Your Medicare Card will also show Your Medicare Part A Effective Date (Typically the first day of your Birth Month when you turn 65) and your Medicare Part B Effective Date.
IF YOU ARE ALREADY RECEIVING SOCIAL SECURITY BENEFITS
If you’ve received Social Security for at least four months before age 65, you’ll automatically get Medicare Part A and Part B when you turn 65. You’ll have the option to delay Part B if you have other qualifying health coverage.
And, If you’ve applied for Social Security, but you haven’t gotten benefits for that long, you’ll automatically be enrolled in Medicare Part A when you become eligible for Medicare. You’ll have to apply for Part B.
IF YOU ARE NOT RECEIVING SOCIAL SECURITY BENEFITS YET
If you aren't receiving Social Security yet, you can apply for Medicare once you're eligible in one of three ways:
- Apply for Medicare online at the Social Security website. (This is the fastest method.)
- You will need to complete CMS Form 40B and possibly CMS Form L564 and submit them to your local Social Security Office. If you are working with a licensed Medicare Broker, they can assist you with this process. Enlisting your Broker to assist you is only a day or two slower than you navigating through the Social Security Administration website. And, you will still need to upload either your completed CMS Form 40B or CMS Form L564 if you are either voluntarily or involuntarily leaving your employer's health plan. by Call Social Security at 800-772-1213. (TTY 800-325-0778.)
- Contact your local Social Security office. You can request a time to set-up a meeting with a SSA representative at your nearest SSA office, but this is not necessary and can delay the process by 4-6 weeks.
The online application typically takes less than 10 minutes, provided you have the forms already completed and uploaded to your files. Additionally, if you set up an account on the SSA.gov website many years ago and do not remember the password you used, it could end up being problematic. If this is the case, contact your licensed, independent Medicare broker and enlist their help in getting enrolled as expeditiously as possible.
Visiting a local Social Security office could mean waiting in a long line, and the Social Security Administration encourages people not to show up without an appointment.
WHAT IF YOU HAVE BEEN RECEIVING DISABILITY AND ALREADY HAVE MEDICARE BEFORE REACHING AGE 65?
Medicare is also available to younger people who get Social Security disability benefits, or SSDI. Usually, they’re enrolled in Medicare automatically after 24 months of disability benefit eligibility.
However, depending on what state you reside in, your state determines if you receive Medicare benefits directly from Medicare with a Medicare Supplemental policy which is also referred to as Medigap. Or, if you have been receiving Medicare benefits through Medicare Part C/Medicare Advantage.
When you do turn 65, you can choose for yourself whether you want to get your Healthcare from Original Medicare with a Medicare Supplement/Medigap plan, or if you prefer to receive Medicare via a Medicare Advantage Plan.
SIGN UP & ENROLL IN MEDICARE DURING YOUR INITIAL ENROLLMENT PERIOD (IEP)
If you’re not enrolled automatically, you should sign up in the three months before your 65th birthday. That way, coverage will start on the first day of your birthday month (unless you were born on the first day of the month, in which case coverage begins on the first day of the prior month).
You technically have seven months around your 65th birthday to enroll: the three months before your birthday month, your birthday month, and the three months after. This is called your initial enrollment period. If your birthday is the first of the month, your initial enrollment period includes the four months before your birthday month and two months after.
If you wait until your birthday month or the three months afterward to apply for Medicare, your coverage will start the following month. If you miss your initial window, you will need to sign up during Medicare's general enrollment period. However, you may be subject to a permanent penalty unless you have continuous coverage from a large employer group health insurance plan.
IF YOU ARE APPLYING DURING THE GENERAL ENROLLMENT PERIOD
If you don't apply during your initial enrollment period for Parts A and B and you're not eligible for a SEP (Special Enrollment Period), you'll have to wait for Medicare's general enrollment period to sign up. This is different from the annual open enrollment period, which runs from Oct. 15 to Dec. 7 each year.
The general enrollment period runs from Jan. 1 to March 31 every year. Coverage doesn't start until the month after you sign up, and late penalties may apply. You will also pay for any health costs you incur during the time you were uninsured before your coverage begins.
MEDICARE DOES HAVE PENALTIES THAT CAN BE HANDED OUT IF YOU ARE UNINFORMED
If you’re not automatically enrolled in Medicare and you don’t apply on time, you may face late enrollment fees:
- Medicare Part A: If you must buy Part A and you don’t purchase it during your initial enrollment period, you may owe 10% more than the monthly premium for twice the time period you didn’t sign up.
- Medicare Part B: If you don’t sign up for Part B during your initial enrollment period, your monthly premium increases 10% for each 12-month period that you went without Part B coverage. This is a permanent penalty as long as you have Part B.
- Medicare Part D: If you go without Medicare drug coverage or other creditable prescription drug coverage for 63 or more days once your initial enrollment period ends, you'll be assessed a permanent penalty for as long as you have Medicare drug coverage. The penalty is calculated as 1% of the “national base beneficiary premium” multiplied by the number of full months you weren’t covered. (There is no cap. If you don’t think you need Part D for 72 months, that’s a 72% penalty.) Your exact penalty amount is recalculated each year.
YOU DID IT, YOU GOT ENROLLED IN MEDICARE, NOW WHAT?
Hopefully, you already found an Agent you like or you are working with a licensed, independent Medicare Broker like us at Braden Medicare. If not, our sincere and honest suggestion is that you search on Google and find a few local Independent Medicare Brokers in your area.
Look at their website, sift through some of the information, and see if you think you would be comfortable speaking with them. Any reputable broker will have been in business for a minimum of 3-5 years. If they do not offer an appealing and organized website, then you run Forest, Run! If it looks like the website is nothing more than a landing page, keep moving. Read their about us section, look to see if they have a Blog or have any articles written, spend about 10-15 looking through their site, and make an educated decision, based on what you see, you are in control. Then either email them or give them a call to discuss things. Ask them how a Broker can help you with the next steps.
What is the difference between an Agent and a Broker? An agent will most typically only work for one or maybe two Insurance companies. So, that means that legally, they can only market and sell those companies' products. On the other hand, a broker typically has multiple companies that they are contracted with. Using us at Braden Medicare as one example, we are contracted with over 34 Insurance Carriers.
We represent what we believe are the best companies to partner with, including Aetna, Allstate, Aflac, AARP, ACE, Anthem, Amerigroup, Banner, BCBS, Bankers Fidelity, Cigna, Globe Life, Gold Kidney, Humana, Lumico, Manhattan Life, Medico, Mutual of Omaha, Nassau, Royal Arcanum, United American, United Healthcare and National General to name a few. We are also licensed to sell every available Medicare Part D Plan in every state we are licensed. It takes a lot more time and commitment to do this, but we believe it is the best way to justly service our clients.
Having multiple options really is a huge advantage so you can ensure you are not overpaying and to ensure that you have the best variety of plans and plan options to choose from.
Working with a Broker is 100% free! It's true! You see, the way Medicare Insurance works is that there is a built-in commission rate pre-determined by each Insurance Company and approved by Medicare and their States Department of Insurance. So, whoever writes the application, receives the commission. Whether you are working with a local licensed Agent or Broker or if you thought it was better to call a company's 1-800 Number and get transferred to an agent, you never get a cheaper rate. This is why it just makes good common sense to work with a professional who actually cares about their clients, respects the Medicare process, and is dedicated to serving others!
FAQ & ANSWERS.......................
DOES MEDICARE COVER VISION CARE?
Medicare does not cover Routine Vision. We define Routine Vision as what you do at an optometrist's office or at an Eye Care Center. However, Medicare does cover anything you would have done at an Ophthalmologist's Office, including Cataract Surgery, Glasses for Post Cataract Surgery, Glaucoma, and Macular Degeneration.
DOES MEDICARE COVER DENTAL CARE?
No, Medicare does not cover Routine Dental Services or Preventative Dental services. They will cover dental work that is a result of an accident or TMJ. Medicare Advantage Plans offer a variety of Dental, Vision, and Hearing coverage based on the individual plan. These are advertised to entice people over to Medicare Advantage plans, but they are slick. While not illegal, many of their advertising campaigns are misleading and contain insufficient information which is unfair to the consumer. For example, a $2,000 Annual Dental Benefit usually = $500 in Dental Benefits each Quarter, and; if you do not use them up, the benefits do not roll over to the next quarter.
WILL MEDICARE PAY FOR MY CPAP MACHINE?
Yes, however, each Insurance company has its own list of equipment providers that you must use. And, these companies are often not the same as you have used in the past or that you may currently be using.
WILL MEDICARE COVER PHYSICAL THERAPY?
Original Medicare covers an unlimited amount of Physical Therapy appointments as long as your Doctor attests to the fact that the treatments are necessary and that you are improving. Medicare Advantage plans will typically cap Physical Therapy at 10 Appointments.
HOW CAN MEDICARE ADVANTAGE PLANS OFFER OTHER BENEFITS THAT ORIGINAL MEDICARE CAN NOT OR DO NOT OFFER?
The honest-to-goodness truth is that Medicare Advantage Companies get paid $1,000 each month for every Medicare Advantage member they have enrolled in one of their Medicare Advantage plans. These payments are authorized by the government, in exchange for the insurance companies assuming the financial risks of managing a member's healthcare.
These private insurance companies, use this money to fuel and fund their advertising campaigns and stay profitable. This is also why they have so many co-pays and co-insurance and require 2nd, 3rd, and even 4th opinions for some procedures. Historically, the majority of Medicare Advantage Insurers receive high marks from healthy members, but much lower marks if a member has had or is currently having problematic health issues.
WILL MEDICARE MAIL ME MY PRESCRIPTION MEDICATIONS?
Yes, both Medicare and Medicare Advantage can mail you your Quarterly supply of Prescription Medications using their own approved, Mail Order Pharmacy.
And, if you are familiar with utilizing Pill Pack from Amazon, You can call Pill Pack directly and request that they send you your Quarterly Medications.
Signing up for Medicare online takes as little as 10 minutes, and you typically need no documentation. You’ll need your Social Security number, birth city, and start and end dates for any current group health insurance plans or any group health plans after age 65.
WHICH IS BETTER, ORIGINAL MEDICARE OR MEDICARE ADVANTAGE?
You realize this is the sort of question that gets the most politically correct answer from the majority of Medicare Brokers. My answer is based on my 8+ years as an Independent Medicare Broker and as someone who has regular interactions with Insurance Companies, Clients, Hospitals, and Doctors, not to mention my own firsthand experience.
There is not even a comparison in my mind. Original Medicare is far and away superior to any Medicare Advantage Plan. Although, some SNP (Special Needs Plans) are the best option for members with Special and Unique care needs.
Healthcare professionals, Police, Firefighters, and Healthcare professionals often refer to Medicare Advantage as MEDICARE DISADVANTAGE for a reason! Many elite and specialty hospitals do not accept Medicare Advantage plans at all.
Overall, Medicare Advantage Plans are difficult to deal with they are famous for denying claims, denying care demanding multiple referrals, and doing anything they can to turn a profit instead of putting the patient's best needs front and center.
Lastly, two other things drive me crazy as a broker. People who decide they are healthy will join an MA/MAPD plan to save some money, then switch to a Medicare Supplement plan later. But, then something happens that makes them ineligible to enroll in a Medicare Supplement or Medigap plan on down the road. This happens a lot more often than anyone would think, and it makes me sick that they were not happy with a bird in the hand, instead, they opted for trying to get the two birds in the bush. The last thing has to do with Cancer Treatments. There is a 20% Co-Insurance for any and all Cancer Treatments for every Medicare Advantage Plan. And, in the fine print in the Explanation of Benefits section of each Medicare Advantage Policy, you will find that this 20% Co-Insurance for Cancer Treatments, meaning Radiation and Chemo is required even if/after the member meets their MOOP for the year!
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