Here you'll find answers to common questions about Medicare, the different types of Medicare plans and plan coverage.
Yes, you still have Medicare when you enroll in a Medicare Advantage plan. However, you are giving permission to your insurance carrier to administer your Medicare coverage for all eligible services and supplies based on your plan benefits. Original Medicare does not process or pay claims while you are a member of a Medicare Advantage plan. If you disenroll from the Medicare Advantage plan, your Original Medicare benefits are again available to you.
Medicare supplement plans act as a secondary payer to Original Medicare. Medicare pays first and a Medicare supplement plan covers remaining eligible charges based on the benefits included with the plan.
Medicare Advantage plans act as the primary and only payer of claims. Original Medicare does not process or pay claims for services while you are a member of a Medicare Advantage plan.
Medicare Cost plans combine these two payment designs. For Part A claims, a Cost plan acts as a secondary payer to Original Medicare. For most Part B services, the Cost plan is the primary and only payer of claims.
When you enroll in a Medicare Advantage plan, you are giving permission to your insurance carrier to administer your Medicare coverage for all eligible services and supplies based on your plan benefits. If you disenroll from the Medicare Advantage plan, your Original Medicare benefits will again be available to you.
When you enroll in a Medicare Cost plan, you keep your Original Medicare coverage. For eligible Part A services, your Cost plan will coordinate benefits with Original Medicare. For most eligible Part B services and supplies, only your Cost plan will provide benefits. If your Cost plan requires you to use a network, you will still have Original Medicare benefits available to you outside the network, but you may be responsible for any costs that Medicare leaves behind.
No, your Medicare coverage will not be cancelled for this reason.
In some cases, you may be denied coverage based on your current or past medical conditions.
If you have received your Medicare card, it will tell you if you have both Part A and Part B and the effective dates of those benefits. If you are approaching your 65th birthday and have not received your Medicare card, contact your local Social Security office.
It depends on the type of plan you want to move to and when you want to move. Each type of plan has different eligibility and enrollment timeframes. Learn more about enrollment requirements for different types of Medicare plans.
A “health history” refers to questions that are asked in an enrollment application about your current and past health conditions. The type of plan that you’re enrolling in and when you choose to enroll determines whether a health history is required for enrollment.
If you intend to work past age 65, consider postponing your Part B benefits. Doing so allows you to keep various enrollment periods open to you for the future. Also, confirm with your employer whether prescription drug benefits on your group coverage are “creditable” when compared to the standard Part D benefit design. If you have “creditable” prescription coverage, you can also postpone enrolling in Part D and avoid a late enrollment penalty in the future. Learn more about enrollment periods for Original Medicare and different plan types.
The Social Security Administration automatically enrolls most people in Original Medicare when they request Social Security benefits. If you request Social Security benefits before age 65, your Medicare card will arrive about three months before your 65th birthday. However, you do not have to be retired to enroll in Original Medicare and you do not have to be receiving your Social Security benefits.
If you are approaching age 65 and want to enroll in Original Medicare but do not intend to request Social Security benefits, contact your local Social Security office to get your Medicare card.
Within the United States (outside of your plan’s service area), plan benefits will generally be accepted by any provider who accepts Original Medicare. Outside of the U.S., Original Medicare will generally not provide you with coverage. Foreign travel benefits vary by plan. You may be required to pay for services when they are received and submit a claim for reimbursement of eligible services when you return to the U.S. Depending on your plan, coverage limits may apply.
Outside of the U.S., Original Medicare will generally not provide you with coverage. Foreign travel benefits vary by plan, but most include an emergency care benefit for travel outside the U.S. You may be required to pay for services when they are received and submit a claim for reimbursement of eligible services when you return to the U.S.
Different plans have different residency requirements. Generally, Medicare Cost and Medicare Advantage plans require permanent residence in a specific service area to remain enrolled. Medicare supplement plans are usually portable, which means you can keep the plan even if you permanently move to another state.
No, your coverage will not be cancelled for this reason.
Plans for Medicare beneficiaries generally do not have a maximum lifetime benefit.
A deductible is a fixed dollar amount that you must pay for eligible services, supplies or prescription drugs before the plan begins paying for eligible charges.
Coinsurance is a percentage of the cost that you pay for eligible services, supplies or prescription drugs. For example, you may be responsible for paying 20 percent of an eligible cost and the plan pays the remaining 80 percent.
A copayment (copay) is a fixed dollar amount that you pay for eligible services, supplies or prescription drugs. For example, if you have a $10 doctor’s office visit copay on your plan, you pay the $10 when you visit the doctor and the plan pays the remaining cost.
An out-of-pocket maximum is an amount that you must pay for eligible services and supplies each calendar year before the plan pays 100 percent for eligible services and supplies for the remainder of the calendar year. Not all plans have an out-of-pocket maximum.
There are several ways you may be able to save on prescription drug costs to reduce the likelihood of reaching the coverage gap:
1. Ask your doctor or pharmacist if there is a generic version of your prescription that you can try. Generics are usually much less expensive than the brand-name version of a drug.
2. If there’s no generic available, ask your doctor if there is a similar brand-name medication that’s less expensive.
3. Ask your doctor for a 3-month prescription of any medications that you take daily. If your plan offers a 3-month supply for two copays, you’ll save on costs. And, if you pay coinsurance, purchasing a 3-month supply will generally result in additional savings too.
4. Ask your doctor if splitting tablets is an option for you. Your prescription may be available in a higher-dose which can be safely split without reducing quality, safety or effectiveness. Your medication would last twice as long for a comparable cost.
5. If your doctor is prescribing a new medication for you, ask to try samples first. If the prescription doesn’t have the desired results or you suffer side effects, you haven’t spent money on a prescription that you will not continue taking.
Although you may not take prescriptions now, enrolling in a Part D plan provides you with protection in the event that your situation changes. Also, a late enrollment penalty may be added to your Part D plan premium in the future if you do not have “creditable” prescription drug coverage.
Some Part D plans offer limited coverage in the coverage gap.
The Medicare Part D coverage gap sometimes called the “donut hole” is part of the standard Part D plan design. This coverage gap is designed to encourage beneficiaries to manage prescription drug costs to keep coverage as affordable as possible for everyone. In the standard plan design, once you and the plan have paid a certain amount in covered drugs for the year, you are generally responsible for paying 100 percent of the costs for covered drugs until you reach your annual out-of-pocket maximum. It’s also important to know that beginning in 2011, the retail price for many brand-name drugs in the coverage gap was discounted by up to 50% through agreements between the manufacturers and CMS. In the coming years, this gap will continue to be closed through larger discounts being applied. Not all brand drugs may be discounted. In addition, generic drugs will be discounted in the coverage gap.
People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for seventy-five (75) percent or more of your drug costs, including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t know it.
For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users call 1-877-486-2048.
If you don’t enroll in a Medicare Part D plan when you are first eligible, you may have to pay a late enrollment penalty. The late enrollment penalty is an additional premium cost added to the monthly premium of the Part D plan that you enroll in at a later date.
To avoid the late enrollment penalty you should enroll in a Part D plan when you are first eligible unless you have “creditable” prescription drug coverage. Creditable coverage is that which is as good as the standard Part D plan. If you have prescription drug coverage, check with your carrier to determine if it is creditable before making a Part D coverage decision.
Most plans provide dental benefits for Medicare-eligible services only. Routine dental care, including annual x-rays and cleanings, are generally not covered. Some plans, like Senior Gold offer optional dental coverage at an additional cost.
The term “in-network” refers to a provider that has a contract with the health plan. Using in-network providers generally gives members the highest level of benefits for eligible services and supplies.
The term “out-of-network” refers to a provider that does NOT contract with the health plan. Some plans still provide benefits for eligible charges at “out-of-network” providers but the member may share more of the cost than if they were using an “in-network” provider. Other plans may not pay for charges from an “out-of-network” provider unless they are due to a medical emergency.
Many plans provide benefits only when members use “network” providers. Network providers are doctors, specialists, clinics, hospitals and other health care providers or facilities that have signed a contract with the health insurance plan. They agree to accept members of the plan and the amounts the plan pays for eligible services. Different plans have different rules about use of in-network and out-of-network providers.