Medicare Basics
What is Medicare?
Medicare is a federal health insurance program that gives you access to specific coverage and benefits. Medicare is different from health insurance you may have had before. It offers you a variety of coverage options And Medicare has key Enrollment Dates and Guidelines you need to follow. MedShep will help you make sense of it all.
How is Medicare Different From Other Health Insurance?
You may be surprised at the differences between Medicare and other types of health insurance. If you’ve had health coverage through your employer, your plan likely included medical and prescription drug coverage, along with other benefits. It also may have covered both you and your spouse.
Medicare ONLY covers one person at a time. This means you and your spouse must enroll separately. In addition, Medicare gives you options that can make it possible to receive your benefits in a variety of different ways.
You can:
Choose hospital and medical coverage delivered through the federal government.
Add prescription drug coverage delivered through a private company.
Purchase a supplemental insurance policy from a private insurer that can help cover some of the costs.
Choose coverage from a private insurer that combines hospital, medical and often prescription drug coverage into one plan.
Medicare enables you to choose coverage that fits your needs, budget and lifestyle. MedShep can help you take full advantage of that freedom.
Who is Eligible for Medicare?
Age 65 +
Under age 65 with certain disabilities
Have End-Stage Renal Disease (ESRD)
When and How Do I Enroll?
If you’re like most people, you’ll enroll in Medicare around the time you turn 65. Your Initial Enrollment Period begins three months before your 65th birthday, includes the month you turn 65 and ends three months after that birthday.
Keep in mind that if you don’t get Medicare during this Initial Enrollment Period, you may have to pay Medicare Part B or Part D late enrollment penalties. Plus, you could be missing out on coverage and benefits that can help protect your health and finances. That’s why it’s generally a good idea to enroll as soon you can. How you enroll generally depends on if you’re getting benefits from Social Security, the Railroad Retirement Board, the Office of Personnel Management or Medicaid.
If you’re receiving benefits from any of these sources at least four months before you turn 65.
You’ll automatically get Medicare Part A and Part B starting the first day of the month you turn 65.
If your birthday is on the first day of the month, Part A and Part B will start the first day of the prior month.
If you’re not receiving benefits from any of these sources at least four months before you turn 65.
You’ll need to sign up with Social Security to get Medicare Part A and Part B.
You can apply online at www.ssa.gov at your local Social Security office or by calling Social Security at 1-800-772-1213 (TTY: 1-800-325-0778).
If you worked for a railroad, call the RRB at 1-877-772-5772.
If you’re under age 65 and have a qualifying disability, you automatically get Part A and Part B.
After you get disability benefits from Social Security for 24 months.
After you get disability benefits from Social Security for 24 months.After you get certain disability benefits from the RRB for 24 months.
The month your disability benefits begin if you have ALS (Amyotrophic Lateral Sclerosis, also called Lou Gehrig’s Disease).
If you have End Stage Renal Disease (ESRD), you can choose to enroll i Part A and Part B.
You’ll need both Part A and Part B to qualify for the full benefits that cover certain dialysis and kidney transplant services.
You can apply online at www.ssa.gov at your local Social Security office or by calling Social Security at 1-800-772-1213 (TTY: 1-800-325-0778).
What If I Continue to Work Past the Age of 65?
Turning 65 doesn’t always mean you have to sign up for Medicare right away, especially if you’re still working. If you or your spouse are actively employed by a company with 20 or more employees and you’re receiving health insurance through that employer, you can:
Stay with the employer health plan as your primary coverage and delay Medicare enrollment.
Enroll in Medicare Part A and use it as secondary coverage to help pay for things the employer health plan doesn’t cover.
Choose to delay enrolling in Medicare Part B until the employment ends or the coverage stops, without paying late enrollment penalties if you enroll later.
What Are the Parts of Medicare?
Medicare has four different parts that provide coverage for specific services. Learning what each part covers can help you better understand your options and feel more confident about your decisions.
The Part A Premium for those who’ve worked and paid Medicare taxes for over 40 quarters is $0 per month. The Part A Premium for those who only worked and paid Medicare taxes for 30 - 39 quarters is $278 per month. The Part A Premium for those who only paid Medicare taxes for less than 30 quarters is $506 per month. The Medicare Part A Deductible per Benefit Period is $1,600 for 2023 and $1,632 for 2024. A Benefit Period is the consecutive days when Part A covered services furnished to a patient may be paid by Medicare.
The Part B Premium for most Medicare beneficiaries is $174.70 per month for 2024. The Part B Annual Deductible is $240 for 2024.
The Part B Premium may be higher if an individuals Modified Adjusted Gross Income (MAGI), reported on their IRS tax return from 2 years prior, is above $97K for a Single return and $194K for a Joint return. There are five (5) income-based levels above the base, each with a higher monthly cost for those who must pay more for their Part B premium. These levels are based on Social Security’s Income-Related Monthly Adjustment Amount {IRMAA) system. There IRMAA system is defined in detail the Social Security website at https://www.ssa.gov/benefits/medicare/medicare-premiums.html.
Note IRMAA also applies to Part D Premiums.
Types of Medicare - Side by Side Comparison
| Plan Option | What It Covers |
Pros | Cons |
|---|---|---|---|
| Original Medicare | Inpatient and outpatient health services, as outlined in the CMS guidelines. |
Extensive network of healthcare providers, administered by the government so you won’t have to change companies ever. | No vision, dental, hearing, or prescription coverage. Only covers a maximum of 80 percent of costs (after deductible) if you don’t purchase Medigap. |
| Medigap | High coinsurance and deductibles found in Original Medicare plans. | Makes Original Medicare affordable, protects you from large financial losses; Out-of-pocket cost limits. | Plan options come and go. If you have a plan that's no longer available to new enrollees, switching out means you can’t switch back. |
Medicare Advantage (Part C) |
Everything that Original Medicare covers. MA plans are alternatives to Original Medicare. Offered in the form of a PPO, HMO, or PFFS. |
May offer additional coverage options not available to Original Medicare enrollees; out-of-pocket cost limits; often has lower deductible amounts. Some MA plans offer additional benefits like Dental, Vision, Hearing Aid coverage as well as Transportation, OTC, etc. |
Insurance company administering the plan could lose its contract or decide not to offer Medicare products; may have excess charges; coverage limited to one service area. |
Prescription Drug (Part D) |
Specific medications as laid out in the plan’s Formulary. | Helps cover the cost of medications which saves seniors lots of money. Many low-cost options available | Not as valuable to people who don’t take medications. Formularies can change or drop a medication you take. |
Medicare Scope of Appointments
The Scope of Appointment (SOA) process is a crucial aspect of Medicare marketing and sales activities designed to protect the interests of Medicare beneficiaries and ensure compliance with regulations. The SOA process is primarily associated with Medicare Advantage (Part C) and Medicare Prescription Drug Plans (Part D) but can also apply to other Medicare-related products like Medicare Supplement Plans.
The Scope of Appointment is a document that outlines the specific topics and types of information that a Medicare sales agent or broker intends to discuss with a Medicare beneficiary during a face-to-face or telephone appointment. It is a critical tool to ensure that the beneficiary understands the purpose of the meeting and has consented to discuss certain Medicare-related topics.
A detailed description of the Medicare Scope of Appointment process is viewable at https://www.medshep.com/scope-appt.
