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What is Medicare?
Medicare is our country’s health insurance program for people age 65 or older. Certain people
younger than age 65 can qualify for Medicare, too, including those who have disabilities and those who have
permanent kidney failure or amyotrophic lateral sclerosis (Lou Gehrig’s disease). The program helps with the cost
of health care, but it does not cover all medical expenses or the cost of most long-term care.
Medicare is financed by a portion of the payroll taxes paid by workers and their employers.
It also is financed in part by monthly premiums deducted from Social Security checks.
The Centers for Medicare & Medicaid Services is the agency in charge of the Medicare program.
But you apply for Medicare at Social Security, and we can give you general information about the Medicare program.
Medicare has four parts
- Hospital insurance (Part A) that helps pay for inpatient care in a hospital or skilled nursing facility
(following a hospital stay), some home health care and hospice care.
- Medical insurance (Part B) that helps pay for doctors’ services and many other medical services and supplies
that are not covered by hospital insurance.
- Medicare Advantage (Part C) formerly known as Medicare + Choice plans are available in many areas. People
with Medicare Parts A and B can choose to receive all of their health care services through one of these
provider organizations under Part C.
- Prescription drug coverage (Part D) that helps pay for medications doctors prescribe for treatment.
You can get more detailed information about what Medicare covers from Medicare & You (Publication No. CMS-10050).
To get a copy, call the Medicare toll-free number, 1-800-MEDICARE (1-800-633-4227), or go to
www.medicare.gov. If you are deaf or hard of hearing, you may call
TTY 1-877-486-2048.
A word about Medicaid
You may think that Medicaid and Medicare are the same. Actually, they are two different
programs. Medicaid is a state-run program that provides hospital and medical coverage for people with low income
and little or no resources. Each state has its own rules about who is eligible and what is covered under Medicaid.
Some people qualify for both Medicare and Medicaid. For more information about the Medicaid program, contact your
local medical assistance agency, social services or welfare office.
Who can get Medicare?
Hospital insurance (Part A)
Most people age 65 or older who are citizens or permanent residents of the United States are
eligible for free Medicare hospital insurance (Part A). You are eligible at age 65 if:
- You receive or are eligible to receive Social Security benefits; or
- You receive or are eligible to receive railroad retirement benefits; or
- You or your spouse (living or deceased, including divorced spouses) worked long enough in a government job where
Medicare taxes were paid; or
- You are the dependent parent of someone who worked long enough in a government job where Medicare taxes were paid.
If you do not meet these requirements, you may be able to get Medicare hospital insurance by
paying a monthly premium. Usually, you can sign up for this hospital insurance only during designated enrollment
periods.
NOTE: Even though the full retirement age is no longer 65, you should sign up for Medicare three months before
your 65th birthday.
Before age 65, you are eligible for free Medicare hospital insurance if:
- You have been entitled to Social Security disability benefits for 24 months; or
- You receive a disability pension from the railroad retirement board and meet certain conditions; or
- You have Lou Gehrig’s disease (amyotrophic lateral sclerosis); or
- You worked long enough in a government job where Medicare taxes were paid and you meet the requirements of
the Social Security disability program; or
- You are the child or widow(er) age 50 or older, including a divorced widow(er) of someone who has worked
long enough in a government job where Medicare taxes were paid and you meet the requirements of the Social
Security disability program.
- You have permanent kidney failure and you receive maintenance dialysis or a kidney transplant and:
- You are eligible for or receive monthly benefits under Social Security or the railroad retirement
system; or
- You have worked long enough in a Medicare-covered government job; or
- You are the child or spouse (including a divorced spouse) of a worker (living or deceased) who has
worked long enough under Social Security or in a Medicare-covered government job.
Medical insurance (Part B)
Anyone who is eligible for free Medicare hospital insurance (Part A) can enroll in Medicare
medical insurance (Part B) by paying a monthly premium.
If you are not eligible for free hospital insurance, you can buy medical insurance, without
having to buy hospital insurance, if you are age 65 or older and you are—
- A U.S. citizen; or
- A lawfully admitted noncitizen who has lived in the U.S. for at least five years.
Medicare Advantage plans (Part C)
If you have Medicare Parts A and B, you can join a Medicare Advantage (formerly Medicare +
Choice) plan. With one of these plans, you do not need a Medigap policy, because Medicare Advantage plans generally
cover many of the same benefits that a Medigap policy would cover, such as extra days in the hospital after you have
used the number of days that Medicare covers.
Medicare Advantage plans include:
- Medicare managed care plans;
- Medicare preferred provider organization (PPO) plans;
- Medicare private fee-for-service plans; and
- Medicare specialty plans.
If you decide to join a Medicare Advantage plan, you use the health card that you get from your Medicare
Advantage plan provider for your health care. Also, you might have to pay a monthly premium for your Medicare
Advantage plan because of the extra benefits it offers.
People who become newly entitled to Medicare can enroll during their initial enrollment period or during the
annual coordinated election period from November 15 – December 31 each year. There also will be special enrollment
periods for some situations.
Medicare prescription drug plans (Part D)
Anyone who has Medicare hospital insurance (Part A), medical insurance (Part B) or a Medicare
Advantage plan is eligible for prescription drug coverage (Part D). Joining a Medicare prescription drug plan is
voluntary, and you pay an additional monthly premium for the coverage. You can wait to enroll in a Medicare Part D
plan if you have other prescription drug coverage but, if you don’t have prescription coverage that is, on average,
at least as good as Medicare prescription drug coverage, you will pay a penalty if you wait to join later. You will
have to pay this penalty for as long as you have Medicare prescription drug coverage.
The initial open enrollment period is between November 15 and May 15. People who become newly entitled to Medicare
should enroll during their initial enrollment period. After the initial enrollment periods, the annual coordinated
election period, to enroll or make provider changes will be November 15 – December 31 each year. There also will be
special enrollment periods for some situations.
Help for some low-income people
If you cannot afford to pay your Medicare premiums and other medical costs, you may be able
to get help from your state. States offer programs for people who are entitled to Medicare and have low income.
The programs may pay some or all of Medicare’s premiums and also may pay Medicare deductibles and coinsurance. To
qualify, you must have Part A (hospital insurance), a limited income, and, in most states, your resources, such as
bank accounts, stocks and bonds, must not be more than $4,000 for a single person or $6,000 for a couple.
If you are not sure if you have Part A, look on your red, white and blue Medicare card. It will show “Hospital
(Part A)” on the lower left corner of the card. If you are still not sure, you can call Social Security toll-free.
You can get more information about these programs from the Centers for Medicare & Medicaid Services (CMS). Ask
for a copy of You could save in Medicare expenses (Publication No. CMS-10126) by calling the Medicare toll-free
number, 1-800-MEDICARE (1-800-633-4227). If you are deaf or hard of hearing, you may call TTY 1-877-486-2048.
Only your state can decide if you qualify for help under these programs. To find out, contact your state or local
medical assistance (Medicaid) agency, social services or welfare office.
You also may be able to get extra help paying for the annual deductibles, monthly premiums and prescription
co-payments related to the Medicare prescription drug program (Part D). You may qualify for extra help if you
have limited income (tied to the federal poverty level) and limited resources. These income and resource limits
change each year, and you can contact us for the current numbers.
If you have both Medicaid with prescription drug coverage and Medicare, Medicare and Supplemental Security
Income, or if your state pays for your Medicare premiums, you automatically will get this extra help and you
don’t need to apply.
For more information about getting help with your prescription drug costs, call Social Security’s toll-free
number or visit our website. You also can apply online at Social Security’s website.
Signing up for Medicare
When should I apply?
If you are already getting Social Security retirement or disability benefits or railroad
retirement checks, you will be contacted a few months before you become eligible for Medicare and given the
information you need. You will be enrolled in Medicare Parts A and B automatically. However, because you must pay a
premium for Part B coverage, you have the option of turning it down.
If you are not already getting retirement benefits, you should contact us about three months before your 65th
birthday to sign up for Medicare. You can sign up for Medicare even if you do not plan to retire at age 65.
Once you are enrolled in Medicare, you will receive a red, white and blue Medicare card showing whether you have
Part A, Part B or both. Keep your card in a safe place so you will have it when you need it. If your card is ever
lost or stolen, you can apply for a replacement card on the Internet at
www.socialsecurity.gov or call Social Security’s toll-free number. You will also receive a
Medicare & You (Publication No. CMS-10050) handbook hat describes your Medicare benefits and Medicare plan
choices.
Special enrollment situations
You also should contact Social Security about applying for Medicare if:
- You are a disabled widow or widower between age 50 and age 65, but have not applied for disability benefits
because you are already getting another kind of Social Security benefit;
- You are a government employee and became disabled before age 65;
- You, your spouse or your dependent child has permanent kidney failure;
- You had Medicare medical insurance in the past but dropped the coverage; or
- You turned down Medicare medical insurance when you became entitled to hospital insurance (Part A).
Initial enrollment period for Part B
When you first become eligible for hospital insurance (Part A), you have a seven-month
period (your initial enrollment period) in which to sign up for medical insurance (Part B). A delay on your part
will cause a delay in coverage and result in higher premiums. If you are eligible at age 65, your initial enrollment
period begins three months before your 65th birthday, includes the month you turn age 65 and ends three months
after that birthday. If you are eligible for Medicare based on disability or permanent kidney failure, your initial
enrollment period depends on the date your disability or treatment began.
When does my enrollment in Part B become effective?
If you accept the automatic enrollment in Medicare Part B, or if you enroll in Medicare Part B
during the first three months of your initial enrollment period, your medical insurance protection will start with
the month you are first eligible. If you enroll during the last four months, your protection will start from one to
three months after you enroll.
The following chart shows when your Medicare Part B becomes effective:
| If you enroll in this month of your Initial enrollment period: |
Then your Part B Medicare coverage starts: |
| 1 |
The month you become eligible for Medicare |
| 2 |
The month you become eligible for Medicare |
| 3 |
The month you become eligible for Medicare |
| 4 |
One month after enrollment |
| 5 |
Two months after enrollment |
| 6 |
Three months after enrollment |
| 7 |
Three months after enrollment |
|
General enrollment period for Part B
If you do not enroll in Medicare Part B during your initial enrollment period, you have
another chance each year to sign up during a “general enrollment period” from January 1 through March 31. Your
coverage begins the following July. However, your monthly premium increases 10 percent for each 12-month period you
were eligible for, but did not enroll in, Medicare Part B.
Special enrollment period for people covered under an employer group health plan
If you are 65 or older and are covered under a group health plan, either from your own or your spouse’s current
employment, you have a “special enrollment period” in which to sign up for Medicare Part B. This means that you may
delay enrolling in Medicare Part B without having to wait for a general enrollment period and paying the 10 percent
premium surcharge for late enrollment. The rules allow you to:
- Enroll in Medicare Part B any time while you are covered under the group health plan based on current
employment; or
- Enroll in Medicare Part B during the eight-month period that begins with the month your group health coverage
ends, or the month employment ends—whichever comes first.
Special enrollment period rules do not apply if employment or employer-provided group health plan coverage ends
during your initial enrollment period.
If you do not enroll by the end of the eight-month period, you will have to wait until the next general enrollment
period, which begins January 1 of the next year. You also may have to pay a higher premium, as described in General
enrollment period for Part B.
People who receive Social Security disability benefits and are covered under a group health plan from either their
own or a family member’s current employment also have a special enrollment period and premium rights that are
similar to those for workers age 65 or older.
Options for receiving health services
Medicare beneficiaries may have choices for receiving health care services.
You can get more information about your health care options from the following publications:
- Medicare & You (Publication No. CMS-10050)—This general guide is mailed to people after they enroll in
Medicare and an updated version is mailed each year after that.
- Choosing a Medigap Policy : A Guide To Health Insurance For People With Medicare (Publication No.
CMS-02110)—This guide describes how other health insurance plans supplement Medicare and offers some
shopping hints for people looking at those plans.
To get a copy of these publications, call the Medicare toll-free number, 1-800-MEDICARE (1-800-633-4227), or
go to www.medicare.gov. If you are deaf or hard of hearing, you may call TTY 1-877-486-2048.
If you have other health insurance
Medicare hospital insurance is free for almost everyone, but you do pay a monthly premium for
medical insurance. If you already have other health insurance when you become eligible for Medicare, is it worth the
monthly premium cost to sign up for Medicare medical insurance?
The answer varies with each person and the kind of other health insurance you may have. Although we cannot give you
“yes” or “no” answers, we can offer a few tips that may be helpful when you make your decision.
If you have a private insurance plan
Get in touch with your insurance agent to see how your private plan fits with Medicare medical insurance. This is
especially important if you have family members who are covered under the same policy. And remember, just as
Medicare does not cover all health services, most private plans do not either. In planning your health insurance
coverage, keep in mind that most nursing home care is not covered by Medicare or private health insurance policies.
One important word of caution: for your own protection, do not cancel any health insurance you now have until your
Medicare coverage actually begins.
If you have insurance from an employer-provided group health plan
Group health plans of employers with 20 or more employees are required by law to offer workers and their spouses
who are age 65 (or older) the same health benefits that are provided to younger employees.
If you are currently covered under an employer- provided group health plan, you should talk to your personnel
office before you sign up for Medicare medical insurance.
If you have health care protection from other plans
If you have coverage under a program from the Department of Defense, your health benefits may change or end when
you become eligible for Medicare. You should contact the Department of Defense or a military health benefits
advisor for information before you decide whether to enroll in Medicare medical insurance.
If you have health care protection from the Indian Health Service, Department of Veterans Affairs or a state medical
assistance program, contact the people in those offices to help you decide whether it is to your advantage to have
Medicare medical insurance.
For more information on how other health insurance plans work with Medicare, call the Medicare toll-free number
1-800-MEDICARE (1-800-633-4227) and ask for Medicare And Other Health Benefits: Your Guide To Who Pays First
(Publication No. CMS-02179) or visit www.medicare.gov. If
you are deaf or hard of hearing, you may call TTY 1-877-486-2048.
This information is taken from the booklet “Medicare” published in the public interest by the Social Security
Administration. http://www.ssa.gov/mediinfo.htm
Source: www.medicare.gov – The official U.S. site for people with Medicare
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