New to Medicare Enrollment Criteria
The initial Enrollment Period for Medicare is three months before, the month of, and three months after your 65th birthday. If you are not receiving a Social Security benefit due to age or disability, you will need to contact Social Security to enroll in Medicare. The enrollment may be done at www.ssa.gov, by phone at 1-800-722-1213 or in person at your local Social Security office. If you are a younger person receiving a Social Security Disability (SSDI) check, you will automatically receive your Medicare card about three months before the 25th month of receiving the SSDI check. If you had elected to receive your Social Benefit retirement benefit prior to 65, you too will automatically receive your Medicare card about three months before your 65th birthday.
For more information, please watch the following video designed for persons new to Medicare.
Medicare Part A
Help Pays for Hospital Stays, Skilled Nursing Facility, Home Health Care, Hospice care
- You can enroll in Medicare Part A at age 65.
- if you have worked at least 10 years under Medicare- or Social Security-covered employment, the Part A benefit will be "free," because you paid toward Part A while you worked. If you have never worked, but your spouse has worked 40 quarters (10 years), you can apply for Medicare A by using your spouse’s work record.
- If you had elected to receive your Social Security retirement benefit before you turned 65, you will automatically be enrolled in Medicare A and B. Your card will arrive about three months prior to your 65th birthday. Likewise, you will automatically receive your Medicare card several months before you reach the 25th month of receiving your Social Security disability benefit.
- If you are not receiving a Social Security benefit, you will need to enroll in Medicare through Social Security.
- If either you or your spouse is actively working and the employer is providing group health coverage, you may proceed to sign up for just Part A. If you have worked 10 years and paid the FICA tax, the Part A will be premium-free and will serve as a secondary to your group health insurance.
Note: If your employer has fewer than 20 employees, check with the benefits administrator, you may be required to sign up for Medicare A and B and the Medicare will by primary. Similarly, if you have Social Security Disability benefit and the employer has fewer than 100 employees, you may be required to sign up for Medicare and the Medicare will be primary.
- Do not sign up for Part A if your employer coverage is through a Health Saving Account (HSA). You can not contribute to an HSA and receive Medicare. (If you are entitled to premium-free Part A, there is not a penalty for delaying Part A enrollment.)
Medicare Part B
Pays for doctors medical, and other services (For example: physical therapy, occupational therapy, etc., lab service, home health care, outpatient hospital services, blood)
- If you are already receiving benefits from Social Security, you will be automatically enrolled in Medicare A and B starting the first day of the month you turn 65 or the 25th month you receive your Social Security Disability check. (If you elect not to receive Part B, because you or your spouse is actively working and has group health insurance through an employer, you can complete the reverse side of the Medicare card and return it to SSA) .
- If you are not receiving a Social Security check, three months before you reach age 65, you should contact Social Security to enroll in Medicare A and B. Although you have a seven-month window (three months before, the month of, and three months after your 65th birthday) to sign-up for Medicare A and B, it is best to sign up early to avoid a delay in the start of your benefits.
- If you did not take Part B when you were first eligible for Medicare at age 65, you may sign up during a General Enrollment Period. This period runs from January 1 through March 31, of each year. Due to the Part B penalty, the cost of your Medicare Part B may go up 10 percent for each twelve-month period that you could have had Part B but did not take it. Your Part B coverage would become effective the following July and you will have to pay the extra 10 percent for the rest of your life.
- The only time you may delay Part B enrollment without a penalty is if you or your spouse is actively employed and the employer is providing group health insurance. You may sign up for Part B at any time while you are working and have the group health coverage. You may also sign up for Part B during a Special Part B Enrollment period which lasts eight months from the time the employer coverage ended. You will need to contact the Social Security office to enroll in Part B and to obtain the paperwork which must be signed by your employer to certify that you have had group health coverage since age 65 or the 25th month of receiving your Social Security Disability benefit..
Medicare Part D
Prescription drug coverage is available to everyone with Medicare. Insurance companies and other private companies approved by Medicare offer the drug plans. Drug plans will vary in monthly premiums, list of covered drugs, deductibles and co-pays and pharmacies accepting the plan.
- The beneficiary should sign up during the seven-month Initial Enrollment Period that begins three months before the month in which the person turns 65 and ends three months after turning age 65.
- If you do not take Part D when you are first eligible for Medicare at age 65 and you did not have credible coverage during the interim, the cost of Medicare Part D may go up approximately $.34 for each month one should have had the coverage and you will have to pay the penalty for the rest of your life.
- It is important to annually review the list of drugs you take and review the plans every year, because the Part D plans are permitted to change their formularies, premiums, deductibles, tier structures and pharmacy contracts every year. Therefore, you may change plans during the open enrollment October 15 through December 7, every year.
Medicare Prescription Drug Plans vary by the following:
- Coverage – Medicare prescription drug plans cover generic and brand name drugs. Each plan can choose what specific drugs they cover in each drug category.
- Cost – Monthly premiums and your share (co-payment) of the cost of your prescription vary depending on which plan you choose.
- Restrictions – Does the plan limit the quantity (how many pills you can get at a time), require prior authorization (before the plan will pay for your prescriptions, your doctor must show the plan that the drug is medically necessary for it to be covered), step therapy (the plan may require a lower cost drug to be tried before the plan will pay for the prescribed drug)?
- Convenience – Does your local pharmacy accept the plan; does the plan have a mail order option?
Medicare is the federal health insurance program for people over 65 or people under 65 who qualify because of a disability. It is not designed to cover all the cost of medical care. Deductibles, co-payments and medical services not covered by Medicare can be expensive.
Most Medicare beneficiaries select one of three options to assist with the gaps (only Medicare approved services are covered):
I. Purchase a Medigap insurance policy as a supplement to Medicare
- A Medigap policy supplements the Original Medicare Plan to help pay for the “gaps” like co-payments, coinsurance, and deductibles that the Original Medicare Plan does not cover.
- The policies are standardized (A to N), each type of policy offering the same basic benefits no matter which insurance company sells it. The only difference between policies is the cost. A policy covers only one person; so a couple must each buy separate policies. Private insurance companies sell these policies.
- A person has an open enrollment period for six months, beginning on the first day of the month in which you were eligible for Medicare and enrolled in Medicare Part B. During this period, an insurance company:
a. Must sell you a Plan
b. Cannot make you wait for coverage to start
c. Cannot charge more for a Medigap policy because of health problems
- A Person can get the names of Medigap Policies approved to be sold in Maryland and their yearly costs by referring to http://www.mdinsurance.state.md.us/, Go to consumer information, publications, Medicare and then choose Medigap policies. People can also call SHIP at 410-887-2059 and they will send you a list.
II. Join a Medicare Advantage plan (substitute for Original Medicare). See list of current plans in the back of your Medicare and You Book.
There are currently four types of Medicare Advantage Plans offered in Baltimore County.
The greatest advantage these plans have over using Original Medicare is their out-of-pocket limits.
- Medicare Health Maintenance Organizations (HMO) covers all Part A and B services and may provide extra services. People who join a Medicare HMO Plan may be asked to choose a primary care doctor they see first for most health problems. They usually need a referral to see a specialist (such as a cardiologist) or to get certain services. People who are considering joining a Medicare HMO and want to keep seeing their current doctor should find out if their doctor is in the plan’s network. The plan includes prescription coverage.
- Medicare Special Needs Plans (SNP) membership is limited to certain groups of people, such as those with certain chronic or disabling conditions or in some institution like a nursing home. Medicare Special Needs Plans are Medicare Advantage plans designed to provide focused care management, special expertise of the plan’s providers, and benefits tailored to enrollee conditions. These plans provide case management, care monitoring, health education, and monitoring tools, if needed, to provide specialized care. The plan included prescription coverage.
- Medicare Preferred Provider Organization (PPO) covers all Part A and B services and may provide extra services. People who join a Medicare PPO plan can go to network doctors, other health providers and hospitals, but they can also go out-of-network for covered services, usually at a higher cost. Typically, they do not need to chose a primary care doctor and in most cases do not need a referral to see a specialist. the plan includes prescription coverage.
- Medicare Cost Plan - Kaiser Permanente Medicare Health Plans covers all Part A and B services and may provide extra service. Option to have drugs covered through a separate Part D plan. Option to go to an out-of-network provider, use Original Medicare and pay all of the co-pays and deductibles associated with it . Only Five-Star plan for Baltimore County, therefore one can join it at any time of the year.
The another type of plan is Programs of All-inclusive Care for the Elderly (PACE), which combines medical, social and long-term care services for frail elderly people to remain in the community . Must be on Medicare and Medical Assistance and is geographically confined to the Eastern edge of Baltimore City.
III. Continue health insurance coverage through an employer retirement plan such as the Federal Employee Health Benefits Program (FEHBP), State and Local government Retiree Health Plans, and private companies Retiree Health Plans.
If a person is income-eligible, they can apply for Medicaid, Qualified Medicare Beneficiary Program (QMB) or Specified Low Income Medicare Beneficiary (SLMB), which provides assistance to people with low income and limited assets.
- The Qualified Medicare Beneficiary Program (QMB) will pay the premiums, deductibles and co-insurance payments of the Medicare Program for older and disabled individuals who are financially eligible.
- The Specified Low Income Medicare Beneficiary Program (SLMB) is similar to QMB but pays only the Part B premium ($104.90 in 2015}.
- Low Income Subsidy (LIS) Medicare Beneficiaries who qualify based on low income and limited assets will receive a subsidy to pay for Medicare Part D premiums, co-payments, deductible and coverage gap (donut hole).
- Senior Prescription Drug Assistance Program (SPDAP) The State of Maryland will pay up to $40 each month toward the Medicare Prescription Drug plan premium. Currently brand drugs are discounted 55 percent and generics 35 percent in the coverage gap. Certain drug plans work with SPDAP in the gap to enable SPDAP to pay 95 percent of the retail cost.
- A person signs up for Medicare A and B at Social Security.
- A person needs to review the eligibility for assistance in paying for Medicare Part A, Part B, and Part D (LIS – Low income Subsidy).
- If not eligible for assistance, a person needs to get a supplement to Medicare to pay the expenses that Medicare does not pay. Either a Medigap policy, Medicare Advantage Plan or sign up for their companies retired employee plan if they have one that qualifies.
- Make sure you sign up for Prescription Drug coverage.
Revised December 10, 2015