Frequently Asked Questions

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Medicare Eligibility & Enrollment

You may have heard various terms and phrases used to describe Medicare, including people referring to “the Medicare system,” “Original Medicare,” “Medicare Parts A, B, C and D,” “Medicare Advantage,” “Medicare Supplements” and “Medigap Plans.” This is where a lot of the confusion about Medicare starts, because people tend to use all of these terms interchangeably when, in fact, they each have their own meaning.

“Original Medicare” is a health insurance program that is sponsored, owned and managed by the Federal Government. Specifically, the Medicare program falls under the supervision of the Department of Health and Human Services, but is managed by the Centers for Medicare and Medicaid Services (“CMS”).

When you hear that you are eligible to enroll in Medicare when you turn 65, that is a reference to enrolling in Original Medicare, which consists of Parts A and B. Part A covers hospital services, such as inpatient hospital stays, skilled nursing facility and/or hospice care, and some home health care, while Part B covers medical services outside of hospitals and skilled nursing facilities, such as physician services, outpatient care, medical supplies, and preventive services. Original Medicare — Parts A and B — DOES NOT include routine dental, vision, or hearing services, nor does it include prescription drug coverage.

Medicare Part C refers to Medicare Advantage, which is administered by private insurance companies. Medicare Part C includes Part A and B services plus additional benefits, such as routine dental, vision, hearing, or prescription drug coverage — services that Original Medicare does not offer. For more information on Part C / Medicare Advantage, please review “What is Medicare Part C?”

Finally, Medicare Part D provides prescription drug coverage to Medicare-eligible beneficiaries, which helps cover the cost of prescription drugs (including many recommended shots or vaccines). For more information on Part D, please review “What is a Medicare Prescription Drug Plan?”

The following individuals are covered by Original Medicare:

  • individuals who are 65 and older;
  • individuals with certain disabilities, regardless of age; and
  • individuals who have been diagnosed with certain maladies regardless of age, such as End Stage Renal Disease or Lou Gehrig’s Disease.

Medicaid is a healthcare program for individuals with very limited income. Although Medicaid is federally-funded, each State has their own Medicaid program that they administer.

Medicaid income limits vary by State, so you should contact your local Health and Human Resources office to determine if you qualify. If you do, you will be assigned a Case Worker who will help you apply for benefits.

There are exceptions for individuals with certain disabilities and/or certain individuals who care coming off of creditable coverage with an employer, but for those aging into Medicare (i.e, turning age 65), every person has their own 7-month “Initial Enrollment Period” during which they may enroll in Medicare. Each person’s 7-month window is unique to them, because it’s based on a person’s 65th birthday month. That 7-month window actually starts before your 65th birthday and includes the following time period:

(1) the 3 months before the month you turn 65;
(2) the entire month in which you turn 65; AND
(3) the 3 months after your 65th birthday month.

Let’s assume that you turn 65 on April 15th. Applying the formula above to your birthday month of April, your personal, 7-month enrollment window would cover January 1st through July 31st and would be calculated as follows:

January, February and March – the 3 months before your 65th birthday month of April;
April – your birthday month; and
May, June and July – the 3 months after your birthday month of April.

There are 3 ways to enroll in Medicare:

(1) go to the Social Security Administration website (SSA.gov) and enroll online;

(2) call the Social Security Administration at 800-772-1213 and enroll over the phone; or

(3) visit your local Social Security Association office. 

Note: If you retired from the Railroad, your enrollment will be similar but you will use the Railroad Retirement Board to enroll.  Visit the website at RRB.gov; call 877-772-5772; or, visit your closest Railroad Retirement Board office.

A “Special Election,” “Special Election Period” or “SEP” means that you meet certain criteria that allow you make certain changes to your Medicare elections at any time of the year. Those criteria include the following “qualifying events”:

  • you lost your current health care coverage (e.g., a loss of employer coverage);
  • you moved outside of your current health plan’s coverage area;
  • you want to enroll in a Five Star healthcare plan; and/or
  • your eligibility for Medicaid or a Low Income Subsidy has changed.

To be certain that you qualify for an SEP, we recommend that you contact one of our licensed agents at 1-888-766-4448. If you do qualify, in most cases, you have three (3) months from the date of a qualifying event in which to enroll in a new MA Plan or MAPD Plan, or switch back to Original Medicare.

Note: An SEP is for those beneficiaries already enrolled in Medicare. If you are new to Medicare, you will have a 7-month Initial Enrollment Period that is unique to you, that is not dependent on the factors identified above. For more information on your 7-month Initial Enrollment Period, please review “When can I enroll in Medicare?”

Once you enroll in Original Medicare, your coverage typically begins on the 1st of the month that you turn 65 — unless your birthday falls on the 1st day of the month.  For example, if you turn 65 on April 15th, your coverage will begin April 1st, assuming you enrolled before April 1st. However, if your 65th birthday is on April 1st, your coverage will begin on the 1st of March.

Note: Effective coverage dates for other situations may vary depending on the situation. If you have questions, please call one our licensed agents at 1-888-766-4448.

As explained in the FAQ, “When can I enroll in Medicare?”, each person has a unique 7-month enrollment window that is based on their 65th birthday month. If you fail to enroll in Medicare during that 7-month window, you will have to wait until the General Enrollment Period that runs annually between January 1st and March 31st.  

Thus, if your 7-month enrollment window ends on September 1, 2021, you cannot enroll in Medicare on September 2, 2021. Rather, you would have to wait to enroll until the General Enrollment Period begins on January 1, 2022.

Moreover, if you miss your enrollment window and enroll during the General Enrollment Period, your coverage will not begin until July 1st of that year. Using the example above, if your 7-month window ends September 1, 2021 and you miss that enrollment window, you must wait for the General Enrollment Period to start January 1, 2022. And even if you enroll in Medicare on January 2, 2022, your coverage will not begin until July 1, 2022.

Finally, in addition to the coverage delay / gap, you will be subject to a late enrollment penalty for Part B and, if you want prescription drug coverage, you will have a late enrollment penalty for Part D as well.  There is a 10% per year penalty for late enrollment in Part B, and a 1% per month late enrollment penalty for Part D, both of which are permanent.  The Centers for Medicare and Medicaid Services (“CMS”) will advise you of the specific penalty amounts when you enroll.

If your Primary Care Physician (“PCP”) accepts Original Medicare, then “yes,” you may continue to see him or her once you enroll. However, if your PCP does not accept Medicare, you would need to find a new PCP who participates with Medicare.

“Yes,” you can move to another plan or go back to Original Medicare. However, you may have to wait for a period of time, depending on what time of the year you want to switch. Because approximately 44 million people are enrolled in Medicare, the Centers for Medicare and Medicaid Services (“CMS”) has set up special times during the year when you can enroll, change your plan, or go back to Original Medicare. The current Medicare enrollment calendar is as follows:

ANNUAL MEDICARE CALENDAR

January 1 — March 31                       Open Enrollment Period
April 1 — October 14Special Election Period
October 15 — December 7Annual Enrollment Period
December 8 — December 31Special Election Period

Let’s look at who may make changes to their Medicare elections during each period.

Open Enrollment Period (“OEP”) (January 1 — March 31)

What you can do: During OEP, Medicare beneficiaries have a 1-time option to switch from any Medicare Advantage Plan (“MA Plan”) or Medicare Advantage Prescription Drug Plan (“MAPD Plan”) to switch to another MA Plan or MAPD Plan.  Beneficiaries with either type of Plan may also switch back to Original Medicare during OEP. 

What you can’t do: You can’t switch MA plans more than once; you cannot change a Part D Prescription Drug Plan; and, someone on Original Medicare may not enroll in a MA Plan or a MAPD Plan.

Special Election Period (“SEP”) (April 1 — October 14; December 8 — December 31)

What you can do: During SEP, Medicare beneficiaries may make changes to their Medicare elections only if they meet certain criteria. Those criteria include the following “qualifying events”:

  • you lose your current health care coverage (e.g., a loss of employer coverage);
  • you move out of your current health plan’s coverage area;
  • you enroll in a Five Star healthcare plan; and/or
  • your eligibility changes for Medicaid or a Low Income Subsidy.

In most cases, an individual has three (3) months from the date of a qualifying event in which to enroll in a new MA Plan or MAPD Plan, or switch back to Original Medicare.

What you can’t do: If you don’t fall within any of the above criteria, you are prohibited from making any changes to your Medicare elections and must wait for the Annual Enrollment Period.

Annual Enrollment Period (“AEP”) (October 15 — December 7)

What you can do: During AEP, any Medicare beneficiary can change their health plan or prescription drug coverage for the upcoming calendar year.  For example, anyone who is enrolled in Medicare may:

  • switch from Original Medicare to an MA Plan or MAPD Plan;
  • switch from their current MA Plan or MAPD Plan, to a different MA Plan or MAPD Plan, as many times as they choose**; or
  • switch back to Original Medicare from a MA Plan or MAPD Plan.

**During AEP, a beneficiary may change their election as many times as they wish and the last plan choice received by CMS as of December 7th will be the plan that takes effect on January 1st.

What you can’t do: During AEP, you can only make one election, e.g., switch from Original Medicare to an MA Plan, switch from one MA Plan to another MA Plan, etc. Once you make that election, you cannot change it until the start of the Annual Disenrollment Period.

The quick answer is . . . . it depends!!

Under these circumstances, there are a number of factors that you need to consider in determining what, if any obligations you have with respect to enrolling in Medicare. With help from your employer, you need to answer the following 3 questions:

Is your employer coverage “creditable”?

You may not have to enroll in Medicare if you have “creditable coverage” through an employer, i.e., coverage that is at least as good as Medicare coverage. How do you know if your employer plan is creditable? Ask your employer.

Does your company require you to enroll in Medicare when you are eligible?

Depending on the number of people employed by your company, you may have to enroll in Medicare, in order to continue receiving employer benefits. The “magic” number of employees usually is 20 — if there are less than 20 employees, you may have to enroll in Medicare to continue receiving healthcare benefits from your employer; if there are 20 or more, you may not have to.  Either way, check with your Human Resource Benefit Specialist.

Are you contributing to a Health Savings Account (“HSA”)? 

If you activate Medicare, you may no longer contribute to your Health Savings Account. This may be irrelevant if you do not have creditable coverage through your employer, or your employer requires to enroll in Medicare in order to continue receiving employer-sponsored benefits. But if enrolling for you is optional, and you want to continue contributing to an HSA, you may want to wait.

I answered the 3 questions . . . now what?

In response to the questions above, let’s assume that

  • you have creditable coverage through your employer;
  • your employer does not require you to enroll in Medicare; and,
  • you are not contributing to an HSA.

In this situation, although you technically do not have to enroll in Original Medicare (Parts A and B) during your personal, 7-month window, you should still enroll in Part A.  Why? Because you won’t pay any premium (assuming you’ve worked the qualifying 40 quarters / 10 years), and Part A will coordinate with your employer coverage in the event of a hospital stay. Doing so will also make certain you aren’t responsible for penalties if enrollment slips your mind when you lose creditable coverage.

On the other hand, if your employer coverage is not creditable, or your company requires you to enroll in Medicare, you must enroll in Original Medicare within your 7-month Initial Enrollment Period, or you will be penalized for failing to do so. To learn more about how to enroll in Medicare, please review “How do I enroll in Medicare?”

Finally, even if you fall into the category of someone who has creditable coverage through an employer and your employer does not require you to enroll in Medicare, you should consider speaking to a licensed agent about the potential cost savings of waiving your employer coverage and enrolling in Medicare now.  Why?  Because many employers are moving towards High Deductible Healthcare Plans to save money, such that employer coverage may cost you more than Medicare coverage.

As long as (1) your coverage is creditable, i.e., at least as good as Medicare, and (2) your spouse’s employer does not require you to enroll in Medicare when you turn 65, you do not have to activate your Medicare as long as that creditable coverage remains in place. 

That being said, if you qualify for premium-free Medicare Part A (meaning, you or your spouse have worked 40 quarters / 10 years), and you are not contributing to a Health Savings Account, it might make sense to enroll in Part A, in the event you have a hospital stay.  In that situation, your employer-provided group plan and Medicare will coordinate benefits, which could result in lower out-of-pockets costs for you. 

Covered Services & Benefits

Remember that Original Medicare consists of Medicare Parts A and B. Medicare Part A covers expenses associated with inpatient care in hospitals. These expenses would include:

  • certain costs associated with an inpatient medical stay;
  • up to 100 days in a skilled nursing facility, following a qualifying hospital stay;
  • hospice care; and
  • certain home health care services.

Medicare part A does not cover eyeglasses, routine dental care, or hearing aids.

Medicare Part B works with Medicare Part A to cover outpatient services that are needed to manage a person’s health, whether that be to prevent illness or to manage illness when the person is not admitted to a medical facility such as a hospital. Thus, Part B covers services such as:

  • doctor visits;
  • therapy visits;
  • required lab tests and procedures;
  • preventative care (e.g., health screenings, annual physical);
  • durable medical equipment (e.g., wheelchairs, hospital beds, canes, walkers, etc.); and
  • certain medications.

Neither Medicare Part A nor Part B provide prescription drug coverage.

For more information on what benefits Original Medicare does and does not provide, as well as options to get additional benefits to which you may be entitled, please review “Why Original Medicare may not provide all of the benefits you need.”

Unfortunately, “no,” Original Medicare (Parts A and B) does not provide routine vision, hearing, or dental care services. The only exception is if there is a “medical necessity” related to a Medicare-covered treatment. For example, if a beneficiary needed to have teeth extracted in preparation for the treatment of cancer via radiation therapy (a Medicare-covered treatment), although a tooth extraction is not a covered Medicare benefit, it may be covered as part of the other, Medicare-covered treatment.

If you are interested in obtaining dental, vision and/or hearing benefits, please review “How do I get dental, vision and/or hearing benefits?”

As you know (if you read the previous FAQ!!), Original Medicare does not provide routine dental, vision, or hearing benefits. So what do you do if you need those services? You have two options:

Option 1: Consider a Medicare Part C plan in your coverage area, otherwise known as a Medicare Advantage plan; or

Option 2: Purchase a dental, vision and hearing stand-alone plan from a private carrier (sometimes referred to as a “DVH plan”).

Let’s look at each option and then compare them.

THE “ADVANTAGES” OF MEDICARE ADVANTAGE PLANS

Let’s start with a Medicare Advantage Plan (Medicare Part C). An “MA Plan” is an alternate way for Medicare beneficiaries to receive their Medicare Parts A and B services through a private insurance company, as well as other benefits and services — such as routine dental, vision and/or hearing — at little to no extra cost.  Let’s look at what you get with Original Medicare versus what you may get with a Medicare Advantage Plan.

ORIGINAL MEDICARE v. MEDICARE ADVANTAGE

COVERS / HELPS PAY FOR / COSTORIGINAL MEDICARE (PARTS A & B)MEDICARE ADVANTAGE PLAN (PART C)
Hospital stays &
in-patient care
YesYes
Medical
care & outpatient services
YesYes
Preventative care
& services
YesYes
Lab / diagnostic servicesYesYes
Durable medical
equipment (e.g., wheelchair)
YesYes
May include
prescription drugs (Part D)
NoYes (if Medicare Advantage
Prescription Drug Plan)
May include routine dental,
vision and/or hearing services
NoYes
Has an out-of-pocket
maximum
NoYes
May include telehealth servicesNoYes
May include fitness benefitsNoYes
CostPart A & B premiumPart A & B premium + $0-$50 extra
Administered by . . . Federal GovernmentPrivate Insurance Carriers

MEDICARE ADVANTAGE SEEMS TOO GOOD TO BE TRUE . . . IS IT?

As you can see, for little to no extra monthly premium ($0-$50), Medicare Advantage provides you with many more benefits and services than Original Medicare. And all of those services are provided by private insurance carriers (not the Federal Government) who compete for your business, meaning that you will have several options to choose from, with multiple carriers trying to offer better benefits at a lower price.

You may be thinking that an MA Plan is too good to be true. Additional benefits beyond Original Medicare with little to no extra cost? That’s not possible! It absolutely is possible. However, much like Original Medicare, there are two popular misconceptions about MA Plans that we routinely hear from our clients.

MA Plan Misconception No. 1: All MA Plans offer top-of-the-line dental, vision, hearing, prescription drug coverage, free transportation, etc.

You may have seen commercials where the person tells you to call about a Medicare plan that will give you “all of the benefits you’re entitled to,” including dental, vision, and hearing benefits, prescription drug coverage, free meals delivered to your home, and maybe even money back in your Social Security check. We know beneficiaries believe this to be the case, because we’ve had multiple beneficiaries call and ask to be enrolled in “the plan from the commercial that has everything.” Suffice it to say, those beneficiaries were not happy when we had to tell them that no such Medicare plan exists. Why not?!

The reason is that insurance carriers only have so much money to pay for a particular Medicare plan’s benefits, so they have to allocate the money across each benefits category. And the way in which a carrier allocates the money may be based on a particular market’s needs. For example, if you looked at County “A” in State “B,” one MA Plan may have excellent dental and vision benefits and offer free transportation, but may not be as good when it comes to hearing benefits. But another MA Plan in that same county may have excellent hearing benefits and free transportation, but it’s dental and vision benefits may not be that good.

Thus, before calling a licensed agent to discuss Medicare Advantage options, you should identify the benefits that are most important to you, so that the agent can make sure to look for an MA Plan that is strong in those particular benefits. BUT DO NOT EXPECT TO GET EVERYTHING! You will need to prioritize. Maybe hearing and vision are not a priority right now, but dental and free transportation are very important to you. There will be certain MA Plan options for you. Or maybe dental and transportation are not important to you right now, but hearing and fitness benefits are. If so, there will be other MA Plan options for you.

MA Plan Misconception No. 2: All Doctors Accept MA Plans.

Much like your medical insurance before you turned 65, not every doctor accepts every Medicare Advantage Plan. Thus, if keeping all of your current doctors is important to you, you need to make sure that you choose an MA Plan that is accepted by all of your current doctors. Otherwise, you will need to select new doctors who do accept the particular MA Plan that you want to enroll in. Don’t worry though; a licensed agent can assist you with this process.

THE STAND-ALONE DVH PLAN OPTION

As discussed above, if you only have Original Medicare but need dental, vision or hearing benefits, and/or prescription drug coverage, your first option is to enroll in a Medicare Advantage Plan. Your second option is to purchase a DVH plan from a private carrier, which plan would work with your Original Medicare. Let’s look at how this option compares to Medicare Advantage.

Covers / Helps Pay For / CostOriginal Medicare + Part D + DVH PlanMedicare Advantage
Dental, Vision & HearingYesYes
Allows you to continue seeing
current Primary Care Physician &
your other doctors
Maybe (depends on DVH plan)Maybe (depends on MA plan)
Has an out-of-pocket
maximum
NoYes
May include telehealth servicesNoYes
May include fitness benefitsNoYes
Costs are paid by plan v. reimbursedDepends on planPaid by plan if covered
CostPart B monthly premium $144.60 (2020) +
$30-$70 per month
Part B monthly premium $144.60 +
$0-$50 per month

As you can see, although purchasing a DVH Plan to work with Original Medicare would somewhat even the playing field with an MA Plan in terms of benefits, an MA Plan still offers more benefits for less money.

After comparing the two options, you may be thinking, “Why wouldn’t I go with an MA Plan? What’s the downside? As discussed above in the MA Plan option, not all doctors accept MA Plans. Thus, if you cannot find an MA Plan that all of your doctors will accept, and you want to keep seeing your doctors, the Original Medicare + DVH Plan may be your best option.

In a word, “maybe,” depending on whether you take medications administered at your physician’s office, are diabetic, or take self-administered medications.

If you have medications that must be administered in your doctor’s office, or if you are diabetic and have a diabetic pump, Part B will cover 80% of the cost of the medication, after your $203 annual deductible is satisfied.  You will be responsible for the other 20%. If you would like to learn about Medicare Supplement / Medigap Plans, which can help cover that 20% “gap,” please review “What is a Medicare Supplement / Medigap Plan?”

On the other hand, Medicare does not cover self-administered medications.  For those, you have 2 options:

  1. you can purchase a Medicare Part D Prescription Drug Plan, sometimes referred to as a “PDP Plan,” through a private insurance company, to help with the cost of your medications; or
  2. you can enroll in a Part C, Medicare Advantage Plan. 

To learn more about Part D / PDP Plans, please review “What is Medicare Part D — Prescription Drug Coverage?” To learn more about Medicare Advantage, please review “What is Medicare Part C — Medicare Advantage?”

Costs & Expenses

“Yes,” but chances are you’ve already paid for part of the premium.

Remember that Original Medicare consists of Part A and Part B. For most people, Part A is premium-free, because you “pre-pay” your Part A premium through payroll deductions / taxes during you or your spouse’s working years. Thus, as long as you or your spouse work 40 quarters, or 10 years, you both qualify for premium-free Medicare Part A.  If you don’t have the qualifying quarters, you can purchase Medicare Part A for $259-$471 per month, with the exact amount being dependent on the number of quarters that you or your spouse worked. 

For Part B coverage, you will pay a monthly premium and also have a relatively minimal, annual deducible. In 2021, the Part B premium is $148.50 for most people, but for people in higher income brackets, they may pay a higher premium based on the Income Related Monthly Adjustment Amount (“IRMAA”). In addition, Part B carriers an annual deductible of $203.

In addition to the Part B premium, you will also be responsible for 20% coinsurance for all Medicare-approved services; in other words, Medicare only covers 80% of your services. For information on plans that help cover the 20% “gap” for which you are responsible, please review “What is a Medicare Supplement / Medigap Plan?”

To summarize, with Original Medicare, at a minimum, you will be responsible for:

(1) Part B monthly premium of $148.50 in 2021*;
(2) an annual Part B deductible of $203 in 2021; and
(3) 20% coinsurance for all Medicare-approved services.

One final point. Medicare Parts A and B do not include prescription drug coverage. Thus, if you need prescription drug coverage, you will need to purchase a plan through Medicare Part D, which will cost you a relatively small monthly premium of approximately $20-$30 per month.

If you are new to Medicare and unsure about what benefits Original Medicare provides or, more importantly, does not provide, please review “Why Original Medicare may not provide you with all of the benefits you need.”

*Note: Part B premium will be increasing for the 2022 plan year. New premium rates should be published in early to mid-September

Medicare Parts A & B -- Original Medicare

Unfortunately, “no,” Original Medicare (Parts A and B) does not provide routine vision, hearing, or dental care services. The only exception is if there is a “medical necessity” related to a Medicare-covered treatment. For example, if a beneficiary needed to have teeth extracted in preparation for the treatment of cancer via radiation therapy (a Medicare-covered treatment), although a tooth extraction is not a covered Medicare benefit, it may be covered as part of the other, Medicare-covered treatment.

If you are interested in obtaining dental, vision and/or hearing benefits, please review “How do I get dental, vision and/or hearing benefits?”

In a word, “maybe,” depending on whether you take medications administered at your physician’s office, are diabetic, or take self-administered medications.

If you have medications that must be administered in your doctor’s office, or if you are diabetic and have a diabetic pump, Part B will cover 80% of the cost of the medication, after your $203 annual deductible is satisfied.  You will be responsible for the other 20%. If you would like to learn about Medicare Supplement / Medigap Plans, which can help cover that 20% “gap,” please review “What is a Medicare Supplement / Medigap Plan?”

On the other hand, Medicare does not cover self-administered medications.  For those, you have 2 options:

  1. you can purchase a Medicare Part D Prescription Drug Plan, sometimes referred to as a “PDP Plan,” through a private insurance company, to help with the cost of your medications; or
  2. you can enroll in a Part C, Medicare Advantage Plan. 

To learn more about Part D / PDP Plans, please review “What is Medicare Part D — Prescription Drug Coverage?” To learn more about Medicare Advantage, please review “What is Medicare Part C — Medicare Advantage?”

Medicare Part C -- Medicare Advantage

As you know (if you read the previous FAQ!!), Original Medicare does not provide routine dental, vision, or hearing benefits. So what do you do if you need those services? You have two options:

Option 1: Consider a Medicare Part C plan in your coverage area, otherwise known as a Medicare Advantage plan; or

Option 2: Purchase a dental, vision and hearing stand-alone plan from a private carrier (sometimes referred to as a “DVH plan”).

Let’s look at each option and then compare them.

THE “ADVANTAGES” OF MEDICARE ADVANTAGE PLANS

Let’s start with a Medicare Advantage Plan (Medicare Part C). An “MA Plan” is an alternate way for Medicare beneficiaries to receive their Medicare Parts A and B services through a private insurance company, as well as other benefits and services — such as routine dental, vision and/or hearing — at little to no extra cost.  Let’s look at what you get with Original Medicare versus what you may get with a Medicare Advantage Plan.

ORIGINAL MEDICARE v. MEDICARE ADVANTAGE

COVERS / HELPS PAY FOR / COSTORIGINAL MEDICARE (PARTS A & B)MEDICARE ADVANTAGE PLAN (PART C)
Hospital stays &
in-patient care
YesYes
Medical
care & outpatient services
YesYes
Preventative care
& services
YesYes
Lab / diagnostic servicesYesYes
Durable medical
equipment (e.g., wheelchair)
YesYes
May include
prescription drugs (Part D)
NoYes (if Medicare Advantage
Prescription Drug Plan)
May include routine dental,
vision and/or hearing services
NoYes
Has an out-of-pocket
maximum
NoYes
May include telehealth servicesNoYes
May include fitness benefitsNoYes
CostPart A & B premiumPart A & B premium + $0-$50 extra
Administered by . . . Federal GovernmentPrivate Insurance Carriers

MEDICARE ADVANTAGE SEEMS TOO GOOD TO BE TRUE . . . IS IT?

As you can see, for little to no extra monthly premium ($0-$50), Medicare Advantage provides you with many more benefits and services than Original Medicare. And all of those services are provided by private insurance carriers (not the Federal Government) who compete for your business, meaning that you will have several options to choose from, with multiple carriers trying to offer better benefits at a lower price.

You may be thinking that an MA Plan is too good to be true. Additional benefits beyond Original Medicare with little to no extra cost? That’s not possible! It absolutely is possible. However, much like Original Medicare, there are two popular misconceptions about MA Plans that we routinely hear from our clients.

MA Plan Misconception No. 1: All MA Plans offer top-of-the-line dental, vision, hearing, prescription drug coverage, free transportation, etc.

You may have seen commercials where the person tells you to call about a Medicare plan that will give you “all of the benefits you’re entitled to,” including dental, vision, and hearing benefits, prescription drug coverage, free meals delivered to your home, and maybe even money back in your Social Security check. We know beneficiaries believe this to be the case, because we’ve had multiple beneficiaries call and ask to be enrolled in “the plan from the commercial that has everything.” Suffice it to say, those beneficiaries were not happy when we had to tell them that no such Medicare plan exists. Why not?!

The reason is that insurance carriers only have so much money to pay for a particular Medicare plan’s benefits, so they have to allocate the money across each benefits category. And the way in which a carrier allocates the money may be based on a particular market’s needs. For example, if you looked at County “A” in State “B,” one MA Plan may have excellent dental and vision benefits and offer free transportation, but may not be as good when it comes to hearing benefits. But another MA Plan in that same county may have excellent hearing benefits and free transportation, but it’s dental and vision benefits may not be that good.

Thus, before calling a licensed agent to discuss Medicare Advantage options, you should identify the benefits that are most important to you, so that the agent can make sure to look for an MA Plan that is strong in those particular benefits. BUT DO NOT EXPECT TO GET EVERYTHING! You will need to prioritize. Maybe hearing and vision are not a priority right now, but dental and free transportation are very important to you. There will be certain MA Plan options for you. Or maybe dental and transportation are not important to you right now, but hearing and fitness benefits are. If so, there will be other MA Plan options for you.

MA Plan Misconception No. 2: All Doctors Accept MA Plans.

Much like your medical insurance before you turned 65, not every doctor accepts every Medicare Advantage Plan. Thus, if keeping all of your current doctors is important to you, you need to make sure that you choose an MA Plan that is accepted by all of your current doctors. Otherwise, you will need to select new doctors who do accept the particular MA Plan that you want to enroll in. Don’t worry though; a licensed agent can assist you with this process.

THE STAND-ALONE DVH PLAN OPTION

As discussed above, if you only have Original Medicare but need dental, vision or hearing benefits, and/or prescription drug coverage, your first option is to enroll in a Medicare Advantage Plan. Your second option is to purchase a DVH plan from a private carrier, which plan would work with your Original Medicare. Let’s look at how this option compares to Medicare Advantage.

Covers / Helps Pay For / CostOriginal Medicare + Part D + DVH PlanMedicare Advantage
Dental, Vision & HearingYesYes
Allows you to continue seeing
current Primary Care Physician &
your other doctors
Maybe (depends on DVH plan)Maybe (depends on MA plan)
Has an out-of-pocket
maximum
NoYes
May include telehealth servicesNoYes
May include fitness benefitsNoYes
Costs are paid by plan v. reimbursedDepends on planPaid by plan if covered
CostPart B monthly premium $144.60 (2020) +
$30-$70 per month
Part B monthly premium $144.60 +
$0-$50 per month

As you can see, although purchasing a DVH Plan to work with Original Medicare would somewhat even the playing field with an MA Plan in terms of benefits, an MA Plan still offers more benefits for less money.

After comparing the two options, you may be thinking, “Why wouldn’t I go with an MA Plan? What’s the downside? As discussed above in the MA Plan option, not all doctors accept MA Plans. Thus, if you cannot find an MA Plan that all of your doctors will accept, and you want to keep seeing your doctors, the Original Medicare + DVH Plan may be your best option.

Medicare Part C, more popularly known as Medicare Advantage, is an alternative way for Medicare beneficiaries to receive their Parts A and B services provided by Original Medicare. However, there are two main differences between Original Medicare (Parts A and B) and Medicare Advantage (Part C):

(1) Medicare Advantage is administered by private insurance companies or health systems — not the Federal Government; and
(2) Medicare Advantage may offer additional services that Original Medicare does not, such as routine dental, vision, and hearing benefits, and prescription drug coverage.

So what’s the “advantage” of a Medicare Advantage plan or “MA Plan”? Although you are still responsible for your monthly Part B premium and annual deductible, many MA Plans include prescription drug coverage (in lieu of you purchasing a Part D Plan), as well as routine dental, vision and other additional benefits that are not offered with Original Medicare.  AND those additional benefits and services are provided at little to no additional cost to you!

To be clear, you may not find an MA Plan that includes routine dental, vision, AND hearing services, as well as free transportation to appointments and meals delivered to your home. Why not? Because insurance companies only have so much money to spend on a particular MA Plan to cover costs and expenses, which means that you will likely only be able to find an MA Plan that includes combinations of dental, hearing, vision, etc.

What about the “cons” of an MA Plan?  With an MA Plan, you are usually limited to working with a network of certain primary care physicians, specialists, pharmacies, and hospital facilities.  Thus, if your current PCP, specialist, pharmacy, etc., does not work within the network of the Plan you want to enroll in, you will need to select new options if you proceed. 

Medicare Part D -- Prescription Drug Coverage

In a word, “maybe,” depending on whether you take medications administered at your physician’s office, are diabetic, or take self-administered medications.

If you have medications that must be administered in your doctor’s office, or if you are diabetic and have a diabetic pump, Part B will cover 80% of the cost of the medication, after your $203 annual deductible is satisfied.  You will be responsible for the other 20%. If you would like to learn about Medicare Supplement / Medigap Plans, which can help cover that 20% “gap,” please review “What is a Medicare Supplement / Medigap Plan?”

On the other hand, Medicare does not cover self-administered medications.  For those, you have 2 options:

  1. you can purchase a Medicare Part D Prescription Drug Plan, sometimes referred to as a “PDP Plan,” through a private insurance company, to help with the cost of your medications; or
  2. you can enroll in a Part C, Medicare Advantage Plan. 

To learn more about Part D / PDP Plans, please review “What is Medicare Part D — Prescription Drug Coverage?” To learn more about Medicare Advantage, please review “What is Medicare Part C — Medicare Advantage?”

Medicare Part D provides prescription drug coverage. A Medicare Prescription Drug Plan — also referred to as a “Part D Plan” or a “PDP Plan” — has its own list of covered drugs that is referred to as a formulary. To obtain Medicare PDP coverage, you need to join a plan run by an insurance company or other private company approved by Medicare. Each PDP Plan varies in cost and drugs covered. Plan options include:

  • Non-Standalone Plans — PDP Plans that are offered as part of Medicare Advantage Plans (Part C Plans).
  • Standalone Plans — PDP Plans that are purchased outside of Medicare Advantage Plans, such that a beneficiary who purchases a Standalone PDP will then have Parts A and B (Original Medicare) and Part D (PDP Plan).

For more information on Medicare Advantage Plans, please review “What is Medicare Part C — Medicare Advantage?”

Medicare Supplement / Medigap Plans

Also known as a “Med Supp” or a “Medigap Plan,” a Medicare Supplement Plan is an offering from a private insurance company that will help cover the 20% “gap” of costs that Original Medicare does not cover. Specifically, a Medicare Supplement can help cover

  • Medicare Part A and B deductibles;
  • copayments and coinsurance;
  • Hospice coinsurance / copays; and
  • Emergency medical costs during international travel.

Similar to both Original Medicare and Medicare Advantage, a Medicare Supplement isn’t the right choice for everyone, so let’s look at the “pro’s” and “con’s”:

PROCON
Helps cover co-payments, co-insurance
and deductibles
Although premiums vary between plans, your monthly premium can be
expensive and is not refundable if you don’t have eligible expenses,
e.g., you pay your premium every month, regardless of whether
you go to the doctor
Caps your financial responsibility
at your monthly premium
You will need to purchase a Medicare Part D plan for
prescription drug coverage and pay a monthly premium
Beyond what you pay for your monthly
premium, you out-of-pocket expenses
may be limited
If you require dental, vision or hearing, you will need to purchase
a stand-alone Dental / Vision / Hearing Plan (“DVH Plan”) which
comes with an additional monthly premium

In sum, although a Medicare Supplement / Medigap Plan will help cover the 20% of costs that Medicare does not, and may also cap your financial obligations in the event that you incur significant medical costs, it can come with a rather high monthly price tag in the form of a non-refundable premium, and you would still need to pay extra for a Part D plan AND a DVH Plan.

Dental, Vision & Hearing

Unfortunately, “no,” Original Medicare (Parts A and B) does not provide routine vision, hearing, or dental care services. The only exception is if there is a “medical necessity” related to a Medicare-covered treatment. For example, if a beneficiary needed to have teeth extracted in preparation for the treatment of cancer via radiation therapy (a Medicare-covered treatment), although a tooth extraction is not a covered Medicare benefit, it may be covered as part of the other, Medicare-covered treatment.

If you are interested in obtaining dental, vision and/or hearing benefits, please review “How do I get dental, vision and/or hearing benefits?”

As you know (if you read the previous FAQ!!), Original Medicare does not provide routine dental, vision, or hearing benefits. So what do you do if you need those services? You have two options:

Option 1: Consider a Medicare Part C plan in your coverage area, otherwise known as a Medicare Advantage plan; or

Option 2: Purchase a dental, vision and hearing stand-alone plan from a private carrier (sometimes referred to as a “DVH plan”).

Let’s look at each option and then compare them.

THE “ADVANTAGES” OF MEDICARE ADVANTAGE PLANS

Let’s start with a Medicare Advantage Plan (Medicare Part C). An “MA Plan” is an alternate way for Medicare beneficiaries to receive their Medicare Parts A and B services through a private insurance company, as well as other benefits and services — such as routine dental, vision and/or hearing — at little to no extra cost.  Let’s look at what you get with Original Medicare versus what you may get with a Medicare Advantage Plan.

ORIGINAL MEDICARE v. MEDICARE ADVANTAGE

COVERS / HELPS PAY FOR / COSTORIGINAL MEDICARE (PARTS A & B)MEDICARE ADVANTAGE PLAN (PART C)
Hospital stays &
in-patient care
YesYes
Medical
care & outpatient services
YesYes
Preventative care
& services
YesYes
Lab / diagnostic servicesYesYes
Durable medical
equipment (e.g., wheelchair)
YesYes
May include
prescription drugs (Part D)
NoYes (if Medicare Advantage
Prescription Drug Plan)
May include routine dental,
vision and/or hearing services
NoYes
Has an out-of-pocket
maximum
NoYes
May include telehealth servicesNoYes
May include fitness benefitsNoYes
CostPart A & B premiumPart A & B premium + $0-$50 extra
Administered by . . . Federal GovernmentPrivate Insurance Carriers

MEDICARE ADVANTAGE SEEMS TOO GOOD TO BE TRUE . . . IS IT?

As you can see, for little to no extra monthly premium ($0-$50), Medicare Advantage provides you with many more benefits and services than Original Medicare. And all of those services are provided by private insurance carriers (not the Federal Government) who compete for your business, meaning that you will have several options to choose from, with multiple carriers trying to offer better benefits at a lower price.

You may be thinking that an MA Plan is too good to be true. Additional benefits beyond Original Medicare with little to no extra cost? That’s not possible! It absolutely is possible. However, much like Original Medicare, there are two popular misconceptions about MA Plans that we routinely hear from our clients.

MA Plan Misconception No. 1: All MA Plans offer top-of-the-line dental, vision, hearing, prescription drug coverage, free transportation, etc.

You may have seen commercials where the person tells you to call about a Medicare plan that will give you “all of the benefits you’re entitled to,” including dental, vision, and hearing benefits, prescription drug coverage, free meals delivered to your home, and maybe even money back in your Social Security check. We know beneficiaries believe this to be the case, because we’ve had multiple beneficiaries call and ask to be enrolled in “the plan from the commercial that has everything.” Suffice it to say, those beneficiaries were not happy when we had to tell them that no such Medicare plan exists. Why not?!

The reason is that insurance carriers only have so much money to pay for a particular Medicare plan’s benefits, so they have to allocate the money across each benefits category. And the way in which a carrier allocates the money may be based on a particular market’s needs. For example, if you looked at County “A” in State “B,” one MA Plan may have excellent dental and vision benefits and offer free transportation, but may not be as good when it comes to hearing benefits. But another MA Plan in that same county may have excellent hearing benefits and free transportation, but it’s dental and vision benefits may not be that good.

Thus, before calling a licensed agent to discuss Medicare Advantage options, you should identify the benefits that are most important to you, so that the agent can make sure to look for an MA Plan that is strong in those particular benefits. BUT DO NOT EXPECT TO GET EVERYTHING! You will need to prioritize. Maybe hearing and vision are not a priority right now, but dental and free transportation are very important to you. There will be certain MA Plan options for you. Or maybe dental and transportation are not important to you right now, but hearing and fitness benefits are. If so, there will be other MA Plan options for you.

MA Plan Misconception No. 2: All Doctors Accept MA Plans.

Much like your medical insurance before you turned 65, not every doctor accepts every Medicare Advantage Plan. Thus, if keeping all of your current doctors is important to you, you need to make sure that you choose an MA Plan that is accepted by all of your current doctors. Otherwise, you will need to select new doctors who do accept the particular MA Plan that you want to enroll in. Don’t worry though; a licensed agent can assist you with this process.

THE STAND-ALONE DVH PLAN OPTION

As discussed above, if you only have Original Medicare but need dental, vision or hearing benefits, and/or prescription drug coverage, your first option is to enroll in a Medicare Advantage Plan. Your second option is to purchase a DVH plan from a private carrier, which plan would work with your Original Medicare. Let’s look at how this option compares to Medicare Advantage.

Covers / Helps Pay For / CostOriginal Medicare + Part D + DVH PlanMedicare Advantage
Dental, Vision & HearingYesYes
Allows you to continue seeing
current Primary Care Physician &
your other doctors
Maybe (depends on DVH plan)Maybe (depends on MA plan)
Has an out-of-pocket
maximum
NoYes
May include telehealth servicesNoYes
May include fitness benefitsNoYes
Costs are paid by plan v. reimbursedDepends on planPaid by plan if covered
CostPart B monthly premium $144.60 (2020) +
$30-$70 per month
Part B monthly premium $144.60 +
$0-$50 per month

As you can see, although purchasing a DVH Plan to work with Original Medicare would somewhat even the playing field with an MA Plan in terms of benefits, an MA Plan still offers more benefits for less money.

After comparing the two options, you may be thinking, “Why wouldn’t I go with an MA Plan? What’s the downside? As discussed above in the MA Plan option, not all doctors accept MA Plans. Thus, if you cannot find an MA Plan that all of your doctors will accept, and you want to keep seeing your doctors, the Original Medicare + DVH Plan may be your best option.

Enrollment Periods

A “Special Election,” “Special Election Period” or “SEP” means that you meet certain criteria that allow you make certain changes to your Medicare elections at any time of the year. Those criteria include the following “qualifying events”:

  • you lost your current health care coverage (e.g., a loss of employer coverage);
  • you moved outside of your current health plan’s coverage area;
  • you want to enroll in a Five Star healthcare plan; and/or
  • your eligibility for Medicaid or a Low Income Subsidy has changed.

To be certain that you qualify for an SEP, we recommend that you contact one of our licensed agents at 1-888-766-4448. If you do qualify, in most cases, you have three (3) months from the date of a qualifying event in which to enroll in a new MA Plan or MAPD Plan, or switch back to Original Medicare.

Note: An SEP is for those beneficiaries already enrolled in Medicare. If you are new to Medicare, you will have a 7-month Initial Enrollment Period that is unique to you, that is not dependent on the factors identified above. For more information on your 7-month Initial Enrollment Period, please review “When can I enroll in Medicare?”

“Yes,” you can move to another plan or go back to Original Medicare. However, you may have to wait for a period of time, depending on what time of the year you want to switch. Because approximately 44 million people are enrolled in Medicare, the Centers for Medicare and Medicaid Services (“CMS”) has set up special times during the year when you can enroll, change your plan, or go back to Original Medicare. The current Medicare enrollment calendar is as follows:

ANNUAL MEDICARE CALENDAR

January 1 — March 31                       Open Enrollment Period
April 1 — October 14Special Election Period
October 15 — December 7Annual Enrollment Period
December 8 — December 31Special Election Period

Let’s look at who may make changes to their Medicare elections during each period.

Open Enrollment Period (“OEP”) (January 1 — March 31)

What you can do: During OEP, Medicare beneficiaries have a 1-time option to switch from any Medicare Advantage Plan (“MA Plan”) or Medicare Advantage Prescription Drug Plan (“MAPD Plan”) to switch to another MA Plan or MAPD Plan.  Beneficiaries with either type of Plan may also switch back to Original Medicare during OEP. 

What you can’t do: You can’t switch MA plans more than once; you cannot change a Part D Prescription Drug Plan; and, someone on Original Medicare may not enroll in a MA Plan or a MAPD Plan.

Special Election Period (“SEP”) (April 1 — October 14; December 8 — December 31)

What you can do: During SEP, Medicare beneficiaries may make changes to their Medicare elections only if they meet certain criteria. Those criteria include the following “qualifying events”:

  • you lose your current health care coverage (e.g., a loss of employer coverage);
  • you move out of your current health plan’s coverage area;
  • you enroll in a Five Star healthcare plan; and/or
  • your eligibility changes for Medicaid or a Low Income Subsidy.

In most cases, an individual has three (3) months from the date of a qualifying event in which to enroll in a new MA Plan or MAPD Plan, or switch back to Original Medicare.

What you can’t do: If you don’t fall within any of the above criteria, you are prohibited from making any changes to your Medicare elections and must wait for the Annual Enrollment Period.

Annual Enrollment Period (“AEP”) (October 15 — December 7)

What you can do: During AEP, any Medicare beneficiary can change their health plan or prescription drug coverage for the upcoming calendar year.  For example, anyone who is enrolled in Medicare may:

  • switch from Original Medicare to an MA Plan or MAPD Plan;
  • switch from their current MA Plan or MAPD Plan, to a different MA Plan or MAPD Plan, as many times as they choose**; or
  • switch back to Original Medicare from a MA Plan or MAPD Plan.

**During AEP, a beneficiary may change their election as many times as they wish and the last plan choice received by CMS as of December 7th will be the plan that takes effect on January 1st.

What you can’t do: During AEP, you can only make one election, e.g., switch from Original Medicare to an MA Plan, switch from one MA Plan to another MA Plan, etc. Once you make that election, you cannot change it until the start of the Annual Disenrollment Period.

Working Past 65

The quick answer is . . . . it depends!!

Under these circumstances, there are a number of factors that you need to consider in determining what, if any obligations you have with respect to enrolling in Medicare. With help from your employer, you need to answer the following 3 questions:

Is your employer coverage “creditable”?

You may not have to enroll in Medicare if you have “creditable coverage” through an employer, i.e., coverage that is at least as good as Medicare coverage. How do you know if your employer plan is creditable? Ask your employer.

Does your company require you to enroll in Medicare when you are eligible?

Depending on the number of people employed by your company, you may have to enroll in Medicare, in order to continue receiving employer benefits. The “magic” number of employees usually is 20 — if there are less than 20 employees, you may have to enroll in Medicare to continue receiving healthcare benefits from your employer; if there are 20 or more, you may not have to.  Either way, check with your Human Resource Benefit Specialist.

Are you contributing to a Health Savings Account (“HSA”)? 

If you activate Medicare, you may no longer contribute to your Health Savings Account. This may be irrelevant if you do not have creditable coverage through your employer, or your employer requires to enroll in Medicare in order to continue receiving employer-sponsored benefits. But if enrolling for you is optional, and you want to continue contributing to an HSA, you may want to wait.

I answered the 3 questions . . . now what?

In response to the questions above, let’s assume that

  • you have creditable coverage through your employer;
  • your employer does not require you to enroll in Medicare; and,
  • you are not contributing to an HSA.

In this situation, although you technically do not have to enroll in Original Medicare (Parts A and B) during your personal, 7-month window, you should still enroll in Part A.  Why? Because you won’t pay any premium (assuming you’ve worked the qualifying 40 quarters / 10 years), and Part A will coordinate with your employer coverage in the event of a hospital stay. Doing so will also make certain you aren’t responsible for penalties if enrollment slips your mind when you lose creditable coverage.

On the other hand, if your employer coverage is not creditable, or your company requires you to enroll in Medicare, you must enroll in Original Medicare within your 7-month Initial Enrollment Period, or you will be penalized for failing to do so. To learn more about how to enroll in Medicare, please review “How do I enroll in Medicare?”

Finally, even if you fall into the category of someone who has creditable coverage through an employer and your employer does not require you to enroll in Medicare, you should consider speaking to a licensed agent about the potential cost savings of waiving your employer coverage and enrolling in Medicare now.  Why?  Because many employers are moving towards High Deductible Healthcare Plans to save money, such that employer coverage may cost you more than Medicare coverage.

Military Personnel / TriCare for Life

Firstly, thank you for your service to our Country! 

Secondly, “yes,” you do need to enroll in Medicare Parts A and B, as doing so is a requirement for TRICARE.  TRICARE will then be the secondary payor to Medicare, and will provide you with prescription drug coverage.

Finally, please be sure to update your DEERS (Defense Enrollment Eligibility Reporting) file once you are approved for Medicare. If you have questions about when you may enroll in Medicare, please review “When can I enroll in Medicare?” or, if you have questions about how to enroll, please review “How do I enroll in Medicare?”

Employer Coverage Through Spouse

As long as (1) your coverage is creditable, i.e., at least as good as Medicare, and (2) your spouse’s employer does not require you to enroll in Medicare when you turn 65, you do not have to activate your Medicare as long as that creditable coverage remains in place. 

That being said, if you qualify for premium-free Medicare Part A (meaning, you or your spouse have worked 40 quarters / 10 years), and you are not contributing to a Health Savings Account, it might make sense to enroll in Part A, in the event you have a hospital stay.  In that situation, your employer-provided group plan and Medicare will coordinate benefits, which could result in lower out-of-pockets costs for you. 

Employer Group Waiver Plans (Egg Whip Plans)

We recommend that you check with your employer’s Benefits Department to make sure that you follow all of the requirements for enrollment in your company’s Employer Group Waiver Plan – sometimes abbreviated as an “EGWP Plan” and pronounced “Egg Whip Plan.”  Enrollment in Medicare is usually a requirement of an EGWP Plan, which offers the services of Medicare Parts A, B, and often D, along with additional benefits not offered by Medicare, but you should confirm this with your Benefits Department.

Medicaid

Medicaid is a healthcare program for individuals with very limited income. Although Medicaid is federally-funded, each State has their own Medicaid program that they administer.

Medicaid income limits vary by State, so you should contact your local Health and Human Resources office to determine if you qualify. If you do, you will be assigned a Case Worker who will help you apply for benefits.