FREQUENTLY ASKED QUESTIONS (FAQs) about medicare

Navigating the complexities of Medicare can be overwhelming, but The Medicare Firm is here to help. We’ve compiled a list of some of the most frequently asked questions about Medicare to help you understand your options, benefits, and requirements. Whether you’re new to Medicare or just need some clarification, these FAQs will guide you through the essentials.

Medicare is a federal health insurance program primarily for individuals aged 65 or older. It also provides coverage for certain younger individuals with disabilities and people with End-Stage Renal Disease (ESRD) or ALS. It’s divided into four parts:

• Part A: Hospital Insurance.
• Part B: Medical Insurance.
• Part C: Medicare Advantage, an alternative way to receive your Medicare benefits.
• Part D: Prescription Drug Coverage.

You’re eligible for Medicare if:

• You are 65 or older and a U.S. citizen or legal permanent resident for at least five continuous years.
• You are under 65 and have received Social Security Disability Insurance (SSDI) for at least 24 months.
• You have End-Stage Renal Disease (ESRD) requiring dialysis or a transplant, or ALS.

Original Medicare includes Part A (Hospital Insurance) and Part B (Medical Insurance). It covers most healthcare services, but you pay deductibles and coinsurance, and there’s no out-of-pocket limit.

Medicare Advantage (Part C) is an all-in-one alternative that includes Parts A and B, often Part D (prescription drug coverage), and extra benefits like vision, dental, and hearing. Medicare Advantage plans are offered by private insurance companies approved by Medicare.

• Part A: Most people receive Part A premium-free if they or their spouse have worked and paid Medicare taxes for at least 10 years. If you don’t qualify, you may have to pay a monthly premium.
• Part B: There is a monthly premium for Part B, which is based on your income. The standard amount may change yearly.
• Medicare Advantage (Part C) and Part D also require a monthly premium, depending on the plan you choose.

Medigap, also known as Medicare Supplement Insurance, helps pay out-of-pocket costs not covered by Original Medicare, such as deductibles, copayments, and coinsurance. You must have Parts A and B to be eligible for Medigap, and it is purchased separately from private insurance companies.

You should enroll in Medicare during the Initial Enrollment Period (IEP), which is a 7-month window that starts 3 months before your 65th birthday, includes your birthday month, and ends 3 months after. Enrolling during this period helps you avoid late enrollment penalties and ensures there are no gaps in your healthcare coverage.

If you miss your IEP, you can enroll during the General Enrollment Period (GEP), which runs from January 1 to March 31 each year, with coverage starting on July 1. However, you may face late enrollment penalties if you delay enrolling without having other creditable coverage.

A Special Enrollment Period (SEP) allows you to enroll in Medicare outside of the usual enrollment periods if you meet specific conditions, such as:

• You or your spouse are still working and covered by an employer health plan.
• You move to a new area that affects your coverage options.
• You lose your current coverage.

Medicare Part D helps cover the cost of prescription medications. You can get Part D through a standalone prescription drug plan that works alongside Original Medicare, or as part of a Medicare Advantage plan that includes drug coverage. It’s important to enroll when you’re first eligible to avoid late enrollment penalties.

The coverage gap, also called the "donut hole," is a temporary limit on what Medicare will pay for prescription drugs after you and your plan have spent a certain amount. During the donut hole, you may pay more out-of-pocket for your medications until you reach the catastrophic coverage level, where your out-of-pocket costs decrease significantly.

Yes, you can switch your Medicare plans during specific times of the year:

• Annual Enrollment Period (AEP): From October 15 to December 7, you can switch between Medicare Advantage and Original Medicare, join a Part D plan, or change your existing coverage.
• Medicare Advantage Open Enrollment Period: From January 1 to March 31, if you are enrolled in a Medicare Advantage plan, you can switch to another Medicare Advantage plan or return to Original Medicare.

A Dual Eligible Plan (D-SNP) is a type of Medicare Advantage plan for individuals who qualify for both Medicare and Medicaid. These plans provide additional benefits and help cover out-of-pocket expenses, such as premiums, deductibles, and copayments. If you qualify for both programs, a D-SNP could provide comprehensive coverage with significant cost reductions.

A Special Needs Plan (SNP) is a type of Medicare Advantage plan that provides customized benefits for individuals with specific needs:

• Chronic Condition SNPs (C-SNPs) for those with chronic conditions.
• Dual Eligible SNPs (D-SNPs) for people with both Medicare and Medicaid.
• Institutional SNPs (I-SNPs) for people in long-term care facilities.

If you have limited income and resources, you may qualify for Medicaid or other Medicare Savings Programs, which can help pay for Medicare premiums, deductibles, and coinsurance. Additionally, the Extra Help program can help with Part D prescription drug costs.

With Original Medicare, you can visit any doctor or healthcare provider in the U.S. that accepts Medicare. With Medicare Advantage plans, you may need to use a network of providers, depending on whether you choose an HMO or PPO plan.

Medicare does not cover everything. Some services and items that are not covered include:

• Routine dental care and dentures.
• Routine vision care and eyeglasses.
• Hearing aids and exams for fitting them.
• Long-term custodial care.
• Acupuncture and cosmetic surgery.

For coverage of these services, you may need a Medicare Advantage plan that includes extra benefits or consider purchasing separate insurance policies.

Yes, you can have both Medicare and employer coverage. If you are 65 or older and still working, Medicare can coordinate with your employer-sponsored insurance. The rules depend on the size of your employer:

• For employers with 20 or more employees, the employer plan usually pays first.
• For employers with fewer than 20 employees, Medicare usually pays first.

The Medicare Firm is here to help you navigate every step of your Medicare journey. We provide:

• One-on-One Consultations to determine your eligibility and help choose the right plan.
• Assistance with understanding your enrollment periods and avoiding penalties.

• Help with completing paperwork and ensuring your enrollment is processed correctly.

Medicare can be complicated, but The Medicare Firm is here to answer your questions and guide you through the process. Whether you're preparing for your initial enrollment or considering switching plans, our team of knowledgeable specialists is ready to help.

Contact us today to get personalized answers to your Medicare questions and let us help you make informed decisions for your healthcare needs.