6 key Medicare questions

Learn about Medicare eligibility, choices, costs, and when and how to sign up.

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6 key Medicare questions

  • What is Medicare?
  • What are my options?
  • How do I sign up?
  • Which plan is right for me?
  • How much do plans cost?
  • Where can I go for help with Medicare?

Diane turned 65. Having also retired, she filled her days with volunteer work, babysitting her grandchildren, and enjoying time with her friends.

Diane was the first among her friends to turn 65 and enroll in Medicare. This made her the go-to expert for all things health care-related.

As her friends neared 65, they called Diane for help. Since she had made her way through the Medicare maze, they figured Diane could answer their questions.

Her friends' health care needs weren't the same as Diane's. She pointed them to places where she had found information but wasn't able to give them the specific answers they needed for their unique situations. She didn't feel ready for Medicare, and neither did her friends.

To help you prepare for enrolling in Medicare with confidence, here are answers to some of the most common questions people like you ask.

1. What is Medicare?

You may have an idea of what Medicare is, based on what you've read or heard up to this point. But, not everyone describes it the same way.

As the Centers for Medicare and Medicaid Services (they're the official federal organization responsible for Medicare) describe it, Medicare is a federal health insurance program for:

  • People age 65 and older
  • Certain younger people with disabilities
  • People with End-Stage Renal Disease (ESRD), which is permanent kidney failure that requires dialysis or a kidney transplant
 

Getting started with a few Medicare basics

You might not know that Medicare only offers individual coverage. Unlike health insurance plans before age 65, there is no family coverage plan with Medicare. That means your spouse or partner won't be covered by your Medicare coverage; they have to enroll on their own when they become eligible for Medicare.

Medicare gives you a 7-month time frame to sign up/enroll. For those who are eligible when they turn 65, that 7 months begins 3 months before the month you turn 65 and ends 3 months after the month you turn 65. This is the Initial Enrollment Period.

Medicare offers a Special Enrollment window for people age 65 who are still working and/or have health insurance through their employer or spouse's employer. This window is also available to you if certain events happen in your life, such as moving or losing other insurance coverage.

If you miss the Initial Enrollment Period without qualifying for the Special Enrollment Period, you may have a big gap in your health care coverage. You would have to wait until the following January when the General Enrollment Period begins (it ends in March).

But here's where missing the Initial Enrollment Period can hurt you: Signing up between January and March means your coverage doesn't go into effect until the following July—and you'll be charged a late enrollment penalty that's tacked on to your monthly premium (what you pay each month for health care coverage).

2. What are my options?

Before Medicare, picking health insurance coverage while working for your previous employers was fairly straightforward: You picked a single plan for your doctor visits, prescriptions, and medical needs.

Medicare is very different. Medicare is made up of parts. Each part covers different things.

And to make it a little more complicated, each part has lots of different options within them. Let's take a look:

Part A: Hospital insurance

Medicare Part A coverage was first introduced in 1965 to help seniors manage the high cost of hospital care. Part A covers hospital visits, certain hospital treatments and procedures, skilled nursing facility care, and hospice care.

Part B: Medical insurance

Medicare Part B covers certain health care costs not covered by Part A, such as doctor visits and services, outpatient hospital care, physical and speech therapy, lab tests, blood transfusions, medical equipment and supplies, and ambulance services.

Part A and Part B together are also known as Original Medicare.

Medigap (Medicare Supplement)

A Medigap policy is private health insurance that helps supplement Original Medicare. This means it helps pay some of the health care costs that Original Medicare doesn't cover (such as copayments, coinsurance, and deductibles). These are "gaps" in Medicare coverage. If you have Original Medicare and a Medigap policy, Medicare will pay its share of the Medicare-approved amounts for covered health care costs. Then your Medigap policy pays its share.

While the federal government provides Parts A and B, private health insurance companies offer Medigap plans. There's a wide variety of Medigap plans to choose from that address services you need that Parts A and B don't cover.

Tip: You can find out which insurance companies sell Medigap policies in your area at Medigap Policy Search

Part D: Prescription drug coverage

Original Medicare and Medigap plans do not provide prescription drug coverage, which means you may want to purchase a Part D plan or a Medicare Advantage plan that includes prescription drug coverage. Enrolling in a Part D plan is not required. However, if you don't enroll in a Part D plan when you first become eligible you may wind up getting penalized financially should you enroll later.

Regardless of the coverage you choose for prescription drugs, it's important to consider the ones that cover the medications you need, how often you need them, and where you purchase them.

Medicare Advantage

This coverage is an alternative to Part A, Part B, and Medigap. Medicare Advantage (which is also called Medicare Part C) is an "all-in-one" managed care plan that provides the coverage you'd find under Original Medicare and Medigap, and can also include Part D prescription drug coverage, vision coverage, or dental care.

Sounds great, right? Well, there's a catch. Medicare Advantage plans provide coverage for what's called "in-network services." Each Medicare Advantage plan works with a network of doctors and health care facilities. Most Medicare Advantage plans require a beneficiary to go through their network for services, but plans vary: For example, while HMOs provide only in-network services, PPOs have a network but allow you to go out-of-network with higher cost sharing.

Tip: If you're considering a Medicare Advantage plan, think about which doctors you see, what your current medical needs are (such as prescription medications) and whether the doctors you now see are in-network for the Medicare plan you're considering. If they aren't in-network, would you mind switching doctors?

3. How do I sign up?

You may know which Medicare coverage you will choose. But how do you go about making it official?

Parts A and B

  1. Apply online at Social Security. If you started your online application and have your re-entry number, you can go back to Social Security to finish your application.
  2. Visit your local Social Security office.
  3. Call Social Security at 800-772-1213 (TTY: 800-325-0778).

Medicare Advantage

There are a few options for signing up for a Medicare Advantage plan. You can enroll during:

  • The same enrollment period for Parts A and B (3 months before the month you turn 65 to 3 months after the month you turn 65).
  • The annual Open Enrollment Period for Medicare Advantage plans, which starts on October 15 and ends December 7. You can also switch or drop a Medicare Advantage plan during this time. To enroll in a Medicare Advantage plan, you must be enrolled in Part A and Part B.
  • The Special Enrollment Period, which depends on your personal situation. The Medicare website provides more details about this kind of period.
 

How you enroll (an online form, a paper application, over the phone) depends on whether you go through a health insurance company, an agent, or a health insurance marketplace website.

Medigap

If you are 65 or older, you have a so-called guaranteed issue right within 63 days of when you lose or end certain kinds of health coverage. At this point, companies must sell you a Medigap policy at the best available rate, regardless of your health status. They cannot deny you coverage. You can purchase a Medigap plan through a health insurance company, an agent, or a health insurance marketplace when you are first eligible for Medicare or during the Medicare Open Enrollment Period. Some insurance companies may allow the purchase of a Medigap plan at different times of the year.

Part D

If you're new to Medicare, you might consider enrolling in a prescription drug plan during the Initial 7-month Enrollment Period that begins 3 months before the month you turn 65, depending on your coverage needs. A person enrolled in a Medicare drug plan may owe a late enrollment penalty if they go without Part D or other creditable prescription drug coverage for any continuous period of 63 days or more after the end of their Initial Enrollment Period for Part D coverage. After you enroll, you can always change to a different prescription drug plan during the annual Open Enrollment Period from October 15 to December 7.

4. What do the plans cost?

Bear in mind that you and your spouse will make separate purchasing decisions since all Medicare policies are individual policies.

Part A

As long as you or your spouse or partner paid Medicare taxes for at least 40 quarters (approximately 10 years), Part A coverage is free. But you are still responsible for paying a deductible per each benefit period ($1,364 in 2019), and a daily coinsurance for extended hospital stays.

Individuals who don't qualify for free Part A because they didn't pay Medicare taxes long enough can purchase Part A coverage (in 2019, $437 monthly if you paid Medicare taxes for less than 30 quarters; and $240 monthly if you paid Medicare taxes 30–39 quarters).

Part B

Medicare sets the cost (premium) for Part B each year at a fixed rate for most participants ($135.50 a month for 2019), but it increases for individuals with an annual income over $85,000 and married couples with an annual income above $170,000. The cost for these higher-earning participants can range from $189.60 to $460.50 per month in 2019. Part B premiums also can be higher if you don't enroll when you're first eligible, unless one of the exceptions discussed above applies. A 10% penalty fee per each year you missed enrolling on time is added to the premium—for the rest of your life.

As with Part A, you will pay an annual deductible for Part B ($185 in 2019). And some covered services require that you pay a percentage of the charges or a copayment amount approved by Medicare (which is 20% of costs for many items or services).

If you are already receiving Social Security benefits, payment for your monthly Part B premium is deducted from your Social Security checks. If you're not yet collecting benefits, Social Security will send you a quarterly bill.

Medicare Advantage

When you enroll in a Medicare Advantage plan, you continue to pay premiums for your Part B benefits. Everyone who enrolls in the same Medicare Advantage plan pays the same premium, regardless of age, gender, or health status.

Tip: You can compare Medicare Advantage plans in your area with Medicare.gov's Medicare Plan Finder.

Part D

The amount that insurance companies charge for prescription drug coverage differs. The variation is based on how health insurance companies set up their deductibles and copayments, and the brand name and generic drugs (drug formulary) they cover.

For higher income individuals and couples, you'll pay more in monthly premiums for Part D coverage. Premiums (PDF) vary depending on modified adjusted gross income (MAGI) and marital status.

There is also an unpopular feature of all Part D coverage plans known as the "donut hole" (that is, a temporary limit on what Medicare will pay for your prescription drug costs). After you and your plan have spent $3,820 on covered drugs, you enter into the donut hole coverage gap and become responsible for paying a much greater percentage of the cost of each prescription until you reach catastrophic coverage levels under your plan, at which point your cost-sharing responsibility significantly decreases again. In 2019, once you are in the donut hole, you'll pay no more than 25% of the plan's cost for covered branded drugs and 37% of the price of covered generic drugs.

Tip: Compare Part D costs at Medicare.gov or your local State Health Insurance and Assistance Programs (SHIP) office.

Medigap

Although the benefits offered under a Medigap plan are standardized across the country, premiums for these plans vary. If you plan to purchase a Medigap plan, compare costs before you buy one. Medigap policies are priced 3 ways: (1) Community rated (i.e., priced the same for all enrolled in the same Medigap plan); (2) Issue-age rated (based on your age at the time of application); and (3) Attained-age rated (based on your current age and continues to increase as you get older). Bottom line: Your premium varies by the way the insurance company has priced their plan, along with your geographical location, gender, and smoking status.

5. Which plan is right for me?

To figure out which Medicare option is the right one for you, it's always good to start by looking at the coverage you have now with your current health care insurer. What would you keep or change?

Narrow your options by asking yourself:

  • How much can I afford to spend to pay for my insurance (premiums) and to pay for my care (in the form of deductibles, copayments, and coinsurance)?
  • What benefits do I need? (You might save money if you don't buy coverage for benefits you don't mind paying for out of pocket.)
  • Do I want to choose my own doctors or health care providers?
  • Does the plan include coverage for my unique situation? (Paying for emergencies outside your state or country may be important if you plan to travel.)
  • How does the cost of each plan compare with other plans that have the same benefits?
 

Tip: Medicare.gov and your local SHIP office can help you compare plan features and costs for Medigap and Medicare Advantage plans in your state.

6. Where can I go for more help?

Now that you have the answers to some common Medicare questions, you're likely to have more questions. There are good sources of information available that can provide answers:

  • The official Medicare site, Medicare.gov, offers several helpful guides and interactive tools to help you compare your options
  • The Social Security site for guidance with Original Medicare
  • Your local SHIP office for free one-on-one help from a SHIP program counselor. Plus, SHIP offices offer additional services, seminars, and publications to help you.
 

Plan ahead

Having the right Medicare coverage is a key part of your retirement plan—along with your overall health and wellness in retirement. Among the many factors to consider in your Medicare decision: health status, cost, coverage, amount of travel you plan to do, and access to existing or preferred doctors and hospitals. Consider working with a Fidelity financial advisor to explore options and check out the resources listed within this article to learn more.

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This information is intended to be educational and is not tailored to the investment needs of any specific investor.

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