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by iNBenefits
Medicare Basics
Original Medicare: Parts A & B
Original Medicare is federal health insurance for people age 65 and older and certain younger individuals with disabilities. It includes Part A (Hospital Insurance) and Part B (Medical Insurance).
Part A – Hospital Insurance
Part A helps cover hospital stays, skilled nursing facility care, hospice, and certain home healthcare services.
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Monthly Premium: $0 for most people who worked and paid Medicare taxes for at least 10 years (or qualify through a spouse).
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Deductible: Applies to each hospital benefit period.
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Skilled Nursing Care: Limited to 100 days per benefit period when Medicare's coverage requirements are met.
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Not Covered: Long-term custodial care, including most assisted living and memory care services.
Part B – Medical Insurance
Part B helps cover doctor visits, outpatient care, preventive services, medical equipment, and other medically necessary treatments.
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Monthly Premium: Most people pay a standard monthly premium. Higher-income individuals may pay more (IRMAA).
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Annual Deductible: Applies before Medicare begins paying for most covered services.
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80/20 Coverage: After the deductible, Medicare generally pays 80% of approved costs, leaving you responsible for 20%.
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No Out-of-Pocket Limit: Original Medicare has no annual cap on your share of covered medical expenses.
Important: Medicare Supplement insurance can help pay Original Medicare's out-of-pocket costs. Medicare Advantage and Medicare MSA plans are alternatives to Original Medicare, with different cost-sharing rules.
Who qualifies for Medicare
You're qualified for Original Medicare (Part A & B) if:
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you're 65 or older
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If you are under 65, you may qualify if you have been receiving Social Security Disability Insurance (SSDI) for at least 24 months.
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Individuals with End-Stage Renal Disease (ESRD), which involves permanent kidney failure requiring dialysis or a transplant, are also eligible regardless of age.
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people diagnosed with Amyotrophic Lateral Sclerosis (ALS) qualify immediately upon diagnosis.
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You must also be a U.S. citizen or legal resident who has lived in the U.S. for at least five years.
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When can I enroll in Medicare Part A & B
Initial Enrollment Period (IEP) Part A & B
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If you plan to enroll at 65, your initial Enrollment Period (IEP) begins three months before, and ends three months after, your 65th birth month. Coverage can begin as soon as the first day of the month you turn 65.
Annual Enrollment Period (AEP) Oct 15 - Dec 7
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During this time you can apply for any type of Medicare plan - Part A, B, C (Medicare Advantage), D (Prescription Drug) and Medigap. It is also the time when you can freely move between plan types.
Open Enrollment Period (OEP) Jan 1 - Mar 31
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This period is limited to those enrolled in a Medicare Advantage Plan. During this time you can switch from your current Medicare Advantage plan to another Medicare Advantage plan (with or without drug coverage) or to Original Medicare (with or without a Part D drug plan)
Special Enrollment Period (SEP)
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Certain events may qualify you for a change in your Medicare coverage, such as leaving your plan service area, changes to your financial eligibility or losing employer coverage.
General Enrollment Period (GEP) Jan 1 - Mar 31
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The General Enrollment Period (GEP) is the time period every year when a beneficiary may enroll in Medicare for the first time if they missed their Initial Enrollment Period (IEP) and do not qualify for the Special Enrollment Period (SEP). Your coverage starts the month after you sign up. You might pay a monthly late enrollment penalty.
Medicare Part D - Prescription Drug Plans
Key Details of Medicare Part D Plans
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Offered by private insurance companies. Prescription drug coverage helps pay for many brand-name and generic prescription medications.
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Available as standalone or bundled plans and each plan has a list of covered medications called a formulary, which may vary by plan.
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Medications are usually placed into tiers, with lower-tier drugs typically costing less than higher-tier or specialty drugs.
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Some plans require a deductible before prescription coverage begins and members pay a portion of the drug cost when filling prescriptions.
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Plans typically have preferred pharmacies where medications may cost less.
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After a beneficiary reaches a certain out-of-pocket spending threshold, their share of prescription costs is significantly reduced.
For more information about Part D plans go to www.medicare.gov
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