If you have questions about Medicare like, "Can I keep my doctor with my plan?" Or "Does Medicare cover my medical procedure or service?" you are in good company. Understanding and signing up for Medicare can be confusing, whether it is Original Medicare or a Medicare Supplement plan.
But fear not: We have the answers you are looking for. Let us dive into 10 commonly asked questions about Medicare, so you can learn how Medicare plans work and determine what is right for you.
1. What is Medicare?
Medicare is a federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant). Medicare typically covers the costs of emergency, preventative, and long-term healthcare.
Medicare is funded by the federal government, but various related programs, like Medicare Supplements, have state oversight. The two main categories of Medicare coverage include Original Medicare (with optional Medicare Supplement and prescription drug insurance) and Medicare Advantage.
2. Who qualifies for Medicare?
There are three groups who qualify to receive Medicare:
- People who are 65 and older.
- People under 65 years old who are disabled and who have been receiving Social Security Disability benefits for at least 24 months.
- Qualified people with End Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis, also known as ALS or Lou Gehrig’s disease.
3. What does Medicare cover?
A wide variety of healthcare services are covered by Medicare, depending on the type of policy you choose, including:
- Ambulance services
- Artificial eyes & limbs
- Bariatric surgery
- Blood processing & handling
- Cardiac rehabilitation programs
- Cardiovascular disease screenings
- Cervical & vaginal cancer screenings
- Depression screenings
- Diabetes prevention programs
- Diagnostic tests (laboratory and non-lab)
- Eye exams (routine)
- Eyeglasses & contact lenses
- Flu shots
- Foot care
- Hearing aids
- Hepatitis B and HIV screenings
- Inpatient hospital care
- Kidney transplants
- Lung cancer screenings
- Mental health care (inpatient and outpatient)
- Occupational therapy
- Opioid use disorder treatment services
- Organ transplants
- Pain management
- Prescription drugs (outpatient)
- Preventive & screening services
- Radiation therapy
- Sexually transmitted infections screenings & counseling
- Sleep studies
- Urgently needed care
- Yearly "wellness" visits
4. Am I automatically enrolled in Medicare when I turn 65?
Many people automatically get Original Medicare - also known as Part A and Part B - especially if they are receiving Social Security retirement benefits when becoming eligible for Medicare coverage. Other people may need to sign up for Medicare.
If you're aging into Medicare, you have a seven-month Initial Enrollment Period (IEP) to apply for Medicare: three months before you turn 65, the month you turn 65, and three months after you turn 65. And you must sign up individually for the parts of the program - Parts A, B, C and/or D - that you want.
5. Do I need Medicare if I already have health insurance?
Most plans that employers offer meet these standards. So, if you have insurance through your job, you probably don't need Medicare. However, by staying on an employer plan, you can delay enrolling in Part B without a penalty and avoid paying Part B premiums.
An important note: When you have Medicare plus additional insurance policies, each provider becomes a "payer." The policy that pays for your specific medical services first depends on the coordination of benefits rules for your plans.
In other words, the primary payer will pay what it owes on your medical bills first, then the provider will send the remaining amount to the secondary payer to pay the rest.
6. What's the difference between Original Medicare, Medicare Advantage, and Medicare Supplement plans?
Medicare is divided into two categories, with Medicare Part D as an additional option for prescription coverage.
When signing up for Medicare, Part A is mandatory, but Parts B, C, and D are optional. But keep in mind that you will incur a late penalty if you do not enroll in Parts B and D when you are first eligible.
Here is a breakdown of the different Medicare parts and plans:
Part A (Original Medicare Plan)
Covers inpatient care in a hospital, inpatient care in a skilled nursing facility (not custodial or long-term care), hospice care, skilled nursing home care, and other types of home health care.
Part B (Original Medicare Plan)
Covers medically necessary services, preventative care, clinical research, mental health care, inpatient and outpatient services, partial hospitalization, and more.
Part C (Medicare Advantage Plan)
Combines Parts A and B into bundled coverage through an approved private insurance company that uses the Medicare network.
Part D (Prescription Drug Coverage)
Pays for several tiers of name brand and generic medications, sometimes up to a limit.
Medicare Supplement Insurance
Extra coverage through an approved private insurance company that fills gaps or "supplements" what Original Medicare does not cover. Also known as a Medigap plan.
You can typically buy Medigap insurance online to help you cover the out-of-pocket costs and additional services that are not covered by your primary plan as examples, a Medicare supplement plan may be used to cover copays, coinsurance fees, and deductibles.
A Medicare supplement plan is a standalone policy, so you will pay an additional cost for the plan outside of your primary Medicare premium. You must also have Medicare Part A and Part B to qualify for Medigap insurance.
Lastly, Medigap policies are guaranteed renewable, which means your insurance company cannot cancel your policy if your health conditions change. You just must pay your premiums on time.
7. Does Medicare cover dental and vision services?
Certain Medicare Advantage Plans (Part C) may cover dental and vision services, so make sure to check your policy before you enroll.
8. Can I have both Medicare and Medicaid at the same time?
In many cases, yes. Medicaid is a federally supported program that helps states provide medical coverage for individuals with a limited income. So you may qualify for both if you meet the economic requirements for Medicaid and the age or disability requirements for Medicare.
Some states also provide expanded Medicaid access to individuals (including those with Medicare) who meet economic qualifications after subtracting their out-of-pocket medical expenses from their income.
For example: If you are a single person who earns $26,000 a year, you probably will not qualify for Medicaid under normal program requirements. But if you live in a state with expanded access, you can subtract your medical expenses from your salary to come to a new income. So, if you spend $7,000 on medical expenses, then your final income for your Medicaid application would be $19,000, so you might qualify for coverage.
Note: If you qualify for both programs, Medicare is automatically designated as your primary insurance provider while Medicaid becomes the secondary payer.
9. Which medications does Medicare Part D cover?
Medicare Part D coverage varies based on your insurance company, but all plans must include a minimum amount of medication coverage that is approved by Medicare.
So qualifying Part D plans must offer at least two medication options from each class of drug category on their formulary to treat common health issues. But not all health conditions are covered.
Check your insurance company's formulary (a list of generic and brand name prescription drugs covered by your specific health plan) to see what prescription drugs are covered. And fortunately, there are lots of other ways to reduce your prescription costs.
If you don't have a Part D plan, it can be added to any Original Medicare policy, Medicare Savings Account (MSA) Plan, some Medicare Cost Plans, and some Medicare Advantage Private Fee-for-Service (PFFS) Plans.
10. How do I check the status of my Medicare application?
The short answer is, "It depends."
If you applied for a standard Medicare Part A or Part B plan, you could check the status of your application by logging into your account on the Medicare website. Your application should show up in your profile within 24 hours of submission.
Get Help with Medicare
Though we covered some common Medicare questions, you might still need help choosing the best Medicare plan for your needs and budget.
Just call 833-265-9655 to reach one of our licensed insurance agents, or you can find and compare Medicare plans to see available options in your area.