Braden Medicare Insurance' Top 10 Most Frequently Asked Questions About Medicare

Michael T. Braden February 12, 20234 GENERAL MEDICARE

Here at Braden Medicare Insurance, we have the honor and privilege of reaching prospects, clients, and leads daily. Interacting with and helping others to unravel and understand Medicare is arguably the best part of our day. We receive many questions about Medicare, which prompted me to write this article on Braden Medicare Insurance's Top 10 Most-Asked Medicare Questions.

WHAT EXACTLY IS MEDICARE?

Medicare is the Federal Insurance Plan for individuals 65 and older and for those with Disabilities or ESRD (End Stage Renal Disease).  Medicare is an 80/20 Health Plan.

THE FOUR DIFFERENT PARTS OF MEDICARE:

• Medicare Part A (In-Patient Hospital Insurance)

  
  

  Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and certain home health care services.

  
  

• Medicare Part B (Out-Patient Medical Insurance)

  
  

  Part B covers sure doctors' services, outpatient care, medical supplies, and preventive services.

• Medicare Part C (Medicare Advantage)

  
  

  Available as an Option to Original Medicare.  Private insurance companies offer these plans and are not managed by the Government. Medicare Advantage plans are designed to offer everything Medicare does and typically provide more benefits than Original Medicare.  However, they also limit you to using doctors only in their Network. 

• Medicare Part D (Prescription Drug Coverage)

  
  

  Helps Medicare beneficiaries pay for Prescription medications. Private insurance companies offer these plans, but they must operate under the rules set in place by Medicare, which is part of the Department of Health and Human Services. 

  
  

  Each plan varies in cost and the specific drugs it covers, but it must provide at least the standard level of coverage set by Medicare. Medicare drug coverage includes generic and brand-name drugs. Plans can vary the list of prescription drugs they cover (called a formulary) and how they place drugs into different "tiers" on their formularies. 

  
  

  Each Part D plan has different monthly premiums.  You’ll also incur other costs throughout the year with a Medicare drug plan. The amount you pay for each drug depends on the plan you choose. 

  
  

THE 3 WAYS YOU CAN CHOOSE TO RECEIVE MEDICARE

ORIGINAL MEDICARE

Original Medicare includes Medicare Part A  (Hospital Insurance) and Medicare Part B (Medical Insurance).  The Government pays for 80% of all Medicare-covered and Medically Necessary procedures, while you, the Medicare Beneficiary, pay for the other 20% of health services not paid for by Medicare. You typically pay for services as you receive them. When you get services, you’ll pay a deductible at the start of each year, and you usually pay 20% of the cost of the  Medicare-approved service, called coinsurance. If you want drug coverage, you can add a separate drug plan (Part D).

ORIGINAL MEDICARE WITH A MEDICARE SUPPLEMENT

Original Medicare covers much, but not all, of the cost of covered health care services and supplies. A Medicare Supplement Insurance (Medigap) policy is designed to help "fill in" the gaps left by my Original Medicare. Medicare Supplemental (Medigap) Insurance can help pay some of the remaining health care costs, such as copayments, coinsurance, and deductibles. Some plans will pay for your entire 20% share of your Healthcare  Costs,  emergency medical care when you travel outside the U.S., as well as your Medicare Part A Deductible.

MEDICARE ADVANTAGE

Medicare Advantage Plans are plans that fall under the category of Medicare Part C. Medicare Advantage plans are offered from private, for-profit companies and not by the government. These plans are designed to be an alternative to Original Medicare. These “bundled” plans include Part A, Part B, and usually Part D. Plans may offer additional benefits that Original Medicare doesn’t cover, such as vision, hearing, and dental services. Medicare  Advantage Plans have yearly contracts with Medicare and must follow  Medicare’s coverage rules. The plan must notify you about any changes before the start of the next enrollment year.

Medicare Advantage Plans are still 80/20 Health Plans, but they are managed by private Insurers, who have the final say on which services are covered and which are not. Hence, you are at the mercy of your individual plan; just because something is covered under Medicare does not mean it will be covered entirely or paid for by a Medicare Advantage plan.

Each Medicare Advantage Plan can charge different out-of-pocket costs. They may also have different rules for accessing services. And, the majority of Medicare Advantage plans are HMO plans, meaning that you typically must use your plan's "Network" of Doctors and Hospitals to get your services paid for. 

IS MEDICARE FREE?

Almost everyone seems to expect that Medicare is entirely free; unfortunately, Medicare is not 100% free.  Medicare is, however, the most affordable Health plan in America, and when coupled with a Medicare Supplement Plan G, it is the most comprehensive coverage you can get.  Most people do not pay for Medicare Part A because they have contributed to Medicare through their working careers. 

Medicare charges everyone a monthly Part B Deductible of $174.70 for 2024.  Every Medicare Beneficiary is required to pay the Medicare Part B Premium of $174.70 per month, regardless of whether they choose a Medicare Advantage Plan, Original Medicare, or Original Medicare with a Medicare Supplement (Medigap) plan.

In addition to the Monthly Part B Deductible, Medicare also has an Annual Medicare Part B Deductible of $240.  This means you will receive a Medicare bill for the first $240 in healthcare costs/services each year.  

Medicare Part D Monthly premiums can range from $0.00 to $169.50 per month, not including copayments and coinsurance for your prescription medications.

WHEN DO I SIGN UP FOR MEDICARE

Everyone should start researching Medicare when they are 64-1/2.  That gives them plenty of time to determine which Medicare Plan they believe will fit them best, and to decide whether it makes more sense to stay with their employer's plan (if they are working past 65) or to enroll in Medicare.  Everyone who is 65  and works for a company with fewer than 100 Employees must enroll in Medicare at 65 to avoid Part B Penalties for not having Credible Coverage.  

Medicare defines Credible Coverage as having the same minimum coverage as Medicare.  Typically, any employer with more than 20 employees is considered to offer Credible Coverage.  Any Employer with 20 Employees or fewer is considered non-creditable coverage.

Other types of Non-Credible coverage past age 65 include Veterans Insurance (Champ, VA & Tri-Care), all Private Healthcare plans, COBRA, Retiree plans, and FEHB (Federal Employee Health Plans).

ENROLLING IN MEDICARE

You can Enroll in Medicare by using the Social Security Administration, website at www.ssa.gov, by calling your local Social Security Office or by applying in person at the Social Security Administration Office closest to you. You can choose to enroll in Part A & Part B or both Parts A & B. 

The process typically takes 4-8 weeks to complete, so starting 3-4 months before your 65th birthday is advised.

Anyone who chooses to receive their Social Security benefits before age 65 will automatically be enrolled in Medicare when they turn 65.

WHAT IS THE MEDICARE INITIAL ENROLLMENT PERIOD?

You can take advantage of your initial enrollment window as early as three months before you turn 65. For those on disability, your Initial  Enrollment Period window will begin after receiving Social Security for  24 months, and then again when you turn 65.

MEDICARE ELECTION PERIODS THAT ARE AVAILABLE EACH YEAR

This is one of the few scenarios where you will receive two opportunities during the Initial Enrollment Period. The other scenario is if you retire, return to work, obtain employer group coverage, and then retire again later.  If you choose this, you will qualify for a Special Enrollment Period (SEP).

If you missed your Initial Enrollment Period 7-month window for one reason or another, you could still enroll during the GEP (General Enrollment Period). Keep in mind that if you enroll during the annual GEP, your Medicare will not start until July 1st. 

Therefore, you may have a coverage gap. If you didn’t maintain creditable coverage, you’d be subject to an endless Part B Premium penalty.

WHO QUALIFIES FOR AUTOMATIC ENROLLMENT INTO MEDICARE?

You qualify for automatic enrollment if you’re collecting Social  Security benefits. You should receive your Medicare card about three months before your 65th birthday. If you’re not collecting Social Security by the time you age into Medicare at 65, you’ll need to enroll yourself, and if you have Railroad Retirement Board disability for at least 24 months. 

WHAT HAPPENS IF I MISS MY INITIAL ENROLLMENT PERIOD (IEP)?

Your effective date for Medicare Parts A and B  depends on when you enroll. If you enrolled within the three months before your 65th birthday, your effective date is the first day of your  Birthday month. If you enroll during the month of your 65th birthday,  your effective date is the first day of the month after your birthday.   

If you enroll within three months of your birthday, your effective date will be the first of the month three, five, or six months after your birthday. This number increases with each month you wait. For example, if you were born on June 11 and enrolled in Medicare in August (two months after your birthday), your effective date will be November 1 (five months after your Birthday month).

DO YOU HAVE TO JOIN MEDICARE PART D?

Technically no, you do not have to do anything you do not want to do, however; if you do not choose to enroll in a Medicare Part D Prescription Drug plan within 63 days of your turning 65 or joining Medicare Part B, you could be subject to a 1% penalty which is about .39 cents per month for each month you went without a Part D plan, and that is not the worst part, this Part D penalty never goes away, so someone who blew off getting a Part D plan for say 2 years would pay about .39 x 24 Months meaning they would owe $9.36 in a Part D Penalty for as long as they are enrolled in a Part D plan.   

DOES MEDICARE COVER VACCINATIONS?

Medicare covers annual Flu Vaccines,  Shingrix (Shingles Vaccine), Pneumonia, Hepatitis, Tdap, and chickenpox.  If you plan to schedule your Shingrix Vaccine (2 shots, 3 months apart), it is advisable to schedule the first shot in September and the second in December.  Why? Because there is a considerable cost difference for Medicare Beneficiaries.  It will cost $155-$210 for the Shingrix Vaccine if you have not met your annual Part D Deductible, and usually between $10-$20 if you have reached your yearly deductible. (Using GoodRx, you can generally pay around $155 for the Shingles (Shingrix) vaccine.)

Under Medicare, some Vaccines are billed under Medicare Part B. In contrast, others are only covered through Part D.  Ask your Broker or call the Member Services Number on the back of your Medicare Supplement or Medicare Advantage Card to be sure.

WHAT IS AND WHEN IS THE MEDICARE AEP (ANNUAL ENROLLMENT PERIOD)?

THE MEDICARE ANNUAL ENROLLMENT PERIOD RUNS FROM OCTOBER 15th - DECEMBER 7th EACH YEAR

From October 15th to December 7th, you can choose a new Prescription Drug Plan for the next year (Beginning on January 1st), change your Medicare Advantage Plan, or stay with your current Medicare Advantage plan if it is still available.  Your new plan will go into effect on January 1st. If you have a Medigap or Medicare Supplement plan, you do not need to do anything during the Annual Enrollment period.

DO I HAVE TO CHANGE MY MEDICARE SUPPLEMENT EVERY YEAR?

No. Once you have a Medicare Supplement Plan, it will never cancel or lapse as long as you make your monthly premium payments.  And, Medicare Supplement plans can be changed any day of the year; there are no special periods to deal with if you have a Medicare Supplement. However, if you switch your Medicare Supplement plan after your initial Guaranteed Issue period, you will be required to answer Medical questions and undergo medical underwriting. 

WHAT IS NOT COVERED BY MEDICARE?

What Things Are Not Covered By Original Medicare

General Annual Eye Exams at an optometrist's office are not covered.  Medicare also does not cover Hearing Aids, Eyeglasses, Contact Lenses, Hearing Tests, or Dental coverage.

However, Medicare will cover procedures and treatments from an Ophthalmologist, such as Cataracts, Macular Degeneration, or any other procedure that is deemed Medically Necessary by your doctor, which could include TMJ and Ear Canals.