What is Original Medicare?
Original Medicare is the federal health insurance program that consists of two parts:
Part A (Hospital Insurance) which covers all or part of:
Hospital stays
Emergency room visits
Care in a skilled nursing facility
Hospice
Some at-home health care
Part B (Medical Insurance) which covers all or part of:
Primary & Specialist doctor visits
Outpatient care
Medical supplies
Preventive services
Should I have any other coverage on top of Original Medicare?
Technically no, but it's important to understand that there is no cap on how much your out-of-pocket expenses could be using Original Medicare only.
As an example:
In 2024, Original Medicare has a deductible of $1632 you must pay out-of-pocket before any services are covered
If you had a unplanned hospitalization that cost $30,000, you would be subject to pay 20% of the bill after the deductible is met
Using the example above, here's how you would be charged if you had Original Medicare only:
$30,000 (Total bill) - $1632 (Deductible) = $28,368 (Balance)
$28,368 x 20% = $5673.60 (Your share)
$1632 (Deductible) + $5673.60 (Your share) = $7305.60 Out-of-pocket
To fix this and lower your overall costs, it is recommended that you add either a:
Medicare Advantage Plan (Part C), or
Medigap Supplement (Plans A - N) with a Prescription Drug plan (Part D)
What are the costs for Original Medicare?
While Original Medicare covers some healthcare costs, it doesn't cover everything.
Here is a breakdown of the common costs you need to be aware of:
Part A Premiums: For the majority of working Americans, you will be eligible for Part A benefits without a premium if you or your spouse paid Medicare taxes for at least 10 years(40 quarters) and are eligible to receive Social Security benefits now or in the future. In some rare instances, a beneficiary may have to pay a monthly premium.
Part A Deductibles/Coinsurance: This is the amount you must pay out-of-pocket before Medicare pays for eligible services.
Part B Premiums: Every person who is eligible to receive Medicare will face a Part B premium. Part B premiums are set by CMS(Centers for Medicare & Medicaid Services) on a yearly basis, but may be higher depending on your yearly household income. For more on this aspect of Part B premiums, please see the FAQ below regarding IRMAA.
Part B Deductible: This is the amount you must pay out-of-pocket before Medicare will cover qualifying services.
For a complete list of this year's costs, visit: https://www.medicare.gov/basics/costs/medicare-costs
What do I need to know about IRMAA?
IRMAA, or Income-Related Monthly Adjustment Amount, is an additional amount tacked onto Part B & Part D premiums for beneficiaries who exceed certain income limits.
Here's some important points to know:
IRMAAs are determined by the Social Security Administration(SSA) by looking back at your tax information from 2 years ago
IRMAAs most often apply to high income earners
IRMAAs are assessed by SSA on a yearly basis. It is possible to have an IRMAA occur one year(for instance, as a result of receiving an inheritance)and then have it dropped the next year when your income falls below the limits
You will receive a predetermination letter in the mail, followed by an initial determination letter explaining the nature of your IRMAA
If you are drawing Social Security Retirement income, your Part B & D premiums with the IRMAA will automatically be deducted from your check
If you are not yet drawing your Social Security benefit, then you will receive a quarterly invoice where you will be given options on how you'd prefer to pay your bill in the future
IRMAAs can be appealed if you have experienced a qualifying life change or hardship that has impacted your current income, or if an error in your tax information is found
Click here to download the IRMAA appeal form
To view this year's IRMAA income tables, visit: https://www.cms.gov/newsroom/fact-sheets/2024-medicare-parts-b-premiums-and-deductibles
How do I sign up for Medicare?
Individuals who took Social Security prior to turning 65, those who have been disabled for two or more years, or those who have certain qualifying diseases are auto-enrolled into Medicare.
Those who have delayed taking their Social Security benefits until after they turn 65 will need to enroll themselves.
The recommended way to enroll is to first register for a free MySSA account by following these steps:
Visit ssa.gov & click the "Sign in" link in the top righthand corner
Click the blue "Sign in with Login.gov" button
Click "Create an Account" and enter the email you will use to access your account & receive important paperless notices from the Social Security Administration
Verify your email (which will be your Username from now on)
Once your email is verified, you will be prompted to create a password & log in for the first time
When logging in, SSA.gov uses two-factor authentication security codes that you will receive either by text or email to finalize the login process each time
To enroll in Original Medicare:
Login to your MySSA.gov account when you reach your Initial Enrollment Period (see the FAQ above regarding that timeframe)
Click the blue "Apply for Medicare Benefits" button that will automatically populate once you are inside your IEP
Complete the application. Allow yourself at least 45 minutes to an hour to finish
Check your mailbox for mail from SSA acknowledging the receipt of your application, and if they require any other information from you
You can expect to receive your Medicare card in the mail 60-90 days after applying. You will also have an electronic version of your card in your MySSA.gov account in as little as 30 days
You may also enroll by visiting your local Social Security office or calling them at 1-800-772-1213
If you'd like some assistance, we are available to help guide you through the process at no cost to you. Simply book an appointment and we'll discuss what you need to do to get started
Who is eligible for Medicare?
Original Medicare is designed for those who are:
U.S. citizens age 65+
Legal residents who have lived in the U.S. for at least 5 years and are age 65+
Younger than 65, and have been declared disabled for 24 consecutive months by the Social Security Administration
Younger than 65, and diagnosed with End-Stage Renal Disease (ESRD) or Lou Gehrig's Disease (ALS)
Is Prescription Drug coverage (Part D) included in Original Medicare?
No. You must have a separate qualifying drug plan through a private insurance company. You are required to have one in place once when you become eligible for Medicare, otherwise you could face permanent penalties.
See the Prescription Drug Plan FAQ section below for more detailed information about Part D
When is my Initial Enrollment Period (IEP)?
For seniors turning 65, once you become eligible for Medicare, the Initial Enrollment Period(IEP) is a 7-month timeframe that includes the 3 months prior to your 65th birthday, the month of your birthday, and the 3 months after your birthday.
For those with disabilities, it is the 7 months that includes the month you receive your 25th disability check, the 3 months before and the 3 months after.
For those delaying Medicare until after 65, you have 8 months from the time you either lose employer coverage or you stop working, whichever comes first. For more on this topic, see the "Can I delay Medicare?" & "What else should I know about delaying Medicare? FAQs below.
*Note: If your IEP happens to run concurrently with the Medicare Annual Enrollment Period (October 15-December 7), your IEP will have priority. This means that you can ignore the annual enrollment dates for that year, because they do not apply to you
Do I qualify for financial assistance?
There are two programs that may be available to you if you meet certain income requirements:
1.) Medicare Savings Program (MSP)
A federal program administered by your state's Medicaid system that eliminates part or all of your Part B Premium, co-pays, deductibles and coinsurance depending on what level you qualify for
Is designed for those who have very limited income and resources
Allows for Part B late enrollment penalties to be forgiven
Eligibility is the same as for Original Medicare (See "Who is eligible for Medicare" FAQ above), as well as that you must be a resident of the state where you will apply for the MSP
The federal government decides the income limits, while each state sets its own resource/asset limits. You will need to call either the Social Security Administration at 1-800-772-1213 or your state's local Medicaid office for more information on what the limits are and what information you need to apply
The Medicare Savings Program is separate from your state's Medicaid system. Go here to see if you qualify for Medicaid and start the application process with your state
2.) Low Income Subsidies(LIS), also called "Extra Help with Part D"
A federal program that reduces the cost of your out-of-pocket prescription drugs
Is designed for lower income individuals
Waives or lowers Part D Premiums, co-pays & deductibles
Allows for Part D late enrollment penalties to be forgiven
If you qualify for Medicaid, are receiving Social Security Income (SSI), or are enrolled in the Medicare Savings Program, you'll be auto-enrolled into LIS
To find out if you qualify and to apply, visit https://secure.ssa.gov/i1020/start . Scroll to the bottom of the page to get started. Once completed, you can expect to receive a decision in the mail within 2-4 weeks
If you'd like some assistance, we are available to help guide you through the process at no cost to you. Simply call or book an appointment and we'll discuss what you need to do to get started.
What else should I know about delaying Medicare?
There are some important points you should know when considering whether or not to delay Medicare:
Some employers allow you to stay on their plan, however, they may charge extra fees onto your monthly premiums once you turn 65
If your employer plan meets the requirements and you decide to delay Medicare, you do NOT need to notify Social Security unless:
You are already receiving Social Security Retirement benefits, or
You were auto-enrolled into Medicare prior to age 65
If either of these apply to you, you will need to visit your local SSA office or call 1-800-772-1213
It is recommended that you still take Medicare Part A(Hospital Insurance) when you first become eligible. If you or your spouse have paid taxes for 10 years, or 40 quarters, then your Part A will not have a premium, and may be used in addition to your employer coverage
If you delay Medicare and you either have a planned retirement date, or were terminated short-notice, you have an 8-month window that begins the day after your last day of work, to complete the following steps in this order:
Download and print the "Request for Employer Information" form
Turn it in to your employer's HR Department. Do NOT fill it out. They must complete it and return it back to you
Apply for Part B Medicare (or Both A&B) by using your MySSA.gov account, visiting your local SSA office or by calling 1-800-772-1213.
Include the completed form with your Medicare application
If your retirement date is planned, it is recommended you start the the process 2 months prior to your retirement date to avoid a lapse in coverage
Failure to complete the above steps within the 8-month timeframe means you will have to wait until the next year's Medicare Open Enrollment Period (Jan 1-March 31) to enroll. You will also accrue permanent monthly Part B & Part D penalties for every month outside of that window where you are without Medicare
You are allowed to have COBRA during the 8-month window, however, it doesn't exclude you from accruing late enrollment penalties if you keep it beyond that timeframe
If you have any other questions, or would like assistance with this process, please book an appointment with us so we can help you navigate the transition.
Can I delay Medicare if I work past 65?
Yes, you can, but only under certain circumstances:
The employer-based plan must be considered "creditable". Short-term medical, medical discount/reimbursement programs and hospital indemnity plans do NOT qualify as "creditable coverage". Your employer is required by law to disclose to you whether or not the coverage they offer meets the federal minimum standard to be considered "creditable"
The employer must have 20 or more employees
The employer doesn't require you to take Medicare in order to stay on their plan
If your employer plan meets these requirements, then you may delay Medicare until you stop working without penalty
ORIGINAL MEDICARE FAQS
(Parts A & B)
Medigap Supplements
Medicare Advantage FAQ's
Part C
What is Medicare Advantage?
Medicare Advantage plans are a "bundle of services" offered by private insurance companies that include your Part A & B coverage, and sometimes Part D.
Medicare Advantage plans also have added benefits* not included in Original Medicare, such as:
Generous Dental Benefits
Comprehensive Hearing coverage, including Hearing Aids
Vision Benefits
Complimentary Gym Membership
Over-the-Counter Spending Money
Healthy Food Allowance
Complimentary Transportation
Flex Spending Account to use toward certain healthcare or utility costs
Capped out-of-pockets costs
And more
*Benefit availability varies by plan and county of residence
How much does Medicare Advantage cost?
Most Part C plans have a $0 monthly premium.
As long as you are up to date with paying your Medicare Part B premium, you will stay enrolled in your Advantage plan
Is prescription drug coverage included in Medicare Advantage plans?
Most of the time, yes. The Kaiser Family Foundation estimates that 89% of all Medicare Advantage plans include prescription drug coverage. These plans are referred to as MAPDs
Who can enroll into Medicare Advantage?
Anyone who is actively enrolled in Original Medicare Parts A & B can enroll into a Medicare Advantage Part C plan.
See the "Who is eligible for Medicare" FAQ above for more info on who qualifies for Original Medicare
How do I enroll in a Medicare Advantage plan?
When you are within a qualifying enrollment period, there several ways:
Go to Medicare.gov or call 1-800-MEDICARE
Choose a company and call or go online
Find a local broker
If you'd prefer a more tailored approach, please call or book an appointment and we'd be happy to help you get started
What is the difference between an HMO plan & a PPO plan?
In an HMO, or Health Maintenance Organization plan:
Coverage is limited to a smaller network of providers
You are required to get a referral by your Primary Physician in order to see any specialists or get certain tests/images
Out-of-pocket cost are typically lower
Plan benefits are often more generous(ex: $2000 dental benefit with an HMO vs. $1000 with a PPO)
Preventative healthcare is limited to your county of residence
No out-of-network coverage, except in the event of an emergency
In a PPO, or Preferred Provider Organization plan:
Access to a larger network of providers
No referrals are required to see specialists
Nationwide coverage
Benefits are less generous
Out-of-pocket costs may be higher
May have an additional monthly premium
Can I get Medicare Advantage if I have pre-existing conditions?
The great news is, yes, you can.
There are no disqualifying pre-existing conditions, and in fact, some Part C plans are tailored to lower out-of-pocket costs for those with certain chronic illnesses* such as diabetes, COPD, high blood pressure, heart disease & dementia.
If you would like to see about switching to one of these types of plans, please call or book an appointment and we'd be glad to help
*Plan availability varies by county of residence
Can I opt out of my Employer's Medicare Advantage plan?
Yes. Some employers offer a Medicare Advantage plan as part of their retirement package, but you are not obligated to take it.
Here's some important things to consider:
Employers often charge an additional monthly premium for their Part C plan
Employers use the same private insurance companies for their plans as the Medicare Advantage plans available to the public
Employer Medicare Advantage plans often do not have a "donut hole" (See Prescription Drug Plan FAQs below for a more detailed explanation)
Some employers charge an additional premium for the prescription drug portion of their plan
If you opt out of enrolling into your employers Medicare Advantage Part C plan, typically you will not be allowed to re-enroll in the future
It's important to speak with your employer's administrator about the costs and timelines that you may be facing before making any decisions
If you'd like a no obligation cost comparison or have other questions about switching to a private Part C plan, please call or book an appointment and we'd be happy to help
When can I enroll in Medicare Advantage?
Only during certain times of the year, or under qualifying circumstances.
If you are New to Medicare or decide your Part C plan is no longer a good fit, you may switch during the following:
Initial Enrollment Period (IEP)
A 7-month window only available to those who are new to Medicare beginning 3 months prior to your birthday, the month of your birthday, and the 3 months following (See the "When is my Initial Enrollment Period" FAQ above for more on IEPs)
The plan you have chosen at the end of this window is the one you will be enrolled in until next year's annual enrollment
Medicare Annual Enrollment Period (AEP)
Runs annually October 15th-December 7th
The plan you have chosen at the end of this window is the one you will be enrolled in which becomes active January 1
Medicare Advantage Open Enrollment Period (OEP)
Runs annually January 1 - March 31
You are allowed a one-time change that you must keep until next year's Medicare Annual Enrollment Period
Special Enrollment Period (SEP)
Can occur at any time during the year
Is triggered by a qualifying event, which includes, but is not limited to:
Retiring and losing your employer coverage
Moving to a new county of residence, even if it's within the same state
Become newly qualified for extra financial assistance(such as gaining Medicaid)
Have been diagnosed with certain qualifying chronic health conditions
Live in a federally declared disaster area
For further guidance on this topic, or if you believe you have experienced a qualifying event, please call or book an appointment and we'd be happy to help
Can I have a Medicare Advantage Plan(Part C) as a retired military veteran?
Yes. If you have TRICARE for Life(TFL) or are VA connected, you may also have a Medicare Advantage plan.
Think of it like this:
TFL/VA is your military healthcare entitlement
Original Medicare is your federal healthcare entitlement
Medicare Advantage is an additional private health insurance plan
These 3 are meant to be used in tandem
I like to do my own research. Where can I compare Medicare Advantage plans on my own time?
You easily view and compare Medicare Advantage plans in your area by going here. (TX, LA & NM only)
Simply input your doctors, meds and any health conditions to get a list of options that could be a good fit for you.
And remember, we're only a phone call away if you get stuck or have questions
Prescription Drug Coverage
Part D
How much does Medicare Advantage cost?
Most Part C plans have a $0 monthly premium.
As long as you are up to date with paying your Medicare Part B premium, you will stay enrolled in your Advantage plan
Do I need prescription drug coverage (Part D)?
Yes, you are required to have a qualifying drug plan in place while in Medicare, regardless of whether or not you take any prescriptions.
You will need to either enroll in a standalone drug plan or a Medicare Advantage plan with drug coverage (MAPD).
Failure to do so means you may face a permanent penalty if you are without qualifying drug coverage for too long