What is Original Medicare?

In the United States, Medicare is a national insurance program, administered by the U.S. Federal Government, that guarantees access to health insurance for Americans aged 65 and older, younger people with disabilities as well as people of all ages with end stage renal disease.


Download the PDF "Medicare & You 2016"


What are the Different Parts to Medicare?

Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals, hospice care, skilled nursing facility care and home health care.


Medicare Part B (Medical Insurance) helps cover outpatient hospital care, services from other physicians and health care providers, home health care, durable medical equipment and some preventive services.


Medicare Part C (Medicare Advantage Plan) includes all services covered under Part A and Part B. Medicare-approved private insurance companies administer it. Usually includes Medicare Prescription Drug coverage (Part D). If you join a Medicare Advantage Plan you can’t use a Medicare Supplement policy.


Medicare Part D (Prescription Drug Plan) helps cover the cost of prescription drugs. They are run by Medicare-approved private insurance companies. A Part D plan may help lower your prescription drug costs.


What are Medicare Supplement Plans (Medigap)?

Original Medicare pays for many health care services, but not all. Medicare Supplement plans are also called Medigap policies. Medicare Supplement insurance policies can help pay some of the costs that Original Medicare does not cover. These are standardized policies sold by private insurance companies and designed to fill in the gaps in Original Medicare.


A Medicare Supplement policy can help cover copayments, coinsurance and deductibles. Medicare will pay for its share of the Medicare-approved amount for covered health care costs, and then your Medicare Supplement policy will pay its share. If you join a Medicare Advantage Plan you can’t use a Medicare Supplement policy. You must have Part A and Part B Medicare for a Medicare Supplement plan.


Download the PDF "Choosing a Medigap Policy"


What are Medicare Advantage Plans (Part C)?

Medicare Advantage (MA) Plans are a replacement for Original Medicare Part A and B. They are another way to get your Medicare coverage. Many Medicare Advantage plans also include Prescription Drug coverage and are know as Medicare Advantage Prescription Drug or “MAPD”.


Medicare Advantage Plans often offer extra coverage, like vision, hearing, and dental programs. In addition to your Part B premium, you may pay a monthly premium for a Medicare Advantage Plan. You can’t use a Medicare Supplement plan while you’re in a Medicare Advantage Plan.


There are different types of Medicare Advantage Plans. Some are:

  • Health Maintenance Organization (HMO) plan. You may only go to doctors, other health care providers, or hospitals in the HMO plan’s network except in an emergency.
  • Preferred Provider Organization (PPO) plan. In a PPO plan, you pay less if you use doctors, hospitals, and other health care providers that belong to the PPO plan’s network. You usually pay more if you use doctors, hospitals, and providers outside of the network.
  • Private Fee-for-Service (PFFS) plans—PFFS plans are similar to Original Medicare in that you can generally go to any doctor, other health care provider, or hospital as long as they accept that specific plan’s terms and conditions. The plan determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care.

Download the PDF "Prescription Drug Coverage"


Who is Eligible for Medicare?

You are eligible for Medicare at the age of 65 if you are a U.S. citizen or legal resident and you or your spouse has worked in the U.S. for at least 10 years. You are also eligible for Medicare if you are under the age of 65 with certain disabilities or have End Stage Renal Disease (ESRD).


How do I Enroll in Medicare?

You will be automatically enrolled in Medicare Part A and Part B if you are already getting benefits from Social Security or the Railroad Retirement Board (RRB) starting the first day of the month you turn 65. If you’re under the age of 65 and disabled, you’ll automatically get Part A and Part B after you get disability benefits from Social Security.


If you’re automatically enrolled, you’ll receive your red, white and blue Medicare card in the mail 3 months before your 65th birthday or 25th month of disability benefits. If you elect to wait to get Part B, follow the instructions on the card and send it back.


If you have End Stage Renal Disease (ESRD), you’ll have to contact Social Secirity to find out when and how to sign up for Medicare.


If you are turning 65, you can sign up for Part A and Part B during the 7 month period that begins 3 months before the month you turn 65. That’s 3 months before your turn 65, the month you turn 65 and 3 months after you turn 65.


If you didn’t sign up for Part A and Part B during those 7 months in which you were eligible, you can sign up between January 1 – March 31 each and your coverage will begin July 1st of that year. You may have to pay higher premiums for late enrollment.


You can apply online to Medicare here.


What Does Medicare Cover?

Medicare covers health services and supplies that would be considered medically necessary to treat a condition or disease, such as lab tests, surgeries and doctor visits. If you’re in a Medicare Advantage plan, you may have different rules, but you must have at least the same coverage as Original Medicare.


In general, Part A covers hospital care, skilled nursing care, hospice and home health services. Part B general covers outpatient hospital care, services from other physicians and health care providers, home health care, durable medical equipment and some preventative services.


Medicare Supplement plans add additional coverage to fill in the “gaps” of Original Medicare.


What is the Open Enrollment Period (OEP)?

Tthe Annual Election Period (AEP) is is from October 15th through December 7th each year. Any changes you make during this time will go into effect on January 1st of the next year. Your Medicare plan benefits and your needs can change on an annual basis, so use the AEP to compare your options or make changes to your Medicare Advantage or Prescription D plans.


During this time, you may switch from Original Medicare Part A and Part B to a Medicare Advantage plan. Or change back from a Medicare Advantage plan back to Original Medicare. You may also switch from one Medicare Advantage plan to another. You may also switch to a plan that offers drug coverage (MAPD) from a Medicare Advantage Plan. This is also a time to join a Prescription Drug Plan (PDP) or switch from one PDP to another.


Once the OEP is over, you can’t make changes to your Medicare plan until the next year. There are also Special Enrollment Periods (SEPs) when you can also make changes to your Medicare Advantage and Prescription Drug plan. These SEPs happen when certain events happen in your life, like if you move or you lose other insurance coverage.


Note: Medicare Supplement Insurance plans are an exception. You can join or change from one plan to another at any time during the year, not just during OEP.


You can find out more information on the different enrollment periods for Medicare here and compare or change plans here.


Download the PDF "Understanding Enrollment Periods"


What is the difference between Medicare and Medicaid?

The words “Medicare” and “Medicaid” are so similar it’s easy to be confused. They are both government programs and both help people pay for health care. But they are two completely different programs. The main difference is that Medicare is generally for people over the age of 65 or those with disabilities.


Medicaid is for people with limited income and resources. The Federal government governs Medicare and State governments govern Medicaid. You can call your State Medical Assistance office to see if you qualify for Medicaid.