FIND A COMMUNITY

Navigating Medicare: A Guide for Seniors

As a senior citizen, Medicare and other healthcare options can be very difficult to navigate. Health insurance is vital for all seniors, but it’s not easy to find the best option for you. Let’s explore your Medicare options, and find the best choice for your stage of life. 

What is Medicare?

Medicare is a federal health insurance program for people aged 65 and older, certain younger people with disabilities, and people with end-stage renal disease. 

Medicare automatically offers comprehensive healthcare coverage to those who qualify. Part of this coverage is premium-free. However, you will still have to pay coinsurance costs unless you also have supplemental coverage or Medigap. 

Eligibility for Medicare

To be eligible for Medicare, you must be a U.S. citizen or permanent resident, and you must meet one of the following conditions:

  • You are 65 years old or older.
  • Under 65 years old and have been diagnosed with certain disabilities.
  • You are under 65 years old and have End-Stage Renal Disease (ESRD) or ALS 
  • If you’re already getting benefits from Social Security or the Railroad Retirement Board (RRB), you’ll automatically get Part A and Part B starting the first day of the month you turn 65. (If your birthday is on the first day of the month, Part A and Part B starts the first day of the prior month.) 
  • You’ll automatically get Part A and Part B if you’re under 65 and have a disability, after you get disability benefits from Social Security or certain disability benefits from the RRB for 24 months. 
  • If you have ALS (amyotrophic lateral sclerosis, also called Lou Gehrig’s disease), you’ll get Part A and Part B automatically the month your Social Security disability benefits begin.

If you automatically get Medicare, you’ll get your red, white, and blue Medicare card in the mail 3 months before your 65th birthday or 25th month of disability benefits. You don’t need to pay a premium for Part A (sometimes called “premium-free Part A”). Most people choose to keep Part B. If you don’t want Part B, let Medicare know before the coverage start date on your Medicare card. If you do nothing, you’ll keep Part B and will have to pay Part B premiums through your Social Security benefits.

Types of Medicare Coverage

There are 4 types of Medicare plans.

  • Medicare Part A covers hospital stays, skilled nursing facility care, hospice care, and some home health care. 
  • Medicare Part B covers doctor visits, outpatient care, and some preventive services.
  • Advantage (also called Part C) is a private health insurance plan that offers a combination of Part A and Part B coverage. It also offers additional benefits. 
  • Part D is a prescription drug plan.

Medicare Advantage Plans

Original Medicare includes Medicare Part A (Hospital Insurance) and Part B (Medical Insurance). You can join a separate Medicare drug plan to get Medicare drug coverage (Part D). You can use any doctor or hospital that takes Medicare, anywhere in the U.S. To help pay your out-of-pocket costs in Original Medicare (like your 20% coinsurance), you can also shop for and buy supplemental coverage.

Medicare Advantage is a Medicare-approved plan from a private company that offers an alternative to Original Medicare for your health and drug coverage. These “bundled” plans include Part A, Part B, and usually Part D. In most cases, you can only use doctors who are in the plan’s network. In many cases, you may need to get approval from your plan before it covers certain drugs or services. Plans may have lower out-of-pocket costs than Original Medicare. Plans may offer some extra benefits that Original Medicare doesn’t cover. For example, vision, hearing, and dental services.

Part D Prescription Drug Plans

Medicare Part D plans help you pay for prescription medications. This coverage is not part of Medicare Part A or B. It is usually included with Medicare Advantage plans (also known as Part C). If you have prescriptions you’d like Medicare to cover, you need to sign up for additional Part D coverage as soon as you are eligible. If you wait to sign up later, you will be charged a late enrollment fee for the entire time you have Part D coverage.

Medicare Part D plans have several cost components. These may include a monthly premium, an annual deductible, copayments for medications, and sometimes a coverage gap (commonly known as the “donut hole”) where you might pay a larger share of the costs for your medications. Some seniors may be eligible for subsidies or assistance programs to help with these costs.

Medicare Cost-Sharing

Medicare cost sharing refers to how much of the costs you will pay for healthcare, compared to how much Medicare will pay.

  • Medicare Part A covers hospital services, and it has a deductible that you pay before Medicare coverage begins. You also pay a coinsurance amount, or percentage of the cost of services. There are no premiums for people who qualify for Part A.
  • Medicare Part B covers medical services such as doctor visits, outpatient care, and preventive services. If you don’t opt out of Part B, you will pay a monthly premium for Part B coverage. This is usually deducted from your Social Security benefits. In addition to the premium, there is also a yearly deductible and coinsurance for Part B services.
  • Advantage (Part C) plans are offered by private insurance companies approved by Medicare. These plans combine the benefits of Part A, Part B, and sometimes Part D (prescription drug coverage) into a single plan. Cost sharing for Medicare Advantage plans can include deductibles, copayments, and coinsurance, which vary depending on the specific plan.
  • Medicare Part D provides prescription drug coverage. Each Part D plan has its own premium, deductible, copayments, and coinsurance. Your cost varies depending on the plan and the medications you take.

Medicare Savings Plans

If you have limited income, you may be able to get help from your state to pay your Medicare costs.

There are 4 kinds of Medicare Savings Programs:

  1. Qualified Medicare Beneficiary (QMB) Program: If you’re eligible, the QMB Program helps pay for Part A and/or Part B premiums. In addition, Medicare providers aren’t allowed to bill you for services and items Medicare covers, including deductibles, coinsurance, and copayments. 
  2. Specified Low-Income Medicare Beneficiary (SLMB) Program: Helps pay Part B premiums only.
  3. Qualifying Individual (QI) Program: Helps pay Part B premiums only. Applications are granted on a first come, first-served basis.
  4. Qualified Disabled and Working Individuals (QDWI) Program: Helps pay Part A premiums only. You may qualify for this program if you have a disability, you’re working, and you lost your Social Security disability benefits and premium-free Part A because you returned to work.

In most cases, to qualify for a Medicare Savings Program, you must have income and resources below a certain limit. States have different limits and ways of counting your income and resources. Check with your State Medical Assistance (Medicaid) office to see if you qualify. Contact your state’s Medicaid office or visit Medicaid.gov to get more information. You can call 1-800-MEDICARE (1-800-633-4227) to get the phone number for your state’s Medicaid office. 

Medigap Supplemental Insurance

Medicare Supplement Insurance (Medigap) policies are sold by private companies. They help pay some of the remaining health care costs for Medicare covered services and supplies, like copayments, coinsurance, and deductibles. Some Medigap policies also offer coverage for services that Original Medicare doesn’t cover, like medical care when you travel internationally. Generally, Medigap doesn’t cover long-term care (like care in a nursing home), vision or dental services, hearing aids, eyeglasses, or private-duty nursing.

Before you can buy Medicare Supplement Insurance (Medigap), you must have Part A and Part B. You will pay the private insurance company a monthly premium for Medigap in addition to the monthly Part B premium you pay to Medicare. Also, if you buy Medigap and a separate Medicare drug plan from the same company, you may need to make 2 separate premium payments. 

It is illegal for anyone to offer you Medigap coverage if you already have a Medicare Advantage (Part C) plan.

Is Medicare Right for You?

For most seniors, Medicare is a cost-effective health insurance option. Most people benefit from having Part A and Part B coverage. Private health insurance premiums tend to be very high, especially for seniors. Unless your coverage is paid by a current or former employer, it may be impossible to afford private health insurance on your own. If you regularly take prescription medications, Part D may be a good option for you. Without insurance, prescriptions can become very expensive. 

There are some cases where Medicare may not be the best option. 

  • If you are 65 years or older but still actively working and receiving health insurance through your employer or your spouse’s employer, you may not need to enroll in Medicare immediately. In this case, it’s essential to assess the coverage provided by your employer plan and understand how it coordinates with Medicare. 
  • If you are eligible for and enrolled in comprehensive healthcare benefits through the Department of Veterans Affairs (VA), you may already have access to healthcare services and prescription drug coverage that meet your needs. 
  • For people who qualify for Medicaid, the joint federal and state program that provides healthcare coverage to low-income individuals, you may have comprehensive coverage that includes services similar to those provided by Medicare. In some cases, individuals may be automatically enrolled in both Medicare and Medicaid (known as “dual-eligible”). 
  • Health Savings Accounts (HSAs): If you have a high-deductible health plan (HDHP) with a Health Savings Account (HSA), you may want to wait for Medicare. Once you enroll in Medicare Part A or Part B, you can no longer contribute to your HSA. If the tax advantages and flexibility of your HSA are important to you, delaying Medicare enrollment may be better. Consult with a qualified tax professional or financial advisor to fully understand the impact on your HSA.

While these exceptions do exist, for most people the benefits of Medicare still outweigh the costs. 

Navigating Medicare healthcare options can be confusing. Stellar Living hopes this guide helps you make the right choice for you!