Medicare Simplified
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Who is eligible for Medicare?

All US citizens become eligible for Medicare when they turn 65. Non-citizen permanent residents are eligible at 65 also, provided they have lived in the country for at least five years.

If you are under 65, you might qualify for Medicare if:
⚪You are permanently disabled and have received Social Security Disability benefits for at least 24 months
⚪You have been diagnosed with end-stage renal disease (kidney failure)
⚪You have been diagnosed with Amyotrophic Lateral Sclerosis (Lou Gehrig’s disease) and are receiving Social Security Disability benefits

As with most large, complex government programs, Medicare can seem a bit overwhelming at first. That’s why we’ve created this guide to help you navigate the application procedure, annual enrollment, and more.

Who is eligible for Medicare?

When should you apply for medicare?
When should you apply for Medicare?

You become eligible for Medicare when you turn 65 years old. However, if you have already claimed Social Security benefits at that time, you will be automatically enrolled in Medicare on your 65th birthday. You will receive Medicare Parts A and B. To enroll in other Medicare programs, such as Part C (Advantage) or Part D (prescription) you must meet with an insurance professional to elect those benefits.

Those who have not already begun to draw Social Security benefits will need to apply for Medicare when they turn 65. The Initial Enrollment Period (IEP) begins three months before your 65th birthday, lasts throughout the month of your birthday, and then for three months after that. So, you have seven months in total to complete the enrollment process.

There is one exception to the above rule: If your birthday falls on the first day of the month, your IEP will begin one month earlier.

Yes, you should apply for Medicare at age 65, even if you aren’t claiming your Social Security benefits yet. In fact, you must apply for Medicare during this initial enrollment period. Otherwise, if you sign up later you will face higher premiums for the rest of your life. Only under very specific conditions can you delay enrollment without incurring a penalty.

What if you miss the Initial Enrollment Period?

The Medicare General Enrollment Period, from January 1 to March 31 each year, allows those who missed their IEP to enroll in Medicare. Aside from qualifying for a Special Enrollment Period due to a life event, this is your only chance to apply for Original Medicare after your Initial Enrollment Period.

When you sign up for Original Medicare during the General Enrollment Period, your coverage will begin on the first day of the month following your enrollment. For example, if you enroll on February 3rd, your coverage would start on March 1.

Important Note: The General Enrollment Period is not a “safety net” for missing your IEP. This enrollment period should only be used as a backup if you miss your Initial Enrollment Period. Late penalties could apply if you enroll during the General Enrollment Period, so make sure you budget for those additional fees.

What if you miss the initial enrollment?

Medicare Enrollment Periods
Medicare Enrollment Periods

When you first enroll in Medicare during your Initial Enrollment Period, you will select Original Medicare (Parts A and B) or a Medicare Advantage plan (Part C) which combines the two types of coverage. Part D (prescription drug) coverage is also available with either of these options.

But once you make your selections, you aren’t stuck with those plans for life. In fact, Medicare offers you opportunities to change your plan(s), depending upon the situation.

Medicare’s Annual Enrollment Period (AEP)

Once you have enrolled in Medicare, you do have the right to review your plan selections and make changes each year. From October 15 to December 7, you can take advantage of the Annual Election Period to make changes to Part C (Advantage) or Part D (prescription) plans.

At this time, you can:
⚪Change from Original Medicare to a Medicare Advantage plan
⚪Drop a Medicare Advantage Plan and go back to Original Medicare
⚪Change from one Medicare Advantage plan to a different one
⚪Enroll in a Part D prescription drug plan
⚪Cancel your Part D prescription drug plan
⚪Change your Part D prescription drug plan

Medicare Advantage open enrollment

Medicare Enrollment
Medicare Advantage Open Enrollment

In the event that you change your mind about a Medicare Advantage Plan for any reason, the Medicare Advantage Open Enrollment Period from January 1 to March 31 gives you the opportunity to make changes.

During this time you can:
⚫Switch from one Medicare Advantage plan to another
⚫Drop Medicare Advantage and return to Original (Parts A and B) Medicare
⚫Add a Part D prescription plan
⚫Drop a Part D prescription plan

Yes, you can drop a Medicare Advantage plan and return to Original Medicare, but don’t count on a Medigap plan if that is your intention. Remember that carriers will screen you and can choose not to enroll you.

Medicare Enrollment


Medicare Advantage Plans

When you become eligible for Medicare, you face a series of choices. One of the first choices involves the type of coverage you prefer.

Medicare Parts A and B comprise what is known as Original Medicare. But if you would prefer to enroll in a plan managed by a private health insurance company, you can choose Medicare Part C, or Medicare Advantage.

Medicare Advantage plans combine Part A and Part B benefits, and often include Part D (prescription drug) benefits as well. Some beneficiaries prefer to have all of their coverage managed under one comprehensive plan.

You must be enrolled in both Medicare Part A and Part B in order to elect an Advantage plan, and you will continue to pay your Part B premiums. Medicare will then pay the Advantage plan administrator a set monthly amount to manage your care, and your Advantage plan will deliver all of your benefits. You also must live within the Advantage plan’s coverage area.

The Difference Between Original Medicare and Medicare Advantage

Much of the difference between the two plans involves the way in which you access your benefits.
With Original Medicare, you are subject to deductibles and a 20 percent co-insurance on Part B. You can access care at any doctor’s office or hospital that accepts Medicare (which most do).
Under a Medicare Advantage plan, you access care through a network of providers in your coverage area. You will owe co-pays that vary for different services, depending upon how your plan is structured. Some plans will charge a per-day co-pay for hospital stays, while others charge a flat amount for the entire stay.

Medicare Advantage plans tend to change more each year, with regard to coverage. However, beneficiaries have the opportunity to review their plans each year, and choose one that best suits their anticipated needs for the upcoming coverage year.

The Benefit of Having a Medicare Advantage Plan

Before Medicare Advantage was created, those with Original Medicare who could not afford a Medigap plan sometimes found themselves swamped in medical expenses when a serious illness or other incident occurred.
Advantage plans were created to provide a sort of safety net for catastrophic expenses. The plans include an out-of-pocket spending cap. When beneficiaries reach that limit, the plan kicks in to cover medical expenses for the rest of the year (although Plan D expenses are calculated and managed separately).

Many Advantage plans also include Part D coverage for prescription drugs, so that beneficiaries don’t have to purchase a separate plan.

How to Choose a Medicare Advantage Plan

With so many options out there, choosing a Medicare plan can feel overwhelming to just about everyone. What works for one person might be completely wrong for another, so this is a very personal decision. Fortunately, insurance professionals dedicate themselves to learning all of the ins and outs of the different options available, and can guide you toward the plan(s) best suited for your needs.
First, ask yourself some important questions to begin identifying yourpriorities:
⚫Are you attached to any specific healthcare providers? Do they accept any Medicare Advantage plans or only Original Medicare?
⚫What types of insurance is accepted at your preferred hospital?
⚫Do you frequently travel out of your coverage area, or do you spend significant time at a second home?
⚫How much risk can you tolerate? Do you have savings or another source of funding in the event of significant medical bills?
⚫How much peace of mind do you want to achieve? Do you need to know that your healthcare spending will remain steady over time? Or are you okay with fluctuating expenses?


HMO stands for Health Maintenance Organization. If you enroll in an HMO plan, you’ll have to select an In-Network Primary Care Physician or PCP. This primary doctor is charged with coordinating your care and must be seen first for all healthcare needs except in an emergency. If a specialist is necessary, the primary doctor will refer you to an In-Network specialist.
HMOs often come at the lowest premiums. However, the plans are less flexible with regard to healthcare providers, and out-of-pocket expenses can vary.
PPO stands for Preferred Provider Organization. In these plans, you do not have to select a primary care doctor and can “self-refer” to a specialist if you deem it necessary. PPO’s have both In-Network and Out-of-Network options. Although you have the freedom to go directly to any doctor you’d like, if that doctor is out of the network it will almost always have significantly higher costs associated.

PPOs can offer more flexibility and out-of-network benefits. However, premiums can run quite a bit higher so it pays to have a broker do some “shopping” for you in order to find the best cost for your circumstances.

Choosing a Medicare plan requires research, time, and expertise.

As you can see, numerous factors will combine to lead you to your decision. The above summaries are a cursory guide, and are only intended to outline your basic options.

Working with a licensed insurance professional to research all of the options available to you, as well as address concerns specific to your situation, is still the best way to locate a Medicare policy that suits your needs and budget.

What if you need to make changes to your plan outside of these times?

In certain situations, such as a move or loss of coverage, you might qualify for a two-month Special Enrollment Period. During this time you can make changes to your Medicare plan(s).

For example, moving from one geographic area to another might qualify you for a Special Enrollment Period, if your network is not available at your new home.

During your SEP, you can switch to a new Medicare Advantage plan or Part D plan, or return to Original Medicare without penalty. In some situations you might also be able to enroll in a Medigap plan without the requirement for medical underwriting (called guaranteed issue rights).

If you believe you might qualify for a Special Enrollment Period, you should contact your plan administrator as soon as possible after the qualifying event. We can assist you with this process.

What if you need to make changes?
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Reina Dizon
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