We’ve compiled the answers to your most frequent questions, and hope it will be a good resource as you go through the process. It’s important you feel informed throughout the process, so please feel free to call us at 800-825-7734 at any time.
How do I become eligible for Medicare?
Most people become eligible for Medicare when they turn 65. If you are under the age of 65, however, you may become entitled to Medicare 24 months after the date that the Social Security Administration (SSA) determines that you first became eligible for SSDI benefits.
How do I enroll in Medicare once I become eligible?
If you are receiving SSDI benefits, you will automatically be enrolled in Medicare Part A and Medicare Part B in the 25th month of your disability payments. You will be enrolled sooner if you suffer from end-stage renal disease or ALS. If you are automatically enrolled, you will not pay a premium for Part A, but you will pay a monthly premium for Part B.
Prior to your Medicare eligibility date, Medicare will send you an initial enrollment package containing information about the program, an Initial Enrollment Questionnaire, and your Medicare card. If you choose to keep Part A and Part B, all you have to do is sign the card and keep it.
To assess your options relative to the other parts of Medicare that are available to you, you can call an SSAD specialist at (800) 825-7734.
Will my family be covered once I become eligible for Medicare?
Medicare is not offered as a family or dependent benefit. This means that all people must qualify on an individual basis in order to be eligible for Medicare benefits. For example, a person under age 65 does not automatically receive Medicare because their spouse turns 65 and enrolls in the Medicare program. In addition, when a parent qualifies for Medicare, this does not entitle their dependent children to Medicare coverage.
If you have a family member who needs health insurance and does not individually qualify for Medicare, you should consider contacting your State Health Insurance Assistance Program to discuss your options.
How much does Medicare cost?
Most people with Medicare get Part A (Hospital Insurance) premium-free because they have sufficiently worked and paid taxes into the system. If you are receiving SSDI benefits, then your Part A will be premium-free. If you do not have enough work history, you have to pay a monthly premium for Part A. Everyone has to pay a monthly premium for Part B (Medical Insurance). In 2011, the monthly premium for Part B is $115.40. Additionally, people with high incomes have to pay a higher Part B premium. Medicare Supplement, Medicare Advantage, and Medicare Prescription Drug Plans are available for an additional monthly premium.
If you have low income and assets, you may qualify for help with some of your Medicare costs. An SSAD Medicare specialist can help you determine whether you qualify.
What is the difference between Medicare and Medicaid?
Medicare is a federal health insurance program for people age 65 and older, people under age 65 who receive Social Security Disability Insurance (SSDI) benefits, and people of any age who suffer from ALS or end-stage renal disease. Your income does not affect your eligibility for Medicare.
Medicaid, on the other hand, is a joint federal and state program that helps with medical costs for some people with low incomes and limited resources. To qualify for Medicaid, you must have low income and limited resources.
I have other health insurance through my former employer or my spouse’s former employer. Do I still need to apply for Medicare?
It depends. Medicare rules allow you to delay enrollment in Medicare Part B and Medicare Part D if you are covered by an employer group health plan with 100 or more participants, only if your health coverage is based on your or your spouse’s current, active employment.
If your employer plan acts as your primary insurer and has high cost sharing, having Medicare as your secondary insurer may help pay some of your costs. However, if your employer plan includes comprehensive medical and prescription drug coverage with low cost sharing, you may decide it’s not worth paying the monthly premium for Medicare Part B and/or Medicare Part D.
If you choose not to enroll in Part B and/or Part D when you become eligible, you may delay enrollment only until you, your spouse, or family member stops working or is no longer covered by the employer group health plan.
If your other health insurance coverage is NOT based on the current, active employment of yourself or a family member, you should contact your employer to determine your obligations under the terms of your insurance plan.
If your other health insurance is COBRA continuation coverage, your coverage will terminate when you become entitled to Medicare.
Will Medicare cover my prescription drug costs?
When you are eligible for Medicare, you have the option to enroll in Medicare Part D, an optional prescription drug insurance program available to everyone who has Medicare, regardless of your income or health status. Part D plans are offered by private insurance companies and require you to pay a monthly premium.
Can I get help paying for my prescription drugs?
The Low-Income Subsidy (LIS) program, also known as “Extra Help,” is available to help pay for a portion of Part D costs, including premiums, copayments, and deductibles, for certain people with low incomes and minimal assets. Depending on your income and assets, the Extra Help program may provide a full or partial subsidy. Some people are automatically enrolled in the Extra Help program, while others must apply for the subsidy.
What Is the Medicare Part D Coverage Gap, aka the doughnut hole?
Most Medicare drug plans have a coverage gap, also known as the “doughnut hole.” This means that after you and your drug plan have spent a certain amount of money for covered medications, you have to pay all out-of-pocket costs for your drugs (up to a limit). Your yearly deductible, your co-insurance or copayments, and what you pay in the coverage gap all count toward this limit.
What happens to Medicare under health care reform?
The Affordable Care Act makes several changes to Medicare that most likely will improve your benefits and your access to primary care services. Some significant changes include:
- Coverage Gap Savings: If you reach the coverage gap in 2010 you will receive a one-time rebate check of $250 from Medicare. In 2011, you will be able to get a 50% discount on brand-name drugs and a 7% discount on generic drugs in the coverage gap. There will be additional savings in the coverage gap each year until it’s completely closed by 2020.
- Preventive Care: Beginning in 2011, Medicare will pay for an annual checkup, including a physical examination and a total elimination of cost sharing for appropriate preventive services and screenings.
Is there someone who can help me better understand what coverage I need?
Yes. An SSAD Medicare specialist can help you develop a customized health insurance strategy when you become eligible for Medicare. We can assist you in determining which parts of Medicare you need and in selecting the best, most affordable Medicare plan available to you based on your unique treatment profile and financial circumstances. Additionally, you may contact Medicare at 1–800-MEDICARE or contact your State Health Insurance Counseling and Assistance Program.
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