Futurity First — Medford, OR
516 Crater Lake Ave, Medford, OR - 97504
MEDICARE BASICS
Medicare can feel complicated at first, but the foundation is fairly simple. Understanding who qualifies, what each part covers, and how the different coverage options work can help you make more confident decisions about your healthcare.
What is Medicare
Medicare is a federal health insurance program primarily for people age 65 and older. It also provides coverage for certain people under 65 who have qualifying disabilities or specific medical conditions.
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Medicare is different from Medicaid. Medicare eligibility is generally based on age, disability, or certain medical conditions, while Medicaid is a separate state and federal program based largely on income and other eligibility requirements.
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Medicare helps cover many hospital, medical, preventive, and prescription drug services, but it does not automatically cover every healthcare expense.
Who Qualifies
You may qualify for Medicare if:
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You are age 65 or older.
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You are under 65 and have received qualifying Social Security or Railroad Retirement Board disability benefits for the required period.
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You have End-Stage Renal Disease, also called ESRD, which is permanent kidney failure requiring dialysis or a kidney transplant.
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You have Amyotrophic Lateral Sclerosis, commonly known as ALS or Lou Gehrig’s disease.
Eligibility and enrollment can also depend on your work history, citizenship or lawful residency status, current insurance, and whether you already receive Social Security benefits.
The Parts of Medicare
Medicare is divided into four main parts. Each part helps cover a different type of healthcare service.
Medicare Part A: Hospital Insurance
Part A generally helps cover:
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Inpatient hospital care
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Skilled nursing facility care under qualifying circumstances
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Hospice care
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Certain home healthcare services
Many people qualify for premium-free Part A because they or their spouse worked and paid Medicare taxes for a sufficient period. Deductibles, coinsurance, and other costs may still apply.
Medicare Part B: Medical Insurance
Part B generally helps cover:
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Doctor and specialist services
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Outpatient care
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Preventive services
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Diagnostic testing
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Ambulance services
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Mental health services
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Durable medical equipment
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Certain medications administered in a medical setting
Part B typically has a monthly premium, an annual deductible, and cost sharing for covered services.
Medicare Part C: Medicare Advantage
Medicare Advantage, also called Part C, is another way to receive your Medicare benefits.
These plans are offered by private insurance companies approved by Medicare. They include your Part A and Part B benefits and often include Part D prescription drug coverage.
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Many plans also offer additional benefits that Original Medicare does not normally cover, such as certain dental, vision, hearing, fitness, or wellness benefits. Availability, provider networks, costs, benefits, and coverage rules vary by plan and location.
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You must generally have both Part A and Part B to enroll in a Medicare Advantage plan.
Medicare Part D: Prescription Drug Coverage
Part D helps pay for covered prescription medications.
Part D coverage is offered through private insurance companies approved by Medicare. It may be purchased as a separate prescription drug plan for someone with Original Medicare or included within many Medicare Advantage plans.
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Each plan has its own list of covered medications, called a formulary, as well as its own pharmacy network, premiums, deductibles, copayments, and coinsurance.
Even if you do not currently take prescription medications, delaying Part D enrollment without other creditable prescription coverage could result in a late enrollment penalty.
The Two Primary Ways to Receive Medicare Coverage
Once you have Medicare Parts A and B, there are two primary approaches for receiving your Medicare healthcare coverage.
Option One: Original Medicare
Original Medicare is administered by the federal government and includes:
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Medicare Part A
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Medicare Part B
With Original Medicare, you may generally visit any doctor or hospital in the United States that accepts Medicare.
You may also choose to add:
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A separate Part D prescription drug plan
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Medicare Supplement insurance, also called Medigap
A Medicare Supplement policy can help pay certain out-of-pocket costs not fully paid by Original Medicare, depending on the plan selected.
Original Medicare does not include a yearly out-of-pocket maximum for Part A and Part B services, so some people consider supplemental coverage to help manage those expenses.
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Option Two: Medicare Advantage
Medicare Advantage plans are offered by private insurance companies and provide your Part A and Part B benefits through the plan.
Most Medicare Advantage plans also include prescription drug coverage, and some provide additional benefits that Original Medicare does not cover.
Depending on the plan, members may need to:
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Use a specific provider network
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Select a primary care provider
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Obtain referrals for certain specialists
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Receive prior authorization before certain services
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Pay plan-specific copayments or coinsurance
Medicare Advantage plans have an annual limit on what members pay out of pocket for covered Part A and Part B services. Plan benefits, costs, networks, medications, and service areas can change from year to year.
What Medicare May Not Fully Cover
Medicare provides substantial healthcare coverage, but it does not pay every expense.
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Depending on your coverage, you may still be responsible for:
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Monthly premiums
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Annual deductibles
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Copayments
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Coinsurance
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Services Medicare does not cover
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Care received outside your plan’s network
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Medications that are not on your plan’s formulary
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Services that require authorization but were not approved
Original Medicare generally does not cover:
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Most routine dental care
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Dentures
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Routine eye exams for glasses or contact lenses
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Most eyeglasses and contact lenses
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Hearing aids and exams for fitting them
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Long-term custodial care
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Routine physical examinations
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Cosmetic surgery
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Massage therapy
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Most healthcare received outside the United States
Certain services may be covered in limited medical circumstances, and some Medicare Advantage plans offer additional dental, vision, hearing, or other benefits. Coverage should always be confirmed before receiving care.
Understanding Medicare Enrollment Periods
Medicare has several enrollment periods. The right enrollment period depends on whether you are new to Medicare, currently enrolled, leaving employer coverage, or experiencing another qualifying life event.
Initial Enrollment Period
For most people, the Initial Enrollment Period is the first opportunity to enroll in Medicare.
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It is a seven-month period that includes:
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The three months before the month you turn 65
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The month you turn 65
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The three months after the month you turn 65
The date your coverage begins can depend on when you enroll. Some people are enrolled automatically, while others must actively apply.
Special Enrollment Period
You may qualify for a Special Enrollment Period if you delayed Medicare because you had qualifying group health coverage through your or your spouse’s current employment.
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Special Enrollment Periods may also be available after certain other qualifying circumstances, including losing Medicaid coverage, moving outside a plan’s service area, or losing other qualifying coverage.
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The length and rules of each Special Enrollment Period vary. Missing the applicable deadline could result in delayed coverage or late enrollment penalties.
General Enrollment Period
The General Enrollment Period runs from January 1 through March 31 each year.
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It is generally available to people who did not enroll in Part A or Part B when first eligible and do not qualify for a Special Enrollment Period.
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Coverage generally begins the month after enrollment. Late enrollment penalties may apply.
Medicare Open Enrollment Period
Medicare Open Enrollment runs from October 15 through December 7 each year.
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During this period, eligible Medicare beneficiaries may generally:
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Switch from Original Medicare to Medicare Advantage
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Switch from Medicare Advantage to Original Medicare
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Change Medicare Advantage plans
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Join, change, or drop a Part D prescription drug plan
Changes made during this period generally take effect January 1 of the following year.
Medicare Advantage Open Enrollment Period
The Medicare Advantage Open Enrollment Period runs from January 1 through March 31 each year.
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It is available only to people who are already enrolled in a Medicare Advantage plan. During this period, they may generally make one change by:
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Switching to another Medicare Advantage plan
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Leaving Medicare Advantage and returning to Original Medicare
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Joining a separate Part D plan when returning to Original Medicare
Someone with Original Medicare cannot use this period to enroll in Medicare Advantage.
Medigap Open Enrollment Period
The Medigap Open Enrollment Period is a six-month period that generally begins the first month you are both:
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Age 65 or older
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Enrolled in Medicare Part B
During this period, you generally have broader rights to purchase a Medicare Supplement policy without being denied or charged more because of health conditions.
This is not an annual enrollment period. After it ends, medical underwriting may apply unless you have another guaranteed-issue right or protection under state law.
Medicare Does Not Have to Be a Solo Project
The right Medicare approach depends on more than premiums alone. Your doctors, prescriptions, travel, preferred pharmacies, anticipated healthcare needs, budget, and current insurance can all affect which options deserve consideration.
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Futurity First Medicare can help you understand your choices, compare available coverage, and identify important enrollment deadlines before you make a decision.
Schedule a Medicare conversation today.
