Making Sense of Medicare Options

Medicare is the federal program that helps people 65 and older pay for their healthcare and prescription drugs.

If you’re new to Medicare, the following is a basic step-by-step process that you can use to get started.

Find out when you become eligible

Most people will sign up for Medicare when they first become eligible. This would be sometime in the 3 months before they turn 65 or in the 7 months following. People with certain disabilities and serious health concerns, such as end stage kidney disease, may sign up earlier. Go to the Medicare website to learn more about when and how to sign up for Medicare.

Review your coverage options

In general, you have 3 choices:

Original Medicare. This program is a fee-for-service program run by the federal government. This is the default plan if you don’t choose another one.
Original Medicare with supplemental insurance. Original Medicare doesn’t cover all of your medical costs. To have complete coverage, some people purchase additional insurance known as a Medigap plan.
Private health insurance. You may choose a private health insurance plan that manages your Medicare coverage, called Medicare Advantage plans. This is also known as Part C. Examine the details of the different plans you are considering to figure out what your monthly costs and co-pays would be.

Consider costs

Medicare does not cover 100% of your costs. Also remember that Medicare is a secondary insurance. That means if you have health insurance from a former employer, Medicare will cover part of the costs that the primary insurance doesn’t cover. Your work history will determine how much you have to pay for Medicare. Some people with low incomes may be able to get government assistance to help pay for healthcare costs.

Pick a healthcare provider

If you have Original Medicare, you can go to most healthcare providers. If you have a private insurance plan (Part C), you must select a primary care manager who is in the network of the insurance carrier you choose. Covered providers may change from year to year. Make sure the provider is accepting Medicare patients.

Get your “Welcome to Medicare” exam

You are entitled to a free comprehensive wellness check to get started as a Medicare recipient. After that, you can have a free wellness check every 12 months.

Know what Medicare covers

Medicare has several basic parts:

Part A. This part covers all hospital-related care, skilled nursing, home health and hospice care. It’s free if you have worked and paid taxes for at least 10 years. If you have worked less than that, you will have to pay for the coverage. There is a deductible for inpatient hospital stays.
Part B. This part covers all of your basic healthcare needs. This means medically necessary services and some preventive services. You will pay a fee for this coverage. How much you pay is based on your income and the health insurance you choose or have already.
Part C. This part allows private health insurance companies to offer Medicare Advantage plans. These provide for all of the same services Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) covers, but they are provided under a private health insurance model. The government reimburses the managing companies. These insurance companies must follow rules set by Medicare. But each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services (like how you get a referral to see a specialist, or if you can only go to specific healthcare providers, facilities, or suppliers that belong to the plan.) Out-of-pocket costs and service access rules can change each year Consumers need to read all plan information very carefully before signing up.
Part D. This part covers prescription drug costs. You will need a plan paired with your Medicare coverage. Enrolling in a prescription drug plan is optional, but if you enroll after a certain initial enrollment period, you may have to pay a late fee.

Know what is not covered

Unfortunately, certain services are not covered by Medicare. These include:

Most vision services
Most dental services
Hearing aids
Cosmetic surgeries
Assistance with housekeeping
Some preventive services
Alternative medicines
Most nonemergency transportation
Care received in another country

Check on enrollment periods

You can sign up for or change your plans, usually only during annual enrollment periods. There are special enrollment periods where you can change plans, for example if you move or lose other coverage. Check with Medicare to see if you are eligible to change plans for other reasons as well. Of course, you can do your health insurance plan research at any time of year.