Medicare Facts: www.medicare.gov
Most people qualify for Medicare when they turn 65. Others qualify for Medicare based on their disability or have End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS known as Lou Gehrig’s disease).
The program helps with the cost of health care, but it does not cover all medical expenses or the cost of most long-term care.
The Centers for Medicare & Medicaid Services is the agency in charge of the Medicare program. But you apply for Medicare at Social Security, and we can give you general information about the Medicare program.
Medicare has Four Parts:
- Medicare Part A, Hospital Insurance
- Medicare Part B, Medical Insurance
- Medicare Part C (Medicare Advantage), which was formerly known as "Medicare + Choice"
- Medicare Part D, Prescription drug coverage
Part A is paid for by a portion of Social Security taxes. It helps pay for inpatient hospital care, skilled nursing care, hospice care and other services.
Part B is paid for by the monthly premiums of people enrolled and by general funds from the U.S. Treasury. It helps pay for doctors' fees, outpatient hospital visits, and other medical services and supplies that are not covered by Part A.
Part C (Medicare Advantage) plans allow the client to choose to receive all health care services through a provider organization. These plans may help lower the cost of receiving medical services, or provide extra benefits for an additional monthly fee. Your client must have both Parts A and B to enroll in Part C. However, since most ITUs do not have contracts with Medicare Advantage Plans, enrollment is not a recommended option for someone who primarily utilizes ITUs for their health care issues.
Part D (prescription drug coverage) is voluntary and the costs are paid for by the monthly premiums of enrollees and Medicare. Unlike Part B in which individuals are automatically enrolled, your client must choose the plan and enroll themselves, except for those described below under the Extra Help (Subsidy) with Medicare Prescription Drug Coverage.
Individuals that have Medicare and are receiving Supplemental Security Income (SSI) and/or Medicaid or who participate in the Medicare Savings Programs are deemed eligible for a subsidy. This means they do not have to file an application for Extra Help (subsidy) and will be auto-enrolled with a Prescription Drug Plan.
If your client is already receiving Social Security benefits, they are automatically enrolled in Medicare Plans A and B when they turn age 65. However, because there is a premium for Part B coverage, ($104.90 for most people in 2013), your client will receive an initial enrollment package by mail a few months before they become eligible for Medicare.
If your client is not already receiving benefits at 65, he or she should file online at www.socialsecurity.gov/pgm/medicare.htm or call Social Security for an appointment three months prior to their 65th birthday so we can help them decide if they should sign up for Medicare. Because Medicare enrollment period rules are very strict, your client should do this even if they plan to continue working or do not think they have enough Social Security work credit. Remember, even someone who does not have enough work credits can apply for Medicare as long as they meet other criteria:
- They must be a U.S. citizen or a lawfully admitted alien who has lived in the United States continuously for the five years before they apply for Medicare.
- They can also file for Medicare based on a spouse who does have enough work credits. When they apply for Medicare, we can also take an application for retirement benefits if needed.
- Your client can apply online for retirement to include Medicare but cannot apply only for Medicare at this time.
If your client’s eligibility for Medicare is based on being disabled, Medicare will begin 24 months after they begin receiving monthly benefits unless they have ALS (Lou Gehrig’s disease) or ESRD (End Stage Renal Disease). For example, if a person starts receiving monthly disability checks in January 2012, they will be eligible for Medicare in January 2014. However, because there is a premium for Part B coverage, your client can choose to refuse Medicare Part B coverage. They will be mailed an initial enrollment package a few months before they become eligible for Medicare.
Effective Date of Part A Enrollment:
When your client first becomes eligible for hospital insurance (Part A), they have a seven-month period (the initial enrollment period) in which to sign up for medical insurance (Part B). A delay in signing up will cause a delay in coverage and result in higher premiums. If your client is eligible at age 65, their initial enrollment begins three months before their 65th birthday, including the month they turn age 65 and ends three months after that birthday. If your client is eligible for Medicare based on disability or permanent kidney failure, their initial enrollment period depends on the date their disability or treatment (dialysis or transplant) began.
Effective Date of Part B Enrollment:
If your client has been automatically enrolled or if they take action to sign up for Medicare Part B during the first three months of their initial enrollment period, their
medical insurance protection will start with the month you are first eligible. If your client enrolls during the first three months of their initial enrollment period, their Part B will
start with the month that they are first eligible. If they enroll during the last four months, their protection will start from one to three months after they enroll.
The following chart shows when Medicare Part B becomes effective:
|If you enroll in this month of your initial enrollment period||Part B coverage starts|
|1st||The month you become eligible for Medicare|
|2nd||The month you become eligible for Medicare|
|3rd||The month you become eligible for Medicare|
|4th||One month after Enrollment|
|5th||Two months after Enrollment|
|6th||Three months after Enrollment|
|7th||Three months after Enrollment|
Medicare Savings Programs—QMB/SLMB/QI:
When individuals need assistance paying for Medicare Part B (and Part A if the individual is subject to a premium), Medicaid has Medicare Savings Programs that may help, depending on the state that they reside in. Qualified Medicare Beneficiary (QMB) pays the Medicare Part A and B premiums plus deductibles and coinsurance. The Special Low Income Beneficiary (SLMB) and QI Qualifying Individual (QI) programs pay Medicare Part B premiums for qualified individuals. Each of these programs considers the individual's (or couple's) resources and the specific program for which the individual qualifies is based on where their income falls in an income range. Only your state can decide if you qualify for help under these programs.
A Medicaid case manager in the local Office of Public Assistance can determine whether an individual qualifies for one of these Medicaid programs, as well as other Medicaid programs. It is very important to assist individuals with applications for Medicaid, because Indian Health Service, Tribal Health Programs and Urban Indian Health Centers (collectively known as the ITU system) rely on Medicare and Medicaid to supplement their funding.
General enrollment for Part B:
If your client does not enroll during the initial enrollment period, they have another chance each year to sign up during a ― general enrollment period from January 1st through March 31st. The coverage would be effective July 1st following the enrollment. Your client’s monthly premium would increase 10 percent for each 12-month period that they were eligible for, but did not enroll in, Medicare Part B.
Special Enrollment Period:
If your client is 65 or older and is covered under a group health plan, either from their own or their spouse’s current employment, they can have a ―special enrollment period in which they can sign up for Medicare Part B. This means that they can delay enrolling in Medicare Part B without having to wait for the next ―general enrollment period and paying the 10 percent premium surcharge for late enrollment. The rules allow you to:
- Enroll in Medicare Part B any time while you are covered under the group health plan based on current employment; or
- Enroll in Medicare Part B during the eight-month period that begins with the month your group health coverage ends, or the month employment ends—whichever comes first.
Special enrollment period rules do not apply if employment or employment-provided group health plan coverage ends during your initial enrollment period.
If your client does not enroll by the end of the eight-month period, you will have to wait until the next general enrollment period, which begins January 1st of each year and may also have to pay a higher premium.
People who receive Social Security disability benefits and are covered under a group health plan from either their own or a family member’s current employment also have a special enrollment period.
Enrollment of Part D – Medicare Prescription Drug Plan:
Medicare offers prescription drug coverage to everyone with Medicare. If your client decides not to join a Medicare drug plan when they are first eligible, and they do not have other creditable prescription drug coverage, or they do not get Extra Help, they will likely pay a late enrollment penalty.
To get Medicare prescription drug coverage, your client must join a plan run by an insurance company or other private company approved by Medicare. Each plan can vary in cost and drugs covered. For information on joining a plan, your client may visit www.medicare.gov or they may call 1-800-633-4227 (1-800-MEDICARE).
Extra Help with Medicare Prescription Drug Plan:
Your client may be able to get extra help to pay for the monthly premiums, annual deductibles, and co-payments related to the Medicare Prescription Drug program. However, they must be enrolled in a Medicare Prescription Drug plan to get this extra help. Your client may file an application for Extra Help online at www.socialsecurity.gov/prescriptionhelp/
Individuals that have Medicare and receive Supplemental Security Insurance (SSI) and/or Medicaid, or who participate in the Medicare Savings Programs are deemed eligible for a subsidy. This means they do not have to file an application for Extra Help (subsidy) and will be auto-enrolled with a Prescription Drug plan.
When a Medicare beneficiary appears to have limited income and resources but is not deemed eligible for subsidized prescription drug coverage, SSA will periodically notify the beneficiary about the availability of Extra Help. These individuals may file an application for Extra Help online or contact their local field office.
End Stage Renal Disease:
For your clients who get Medicare because they have end stage chronic renal disease, there are special rules about when their coverage starts. Medicare A and B begin in the 3rd month after the month that they begin a regular course of dialysis or in the month after a kidney transplant is received. If your client enters the hospital as an inpatient
early to have treatment before the transplant, their Medicare coverage begins in the month that they enter the hospital. Their Medicare coverage ends 36 months after the month that their transplant occurred or 12 months after their dialysis treatment stops.
Affordable Care Act (ACA):
The part of the Affordable Care Act (ACA), that the President signed into law in March 2010, will enable all US citizens and legal resident to purchase health insurance beginning January 1, 2014. Plans will be available through the Health Insurance Marketplace. Refer inquirers to www.HealthCare.gov or call 1-800-318-2596.
If your client is already receiving Social Security benefits, he or she will automatically be enrolled in Medicare Parts A and B upon turning age 65. However, because a premium is charged for Part B coverage, your client has the option of refusing the Part B. Your client will receive an initial enrollment package, including the Medicare Card, by mail a few months before he or she becomes eligible.
If your client is not already getting benefits when he or she turns 65, they should file online at www.socialsecurity.gov/pgm/medicare.htm or call 1-800-772-1213 three months prior to their 65th birthday so we can help them decide if they should sign up for Medicare. Your client should do this even if he or she plans to continue working or do not think they have enough work credit under Social Security, because Medicare enrollment period rules are very strict. If your client wants to file for Medicare only, he or she can call the 800 number listed above between 7:00 a.m. and 7:00 p.m. on business days. Our representatives there can make an appointment for them at their local Social Security office. When your client applies for Medicare, we often take an application for retirement benefits if needed. If your client wants to apply, consider applying for retirement and Medicare benefits online.
If your client’s eligibility for Medicare is based on being disabled, entitlement will be effective 24 months after his or her entitlement to monthly benefits begins. As an example, if entitlement to monthly disability checks begins in January 2009, then eligibility for Medicare starts in January 2011. However, because your client must pay a premium for Part B coverage, he or she will have the option of refusing it. Your client will want to evaluate their health insurance to make an informed decision before refusing Part B since refusing coverage can result in premium penalties. As mentioned earlier you want to always refer them to the State for the Medicare Savings Programs if it appears they meet income and resource limits and they indicate they cannot afford the premiums.
Q and A
Q. How do Medicare and Medicaid work with a client’s eligibility for medical services under Indian Health Service (IHS)? Can they use all of them at the same time?
A. Medicare and Medicaid can be used at an IHS clinic or hospital for medical services the Indian Health Service does not cover. Additional information about Medicare and Medicaid can be found online at the Centers for Medicare and Medicaid Service (CMS) website at www.cms.gov.
Q. If a client did not apply for Medicare when they turned 65, can they apply later?
A. General Enrollment Period from January 1 through March 31 of each year permits people who refused or later terminated their Part B Medicare coverage to sign up if they do not qualify for a Special Enrollment Period. Please refer to the Retirement and Disability Q & A’s regarding the Special Enrollment Period.
For additional information about the Indian Health Service please check their Frequently Asked Questions web page at: www.ihs.gov/forpatients/FAQ.