When you have questions regarding Medicare, we want to help you find the answers. Read our frequently asked questions and get the answers you need today.
What is Medicare?
Medicare is Federal health insurance for American citizens and permanent legal residents that have lived in the USA for five continuous years that are 65 or older, or for those who have a qualifying illness or disability. Medical benefits include Part A hospital insurance and Part B medical insurance. Prescription drug coverage Part D is not included. Part D can be purchased through a Medicare-approved private insurance company
Do all doctors accept Medicare?
No, not all doctors accept Medicare assignment or payment agreement. Find a participating doctor in your area by using the Medicare.gov Physician Compare tool.
Does Medicare coverage need to be renewed yearly?
Once you are enrolled in Medicare, Medicare Advantage, or a Medicare prescription drug plan, you do not need to take further action. As long as you continue to pay the premiums, these services automatically renew yearly. However, if Medicare Advantage or Medicare Part D changes or does not renew their contract with Medicare, you may need to take action regarding your coverage.
If I am still working at age 65, do I need Medicare Part A or Part B?
While each situation is different, typically an American citizen or permanent legal resident of five continuous year would need to have worked 10 years or 40 quarters and paid Medicare taxes under a Medicare-covered employment to qualify for premium-free Medicare Part A. If this is the case, automatic enrollment starts at age 65 even if you still work.
However, if you do not have the qualifying work history, you may not qualify for Medicare Part A without paying a premium. At that point, you may be able to delay enrollment in Part A and Part B if you have health care coverage through your employer or union. Keep in mind that Part B has a monthly premium, regardless of work history. The caveat is if you do not sign for Medicare, and you do not have other employment coverage you may have to pay the penalty for late enrollment that applies to both Part A and B. You do have an 8-month Special Enrollment
Period (SEP) once your employer group coverage ends or you stop working.
If you are no longer working, but carry COBRA coverage, do not wait until the COBRA coverage ends to sign up for Medicare. You may have a lack of coverage and may need to wait until the next General Enrollment Period (GEP) that runs every January 1st through March 31st.
Even if you have employer-based coverage, Medicare may pay for costs not included in your health plan.
Does Medicare Pay for Ambulance Services?
Yes, but they are limited services.
- If you reside in a skilled nursing facility (SNF) or have a hospital stay that other transportation may be a danger to your life or health.
- If the care is not available to you locally – Medicare may help pay for transportation by ambulance to the closest facility.
- Often Medicare determines the amount of payment based on what it would cost to go to the closest facility.
- Air ambulance is only covered in an emergency situation when land transportation could jeopardize your life or health. However, Medicare will only pay the land rate; you are responsible for the difference between the land rate and the air rate.
In some cases, ambulatory services to and from a dialysis facility are covered if you have end-stage renal disease (ESRD)
If you have other questions about ambulance transportation coverage, contact Medicare at 1-800-MEDICARE (1-800-633-4227; TTY users 1-877-486-2048), 24 hours a day, 7 days a week.
What Does Medicare Part A Cover?
Medicare Part A part of the Original Medicare is hospital insurance, for American citizens and legal residents aged 65 and older or for any age enters their 25th month of receiving disability benefits through Social Security or the Railroad Retirement Board or have certain health conditions. This generally covers necessary services and medical supplies used to treat specific diseases and medical conditions.
While this is not an exhaustive list, here are a few services covered by Part A:
- Hospital Inpatient Care
- Long-term Care Hospital Stay
- Skilled Nursing Facilities
Under qualifying circumstances, Medicare may cover supplies and services that include semi-private rooms, meals, skilled nursing care, medications, medical supplies and equipment, ambulance transportation, and hospice. This is not an exhaustive list. Check with Medicare to see if your situation is covered.
What does Medicare Part B Cover?
Medicare Part B is different from Part A and typically covers preventive services like checkups and screenings. It also covers medical necessities to treat the medical condition. There are limits and restrictions on covered services. This is not an exhaustive list of covered services. The list is quite long and can change. Check with Medicare to confirm your situation is covered.
- Ambulance Services
- Mental health care (outpatient)
- Cardiac rehabilitation
- Chiropractic services (limited)
- Diabetes self-management training
- Diabetes supplies
- Durable medical equipment (such as walkers)
- Emergency room services
- Eyeglasses (limited)
- Hearing and balance exams
- Kidney dialysis services and supplies
What is Medicare Effective Date?
If you have already enrolled in Medicare, you will have a Medicare card with your information. Typically, the effective date is listed on the lower right corner of the card. You can also contact the Social Security Administration or the Railroad Retirement Board with any questions.
- Social Security at 1-800-772-1213, Monday through Friday, from 7 AM to 7 PM. For TTY services, call 1-800-325-0778.
- Railroad Retirement Board at 1-877-772-5772, Monday through Friday, from 9 AM to 3:30 PM. For TTY services, call 1-800-325-0778.
Do I qualify for Medicare if I receive Social Security Disability Benefits?
Automatic enrollment in Original Medicare typically happens once you have received Social Security Disability for two years straight. Medicare coverage starts 24 months from the month qualified; often earlier than the month you received your first check. Specific conditions may apply if under the age of 65 with different enrollment requirements.
Is Medicare Part D optional?
Yes, it is optional. However, if you decide at a later date that you need Medicare Part D and are not enrolled in a credible prescription drug plan for 63 days or more, you may have to pay a late-enrollment penalty.
What is creditable prescription drug coverage?
Creditable drug coverage includes health insurance that covers as much if not more than Medicare’s standard drug coverage. You can continue to use credible drug coverage alongside your Medicare benefits without penalty.
Credible drug coverage can be from:
- Employer group coverage or union plans
- United States Department of Veterans Affairs (VA)
- Indian Health Service (IHS)
How Often Can You Change Medicare Plans?
Annual Election Period – Oct 15th – Dec 7th each year
You can change Medicare Advantage or Medicare Part D Prescription Drug Plans, Change from Original Medicare, Part A, and Part B, to a Medicare Advantage plan and change from one Medical Advantage plan to another during this period. New coverage will start the following year on January 1st.
Medicare Advantage Disenrollment Period – January 1 thru February 14th of every year.
Switching from Medicare Advantage back to Original Medicare, Part A, and Part B, you can do so during the Medicare Advantage Disenrollment Period.
Special Election Period – For Unexpected Life Changes
Medicare has certain provisions to help you change or modify your Medicare coverage when you face unexpected life changes. This is not an exhaustive list but may include, and are not limited to:
- Address Change
- Loss of Current Coverage
- Qualifying for other coverage
What happens if you do not pay a Medicare premium?
If you miss your Medicare premium payment, you are at risk for losing coverage. For the most part, Part A is free for enrollees, but Part B and D charge premiums. You will get a warning before losing coverage.
What is not covered in Medicare Part A and Part B?
Some services that Medicare does not cover:
- Long-Term Care
- Most Dental Care
- Eye Exams
- Cosmetic Surgery
- Hearing Aids including exams and fitting appointments
- Foot care
With Medicare, not all medical expenses will be covered. If you encounter medical procedures or tests that are not included or covered by Medicare, you are required to pay for these expenses either out of pocket or with insurance plans that cover these expenses.
How to get prescription drug coverage
Drug prescription coverage with Medicare is optional. To get drug coverage with Medicare, you must first enroll in a Medicare plan that offers prescription drug coverage. There are two ways you can receive coverage for prescription drugs:
- Medicare Advantage Plan Part C, such as an HMO, PPO, or another Medicare healthcare plan that provides drug coverage.
- Medicare Prescription Drug Plan Part D. This plan can also be referred to as PDPs, which is an added coverage to the Original Medicare plan, Medicare Private Fee-for-Service (PFFS), Medicare Cost Plans, or Medicare Medical Savings Account (MSA) plans.
What do Medicare Part D drug plans cover?
Medicare offers prescription drug coverage with the Medicare Part D plan. However, this plan has a standard level of drug coverage that is set by Medicare. The covered prescription drugs can vary depending on the policy, which is referred to as the formulary along with what tier the formularies fall under.
Each plan that offers prescription drug coverage through Medicare Part D must give at least a standard level of coverage set by Medicare. Policies can vary the prescription drugs they cover (called a formulary) and how they place drugs into different “tiers” on their formularies.
Formulary. Medicare drug plans have specific lists of common medications that are covered, which is called formulary. These medications can be both brand-name and generic drugs. Formulary lists have a minimum of two commonly prescribed classes and categories.
Tiers. Tiers were created to help lower the costs of medications. Each drug plan coverage lists different medications into different tiers in the formularies. Tiers are divided into different categories, and each tier has a different cost. Typically, the lower the tier the lower the price.
- Tier 1 – Low copayment and includes many generic medications
- Tier 2 – Medium copayment and includes favored brand-name medications
- Tier 3 – High copayment and includes non-favored brand-name medications
- Specialty Tier – Highest copayment and consists of a higher expense for prescription medications
The above is just an example of how tiers are typically structured, and tiers and pricing can vary depending on your plan.
How does Medicare work with other insurance?
If you currently have Medicare along with another health insurance or coverage plan, each coverage is referred to as the “payer.” When you have more than one payer, the “coordination of benefits” makes the final decision on which payer pays in the beginning. Typically, what happens is the “primary payer” will pay their portion of your medical bill and then will pass the remaining bill to the “secondary payer.” This process continues until there are no other payers.
What is Medicare Supplement Insurance (Medigap)?
Medicare Supplement Insurance or Medigap aids in paying come medical costs that Medicare does not cover. Some of these expenses can include:
What does Medicare Medigap not cover
If you have Medigap coverage, this policy typically does not cover the following medical expenses:
- Private-Duty Nursing
- Long-Term Healthcare
- Vision Care
- Dental Care
- Hearing Aids
What is the Medicare Part A late enrollment penalty?
If you do not qualify for the Premium-Free Part A and you do not enroll in this program when you are eligible, your monthly premium could increase by 10%. This means you are responsible for paying a higher premium for double the number of years you could have enrolled in Part A.
What is the Medicare Part B late enrollment penalty?
If you miss the Part B enrollment when you are eligible, you can be responsible for paying a late enrollment penalty. Also, the monthly premium for Part B could increase by 10% of each 12 months that you were eligible for Part B. However, if you enroll in Part B during a Special Enrollment Period, you may not be held responsible for paying a late enrollment penalty.
Can I receive help with paying my Medicare insurance costs?
If you have limited income, you may be eligible to receive help to pay for your Medicare costs with the Medicare Savings Program. Four different types of Medicare Savings Programs:
- Qualified Medicare Beneficiary (QMB) Program – helps pay for Part A and Part B premiums.
- Specified Low-Income Medicare Beneficiary (SLMB) Program – helps pay for Part B premiums.
- Qualifying Individual (QI) Program – helps pay for Part B premiums. However, QI funds are minimal, and funds are granted on a first-come basis.
- Qualified Disabled and Working Individuals (QDWI) Program – helps pay for Part A premiums. To be eligible for QDWI, you must have a disability and still working.
What rights do I have if my insurance plan no longer supports Medicare?
There can be instances where Medicare and prescription coverage does not partake in Medicare for the following years. If this happens, the coverage in which you had ends after December 31st. If this occurs, you do have some options:
- Choose another insurance plan between October 15th – December 7th, and your coverage will go into effect on January 1st.
- The option to join a different Medicare plan until February 29, 2020.
- Have the right to buy specific Medigap plans within 63 days after your previous coverage ends.
What is Advance Beneficiary Notice of Noncoverage (ABN)?
If you receive treatment that your healthcare provider or doctor believes is not covered by Medicare, you may receive a notice known as an “Advance Beneficiary Notice of Noncoverage.” This notice states that Medicare may not pay for some of the services provided.
What happens when I receive an ABN?
When you receive an ABN notice, you can choose if you want to proceed with the services listed on the ABN. However:
- If you decide to proceed with the listed services on the notice, you will be responsible for the medical expenses if Medicare does not pay.
- You will be required to sign the notice stating that you have read and understood some services might not be covered, and you will be held responsible.
- Some healthcare professionals, doctors, or suppliers can give you an ABN in the case some services are never covered under Medicare.
- When receiving an ABN, this is not a denial letter by Medicare. In this case, Medicare denies a payment you can appeal. If you do appeal, you are required to pay for the services until other arrangements have been made.
Does Medicare cover chiropractic services?
In some cases, Medicare will cover some expenses related to chiropractic services. Medicare.gov states, “Medicare Part B (Medical Insurance) covers manual manipulation of the spine if medically necessary to correct a Subluxation when provided by a chiropractor or other qualified provider.” Medicare also states there is no Part B coverage for “other services or tests ordered by a chiropractor, including X-rays, massage therapy, and acupuncture.”
Should I get Medicare Part B?
If you have insurance through an employer or union, it is advised to contact the employer or union to see if your insurance coverage is compatible with Medicare. However, if you already have insurance through an employer or union, you may opt-out of the Part B enrollment.
If you have TRICARE, you can enroll in Medicare Part A and B when eligible. If you are an active-duty service member or dependent family, you are not required to enroll in Part B to keep TRICARE coverage.
How much does Medicare Part A cost?
If you or your spouse paid Medicare taxes while employed for a specific amount of time, you might not have to pay a monthly premium for Part A coverage. If you choose to opt for Part A coverage, you may also have to purchase Part B coverage and pay both premiums monthly. However, if you do not purchase Part A, you can still be eligible to purchase Part B. Those who have Part A coverage can pay up to $437. To see the current cost information, you can visit Medicare.gov.
How much does Medicare Part B cost?
In 2019 the average cost for Medicare Part B is $135.50. If your adjusted gross income on your IRS return is higher than a specific amount, you may be required to pay this average cost and an Income Related Monthly Adjusted Amount (IRMAA). The IRMAA is an added charge to your monthly premium.
Are prescription drugs covered under the Original Medicare coverage?
Typically, many prescription drugs are not covered under the Original Medicare plans. However, there are a few exceptions. If you wish to add prescription coverage, you can do so by adding the Medicare Prescription Drug Plan.
How do private accounts affect those with Medicare?
Some health providers and doctors do not work with Medicare and have the option to opt-out of Medicare. However, you can still see these providers but required to have a private contract with them unless in the state of an emergency. If you have a private contract with a doctor, Medicare is not responsible for the medical expenses incurred, and you will be liable to pay for these charges out of pocket.
What costs do I pay with Medicare?
With Original Medical, your out-of-pocket expenses can vary depending on the following:
- If you have Part A or Part B coverage.
- If your healthcare provider accepts “assignment.”
- The kind of care you need and how frequent.
- If you receive supplies or services that Medicare does not cover – you are responsible for these costs unless you have other coverage.
- If you have Medicaid or assistance from the state.
- If you have Medicare Supplement Insurance (Medigap).
- If you and your doctor have a private contract.
How do I know what Medicare pays?
With Original Medicare coverage, you will receive a Medicare Summary Notice (MSN) every three months by mail that states the services that were billed to Medicare. On this notice, you will receive a breakdown of what Medicare may owe your healthcare provider. It should state that MSN is not an actual bill.