What Medicare Covers

Are you nearing your 65th birthday? Whether your birthday is just around the corner or a few years away, it’s time to start getting Medicare explained! Tens of thousands of people turn 65 every day, and most of what they know about Medicare is what they’ve seen on TV or gotten in the mail.

It’s no secret that Medicare is a little hard to understand. But if you take the time to read through this page, you’re sure to have a good grasp on what Medicare is and how it works.

Transitioning to Medicare explained

The first thing you need to know is that if you wait to enroll, you may have a penalty to pay and may experience a gap in coverage. There are only certain times when people can enroll in Medicare. Some get Medicare automatically, while others need to apply. The first time you can enroll is called your initial enrollment period and it lasts seven months. Your initial enrollment period usually begins three months before the month you turn 65 and ends three months after the month you turn 65. If you are already receiving Social Security benefits, you will be auto-enrolled into Medicare. If not, you have to enroll yourself.

Original Medicare Coverage

Original Medicare includes Part A and Part B, covering inpatient and outpatient services like hospital stays, doctor visits, medical equipment, lab tests, and preventive care.

Part A, often referred to as hospital insurance or inpatient insurance, primarily covers room and board expenses if you are admitted to a hospital or skilled nursing facility as an inpatient. It also includes coverage for hospice care and certain home health services.

Part B covers a wide range of outpatient medical services, including preventive care such as cancer screenings, vaccines, lab tests, and more. It also helps pay for mental health services and durable medical equipment.

While Part A covers hospital room and board, Part B helps pay for services received during a hospital stay, including diagnostic imaging, surgeries, dialysis, chemotherapy, and injected medications.

Part B is optional, but delaying enrollment may lead to penalties unless you qualify for a special enrollment period.

Medicare Advantage Coverage

Medicare Advantage (Part C) plans are private, Medicare-approved alternatives to Original Medicare that combine Part A, Part B, and often Part D coverage. These plans may include extra benefits like vision, hearing, and dental services. Medicare Advantage plans follow Medicare’s coverage rules but can vary in costs, provider networks, and service requirements.

Part D Coverage

Medicare Part D, also called the prescription drug benefit, helps cover most outpatient prescription medications. It is offered by private companies either as:

● A stand-alone plan for those with Original Medicare

● A bundled benefit within a Medicare Advantage plan

Part D plans have a formulary, a list of covered medications. If a needed drug isn’t on the formulary, you may request an exception, pay out of pocket, or file an appeal to have your plan reconsider its decision.

Enrolling in Medicare

Enrolling in Medicare may seem overwhelming, but choosing the right plan is the biggest task. The actual sign-up process is simple, especially with a broker like MAC Insurance.

Most people qualify for Medicare at 65, but those on disability for two years or diagnosed with ESRD or ALS may qualify earlier.

Your Initial Enrollment Period (IEP) lasts seven months, starting three months before your 65th birthday and ending three months after. You can enroll online, by phone, or in person through Social Security. If you receive Social Security benefits, enrollment in Parts A and B is automatic.

Enrollment at 65 isn’t mandatory. If you have creditable health coverage, you can delay without penalties. However, ensure your plan meets Medicare’s standards to avoid late fees.

What does Medicare not cover?

Original Medicare does not cover long-term care, acupuncture, or routine dental, vision, and hearing services. It also does not pay for hearing aids or cosmetic procedures.

Medicare Age Guidelines

Individuals receiving disability benefits for 24 months or those diagnosed with ALS (Amyotrophic lateral sclerosis) or ESRD (End-Stage Renal Disease) can qualify for Medicare at any age. Otherwise, eligibility begins at 65.

Choosing additional Medicare Plans

Original Medicare (Parts A and B) provides essential coverage but leaves out-of-pocket costs. Many add extra coverage through either Medicare Advantage or Medigap.

Medicare Advantage combines hospital, medical, and often drug coverage, plus extras like dental, vision, and wellness benefits.

Medigap helps cover deductibles, copays, and coinsurance but doesn’t include extra benefits. If choosing Medigap, you may need a separate Part D plan for prescriptions and a DVH policy for dental, vision, and hearing care.

Losing Medicare Coverage

Individuals cannot be removed from Medicare unless they fail to pay their premiums or no longer meet the disability requirements for eligibility.

Effective Dates for

MEDICARE COVERAGE

Medicare coverage typically begins at age 65 or after 25 months of disability benefits. However, not everyone is automatically enrolled, so start dates depend on when an individual applies.

The Initial Enrollment Period is the ideal time to apply for those turning 65. It starts three months before their 65th birthday and ends three months after.

In some cases, individuals may qualify for a Special Enrollment Period . For those who miss their initial window and don’t qualify for special enrollment, the General Enrollment Period runs from January 1 to March 31, with coverage starting on July 1.

ADDITIONAL QUESTIONS TO BE ADVISED ON:

What are the coverage differences between Original Medicare and Medicare Advantage?

Original Medicare (Parts A and B) covers hospital stays and doctor visits but does not include prescription drugs, dental, vision, or hearing care. Medicare Advantage (Part C) covers everything Original Medicare does and often includes extra benefits like drug coverage, dental, vision, hearing, and wellness programs.

Does Medicare cover routine dental, vision, and hearing care?

Original Medicare does not cover routine dental, vision, or hearing care. However, some Medicare Advantage plans include these benefits.

Are prescription drugs covered under Original Medicare?

Original Medicare does not cover most prescription drugs. You need to enroll in a separate Medicare Part D plan or a Medicare Advantage plan that includes drug coverage.

Does Medicare cover emergency medical services and ambulance transportation?

Yes, Medicare covers emergency medical services and ambulance transportation when medically necessary.

We are not connected with or endorsed by the United States government or the federal Medicare program. We do not offer every plan available in your area, and any information we provide is limited to those plans we do offer in your area. Please get in touch with Medicare.gov or 1-800-MEDICARE to get information on all your options.

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