General Medicare Frequently Asked Questions
General Medicare FAQ's
Medicare is a federal government program that helps older folks and some disabled people pay their medical bills and prescription drug costs. The program is divided into four parts: Part A, Part B, Part C, and Part D.
- Part A is called hospital insurance and covers most hospital stay costs, as well as some follow-up costs.
- Part B, medical insurance, pays some doctor and outpatient medical care costs.
- Part C is also called Medicare Advantage. It is run by private insurers and Medicare Managed Care plans (such as an HMO that provides Medicare-covered services as well as other coverage).
- Part D covers some prescription drug costs.
There are four “parts” of Medicare. Here’s a quick rundown, along with links to learn more about each part:
- Part A is Hospital Insurance, or HI. This primarily covers hospital stays and some stays in skilled nursing facilities.
- Part B is Medical Insurance. This covers doctors’ visits, lab tests, and outpatient procedures, just to name a few.
- Part C is Medicare Advantage. These are plans offered by private companies to provide Medicare benefits.
- Part D is Prescription Drug Coverage. This is optional for beneficiaries.
Parts A and B are collectively referred to as “Original Medicare,” and are generally what’s being referred to when I use the term Medicare.
Medicare Part A is funded primarily by payroll taxes, which end up in the Hospital Insurance Trust Fund. Medicare Part B revenue comes from both general revenues and premiums paid by Medicare beneficiaries. Medicare Advantage (Part C) is also funded by general revenues and by beneficiary premiums, while the Medicare Part D prescription drug plan is funded by general revenues, premiums and state payments.
You will have to pay a late-enrollment penalty of 10% of the Medicare Part B premium for every year you should have had coverage. The penalty applies as long as you receive Medicare benefits. If you miss the initial enrollment period or the eight-month window after you or your spouse stops working, you can only sign up from January through March in any year for coverage to begin July 1.
Medicare covers a large variety of medical services. This includes doctor visits, preventive care, lab tests, emergency services, and even medical equipment. It also includes things like surgeries, and the treatment for cancer and do not forget hospital stays.
Medicare only covers care that is medically necessary.
Although enrolling in Medicare Part B is optional, you should NOT skip Part B unless you have other coverage. Otherwise you will be stuck owing 20% of the cost of a surgery or expensive CT scan.
Anyone age 65 or over is eligible for Medicare. Most people age 65 and over are covered under Medicare Part A at no cost, based on their work records or on their spouse’s.
People over 65 who are not eligible for free Medicare Part A coverage can enroll in it and pay a monthly fee for the same coverage. The premium base rate will depend on the number of work credits you have earned. If you pay for Part A hospital insurance, you must also enroll in Part B medical insurance, for which you will pay an additional monthly premium.
No. You have to be enrolled in Medicare in order to be eligible to enroll in a Medicare Part D plan, Medigap plan, or Medicare Advantage plan. A Medicare Part D prescription drug plan only requires that you be enrolled in Medicare Part A. However, in order to enroll within a Medigap plan or a Medicare Advantage plan, you must first be enrolled in both Medicare Part A and Medicare Part B.
Medicare covers most clinical services and supplies that are medically necessary to treat a beneficiary’s condition or injury. Your benefits and costs will depend on which parts of Medicare you’re enrolled in, whether you get your coverage through Original Medicare or a Medicare Advantage plan, supplemental coverage, and whether you have prescription drug coverage.
Medicare generally does not cover health-care services if you are moving to another country, even if you are still enrolled in Medicare. If you are a Medicare beneficiary moving outside the U.S., plan ahead and make sure you have health-care coverage (other than just Medicare) in that country. However, you might still want to retain your Medicare coverage in case you ever move back to the U.S.
According to Medicare.gov, a pre-existing condition is any health condition or disability that you have prior to the coverage start date for a new insurance plan. If you have Original Medicare or Medicare Advantage, you are generally going to be covered for all Medicare benefits even if you have a pre-existing conditions or a disability. However, if you’re enrolled in a Medicare Supplement (Medigap) plan or have end-stage renal disease (ESRD), there are some exceptions.
All the rules about how much Medicare Part A will pay depends on how many days of inpatient care you have during what is called a “benefit period,” or spell of illness. The benefit period will begin the day you enter the hospital or skilled nursing facility as an inpatient and will continue until you have been out for 60 consecutive days. If you are in and out of the hospital or nursing facility several times but have not stayed out completely for 60 consecutive days, all of your inpatient bills for that time will be figured as part of the same initial benefit period.
Medicare Part A pays only certain amounts of a hospital bill for any one benefit period—and the rules are slightly different depending on whether the care facility is a hospital, psychiatric hospital, or skilled nursing facility, or whether care is received at home or through a hospice.
All people covered by Medicare Part A must pay an initial amount before Medicare will pay anything. This is called the hospital insurance deductible. The deductible is increased yearly every January 1.
Part B medical insurance is intended to cover basic medical services provided by doctors, clinics, and laboratories. However, the lists of services specifically covered and not covered are long, and do not always make a lot of sense.
Making the effort to learn what is and is not covered can be important, because you may get the most benefits by fitting your medical treatments into the covered categories whenever possible.
Part B insurance will pay for:
- doctor services (including surgery) provided at a hospital, a doctor’s office, or your home
- mammograms, pelvic exams, bone density tests, and PAP smears for women
- an annual flu shot
- a one-time physical exam (called a “wellness exam”) done within six months of when you enroll in Medicare Part B
- medical services provided by nurses, surgical assistants, or laboratory or X-ray technicians
- outpatient hospital treatment, such as emergency room or clinic charges, X-rays, injections, and lab work
- an ambulance, if required for a trip to or from a hospital or skilled nursing facility
- drugs or other medicine administered to you at a hospital or doctor’s office (for prescription drug benefits, consider enrolling in Medicare Part D, discussed below)
- medical equipment and supplies, such as splints, casts, prosthetic devices, body braces, heart pacemakers, corrective lenses after a cataract operation, glucose monitoring equipment, and therapeutic shoes for diabetics, and equipment such as ventilators, wheelchairs, and hospital beds
- some kinds of oral surgery
- some of the cost of outpatient physical and speech therapy
- a limited number of services by podiatrists and optometrists
- some care and counseling by psychologists, social workers, and daycare personnel
- some preventative screening exams, such as for cancer, glaucoma, and osteoporosis; as well as diabetes and heart disease, but only if your doctor says you’re at risk for them
- manual manipulation of out-of-place vertebrae by a chiropractor
- Alzheimer’s-related treatments
- scientifically proven obesity therapies and treatments, and
- part-time skilled nursing care, physical therapy, and speech therapy provided in your home.
When all of your medical bills are added up, you will see that Medicare pays, on average, only about half the total. There are three major reasons why it pays so little.
First, Medicare does not cover a number of major medical expenses, such as glasses, hearing aids, dental work, dentures, and a number of other costly medical services.
Second, Medicare pays only a portion of what it decides is the proper amount—called the approved charges—for medical services. When Medicare decides that a particular service is covered, it determines the approved charges for it. Part B medical insurance then usually pays only 80% of those approved charges; you are responsible for the balance of 20%.
Third, the approved amount may seem reasonable to Medicare, but it is often considerably less than what doctors usually charge. If your doctor or other medical provider does not accept assignment of the Medicare charges, you are personally responsible for the difference, up to a certain maximum.
Note that there are several types of treatments and medical providers now for which Medicare Part B pays 100% of the approved charges versus the usual 80%. These categories of care include home health care, clinical laboratory services, and flu and pneumonia vaccines.
For Original Medicare, Part A and Part B a simple way to determine your exact Medicare effective date is to refer to the lower right corner of your Medicare card or to refer to your letter from either the Social Security Administration or the Railroad Retirement Board.
If you have any questions about when your Medicare coverage starts, you can contact Social Security at 1-800-772-1213, Monday through Friday, from 7AM to 7PM. For TTY services, call 1-800-325-0778.
If you worked for a railroad, you can call the Railroad Retirement Board at 1-877-772-5772, Monday through Friday, from 9AM to 3:30PM. For TTY services, call 1-800-325-0778.
If you enroll into a Medicare Advantage or Medicare Prescription Drug Plan, the date your coverage starts can vary, depending on when you enroll and which election period you qualify for. For questions about your effective date on these types of Medicare plan options, you must contact the Medicare health or drug plan directly.
If you get Social Security benefits, you can change your Medicare address online at the Social Security website. If you change your address online, you will be asked a series of questions to verify your identity. Your answers must match the information Social Security has in its records. You can only change your address online if you have established a permanent password, which can be created by visiting My Social Security.
If you do not want to answer the questions online or you do not have a permanent password, you cannot submit a change of address online. Instead, you can call the Social Security Administration at 1-800-772-1213 (TTY 1-800-325-0778), Monday through Friday, from 7AM to 7PM and speak to one of their representatives or visit your local Social Security office.
Not every doctor may accept Medicare assignment (a payment agreement). Doctors who have been approved to accept Medicare assignment can fall into any of the following categories:
- Participating doctors accept Medicare assignment, meaning that they accept the Medicare-approved amount as payment for their services. These doctors charge the Medicare program 80% and the beneficiary 20% of the cost of the benefit.
- Non-participating doctors can choose to either accept or not accept Medicare assignment. If the doctor does not accept Medicare assignment, you might have to pay a 15% additional charge above the cost of the service, known as a Medicare excess charge. You would then be responsible for up to 35% of the reduced Medicare-approved amount instead of 20%.
- Doctors who have opted out of Medicare may charge you whatever they see fit for services and supplies, and you are responsible for the full cost of these benefits.
To find a participating doctor in your area, you may use the Medicare.gov Physician Compare tool. This tool will help you find an approved Medicare doctor based on medical specialty, geographical area, or doctor’s name. In addition to finding Medicare-approved physicians, this tool provides information about each doctor, along with maps and directions to help you find the doctor’s office.
That will depend on your situation. If you have worked at least 10 years (40 quarters) under Medicare-covered employment and paid Medicare taxes during that time, you qualify for premium-free Medicare Part A and will be automatically enrolled at age 65 even if you’re still working. If your spouse has enough employment quarters, you can also qualify for premium-free Medicare Part A based on his or her work history.
Another Medicare eligibility requirement is that you need to be an American citizen or permanent legal resident of at least five continuous years.
If you don’t have enough work history to get Medicare Part A without paying a premium, you can decide to delay enrollment if you already have health coverage through an employer or union (or through your own work or your spouse’s employer). Medicare Part B always comes with a monthly premium, so you may similarly choose to delay your Part B enrollment if you or your spouse are still working and have employer-based group coverage.
Remember that if you don’t sign up for Medicare when you’re first eligible and don’t have other coverage based on current employment, you could have to pay a late-enrollment penalty later when you do enroll. The late-enrollment penalty applies to Medicare Part B (and Part A, if you have to pay a premium for it).
One thing to consider is that even if you have health coverage through your employer or union, Medicare may help pay for some of the costs not covered by your group health plan. For example, enrolling in Medicare may be useful if you work for a small company (less than 20 employees) because Medicare could be the primary payer before your group health insurance. You may want to consult with your employer or union benefits administrator for specifics on how your health coverage and costs may compare with Medicare.
If you do decide to wait until your group coverage ends to enroll in Medicare Part A and/or Part B, you’ll have an 8-month Special Enrollment Period to sign up for Medicare that starts once you stop working or your group coverage ends (whichever happens first). You can also enroll in Medicare at any time that you are still working and have employer-based coverage.
If you choose COBRA after you stop working, do not wait until your COBRA coverage ends to sign up for Medicare. If you delay enrolling in Medicare Part A and/or Part B after your Special Enrollment Period ends, you’ll have to wait until the next General Enrollment Period (January 1 to March 31 every year) to enroll, and you may have to pay a late-enrollment penalty.
Medicare Part A, also known as hospital insurance, is part of Original Medicare, which is federal Medicare health insurance for qualified Americans aged 65 and older or to those of any age who enter their 25th month of receiving disability benefits through Social Security or the Railroad Retirement Board. You may also qualify at any age if you have certain health conditions, such as end-stage renal disease or amyotrophic lateral sclerosis (or Lou Gehrig’s disease). To be eligible for Medicare, you must be a U.S. citizen or a legal permanent resident of at least five continuous years.
Medicare Part A generally covers medically necessary services and supplies needed to treat a certain disease or condition and care when you’re a hospital inpatient in a Medicare-enrolled hospital. The following list describes some of the main services and supplies Part A specifically covers (this is not necessarily a complete list).
- Hospital care: If you’re admitted as an inpatient, Medicare covers semi-private rooms, prescription drugs given as part of your inpatient treatment, meals, general nursing, and more.
- Long-term care hospitals: Medicare covers long-term care hospital services if you were transferred from an acute-care hospital or admitted to the long-term care hospital within 60 days of being discharged from an inpatient hospital stay.
- Skilled nursing facility care: If your doctor determines that you need care in a Medicare-certified skilled nursing facility, Medicare Part A covers certain services and supplies, generally for a limited time.
Medicare may cover services and supplies including, but not limited to: semi-private rooms, meals, skilled nursing care, medications, medical supplies and equipment, and ambulance transportation. There are several qualifying factors that determine whether Medicare will cover your stay in such a facility.
- Nursing home care: Medicare might cover care in a skilled nursing facility (described above) as long as you need skilled nursing care and not just custodial care (help with eating, dressing, bathing, etc.).
- Hospice: Medicare covers doctor services, nursing care, medical equipment, medical supplies, and more. To qualify, your doctor must certify that you’re terminally ill and expected live six months or less; you must agree to accept palliative care (aimed at easing your pain instead of delivering a cure); and you must sign an agreement stating that you’re accepting hospice care instead of other Medicare-covered treatments for your health condition.
- Home health services: Medicare may cover certain home health services, generally for a limited time while you recover from a hospital stay. Medicare may cover intermittent at-home skilled nursing care, physical therapy, occupational services, and more for beneficiaries whose doctors certify that they need this care at home. The home health agency caring for the beneficiary must be Medicare-certified.
Medicare is a federal health insurance program that provides benefits to American citizens and permanent legal residents (of at least five continuous years) aged 65 and older, or who have a qualifying disability or illness. Most people are automatically enrolled into Original Medicare, Part A and Part B, when they become eligible; however, some people need to manually enroll in Medicare. Medicare Part A is hospital insurance; Medicare Part B is medical insurance.
You may want to take a look at these Medicare plan options.
- Medicare Advantage (Medicare Part C) gives you a way to get your Original Medicare coverage through a private, Medicare-approved insurance company instead of directly through the government. Medicare Advantage plans provide all your Medicare Part A and Part B benefits other than hospice care, which Part A still covers. But many Medicare Advantage plans include extra benefits, such as routine dental and vision services. And most Medicare Advantage plans include prescription drug coverage, letting you get all your Medicare benefits through a single plan. You still need to continue paying your Medicare Part B monthly premium, besides any premium the Medicare Advantage plan might charge.
- If you stay with Original Medicare, be aware that prescription drugs aren’t covered in most situations. Medicare Part D offers prescription drug coverage through private, Medicare-approved insurance companies. You may want to consider adding a stand-alone Medicare Prescription Drug Plan.
- If you decide to stay with Original Medicare, another option you may have is to sign up for a Medicare Supplement (Medigap) insurance plan to help pay for Original Medicare’s out-of-pocket costs. Different Medigap plans pay for different amounts of those costs, such as copayments, coinsurance, and deductibles.
Availability and costs of Medicare plan options may vary from one insurance company to another, and from one geographic area to another.
Medicare pays just for limited ambulance services. If you go to a hospital or skilled nursing facility (SNF), ambulance services are covered only if any other transportation could be a danger to your life or health. If the care you need is not available locally, Medicare helps pay for necessary ambulance transportation to the closest facility outside your local area that can provide the care you need.
If you choose to go to another facility farther away, Medicare payment is determined based on how much it would cost to go to the closest facility. All ambulance suppliers must accept assignment. Medicare does not pay for ambulance transportation to a doctor’s office. Air ambulance is paid only in emergency situations, such as when you can’t be easily reached by land, or if heavy traffic could prevent you from getting crucial care quickly. If you could have been transported by land ambulance without serious danger to your life or health, Medicare pays only the land ambulance rate and you are responsible for the difference.
If you have end-stage renal disease (ESRD), in some cases Medicare may cover ambulance services to and from a dialysis facility. If you have questions about Medicare coverage of ambulance transportation, contact Medicare at 1-800-MEDICARE (1-800-633-4227; TTY users 1-877-486-2048), 24 hours a day, 7 days a week.
Original Medicare is made up of Part A (hospital insurance) and Part B (medical insurance), and includes certain coverage for mental health care when the care comes from a Medicare-assigned health-care provider. Learn more about this Medicare coverage below.
Medicare Part A covers hospital inpatient mental health care, including room, meals, nursing, and other related services and supplies. This care can be received in a general hospital or a psychiatric hospital.
Medicare has a lifetime limit of 190 days of inpatient care in a psychiatric hospital.
Medicare uses benefit periods for hospital coverage. A benefit period begins the day you’re admitted as a hospital inpatient, and ends when 60 days in a row have passed since you have received inpatient care.
Your Medicare Part A costs for mental health care are listed below. Please note that the deductible and coinsurance amounts may vary year to year. You pay:
- The Medicare Part A deductible – $1,364 in 2019 (the full deductible amount is applied for each benefit period)
- No coinsurance ($0) for days 1-60
- $341 coinsurance per day in 2019 for days 61-90
- $682 coinsurance in 2019 per “lifetime reserve day” after the 90th day. Lifetime reserve days are days that you remain an inpatient beyond the 90-day hospital stay that Medicare covers. Medicare pays for your covered costs, charging you a daily coinsurance amount, for up to 60 of these days in your lifetime.
- All costs after your lifetime reserve days are used up
In addition to Medicare Part A costs, you may have some costs associated with Medicare Part B even when you’re a hospital inpatient (for example, doctor services).
Medicare Part B covers mental health services usually given outside a hospital, including visits with health professionals such as doctors, clinical psychologists, and clinical social workers. Some of the other mental health services that Medicare Part B may cover include, but aren’t limited to:
- Annual depression screenings
- Psychiatric evaluation
- Certain diagnostic tests your provider orders
- Partial hospitalization (a structured program of outpatient psychiatric services as an alternative to inpatient mental health care)
- Individual and group psychotherapy by licensed professionals permitted by the state where therapy takes place
- Medication management
- Family counseling as part of your treatment
Your Medicare Part B costs for mental health care are listed below. Please note that the deductible and coinsurance amounts may vary year to year. The annual depression screenings are free if you get them from a Medicare-assigned health-care provider. For other mental health services, you pay:
- The Medicare Part B deductible – $185 in 2019
- 20% of the Medicare-approved amount of health-care provider services
- A possible additional copayment or coinsurance if you receive your services as a hospital outpatient. The amount you pay depends on the service provided, but is generally 20%of the Medicare-approved amount.
If you’re enrolled in a Medicare Advantage plan, you still get the same coverage listed above, and your plan might include additional benefits, such as prescription drug coverage. Offered by private Medicare-approved insurance companies, Medicare Advantage plans must provide at least the same coverage as Medicare Part A and Part B (except for hospice care, which Medicare still covers). You still continue paying your Medicare Part B premium along with any premium the Medicare Advantage plan may charge.
The only chiropractic service covered by Medicare is manual manipulation of the spine to correct subluxation. Subluxation of the spine is when one or more of the bones of your spine move out of position. This is covered by Medicare Part B (medical insurance) in instances where it is medically necessary and provided by a chiropractor or other qualified provider. You do not need an X-ray to prove you have a subluxation of the spine.
One way you may be able to get additional Medicare chiropractic coverage is through a Medicare Advantage (MA) plan. Some Medicare Advantage plans could provide additional chiropractic coverage benefits. Check with your Medicare Advantage plan directly to see what chiropractic services are covered. You still need to continue paying your monthly Part B premium along with any premium the plan might charge.
No. Original Medicare does not cover dentures. In general, Medicare does not cover any routine dental care, including cleanings or check-ups, and never pays for dentures. It may cover the cost of teeth extraction before an inpatient procedure, but will not cover the cost of dentures after the procedure. For example, if you broke your jaw, then Original Medicare would cover any teeth extraction related to the jaw injury.
Certain Medicare plan options offered by private Medicare-approved insurance companies — such as Medicare Advantage plans — might offer dental coverage.
Original Medicare, Part A and Part B, does not generally cover routine eye exams for eyeglasses or contact lenses. However, Medicare Part B will cover an annual eye exam every 12 months if you have diabetes or are at high risk for glaucoma. Part B coverage also includes diagnostic tests and treatment for certain eye diseases, such as lucentis, aflibercept, and ocular photodynamic therapy.
Because Medicare Advantage plans must offer at least the same coverage as Original Medicare, these plans (offered by private, Medicare-approved insurance companies) also cover the circumstances described above. However, some Medicare Advantage plans may offer additional coverage, which could include routine vision benefits. Certain Medicare Supplement (Medigap) plans may also cover vision-related costs or provide additional eye coverage for an extra cost.
Durable medical equipment (DME) is reusable medical equipment, such as walkers, wheelchairs, or crutches. If you have Medicare Part B, Medicare covers certain medically necessary durable medical equipment if your physician or treating practitioner prescribes it for you to use in your home.
To be covered, the prescribed medical equipment must be:
- Used for a medical purpose.
- Not typically useful if you aren’t sick or hurt.
- Used in your home.*
*If you are currently residing in a hospital or nursing home that is providing you with Medicare-covered care, these facilities don’t qualify as your “home.” However, a long-term care facility does qualify as your home. If you’re staying in a skilled nursing facility and the facility provides you with durable medical equipment, the nursing facility is responsible for the durable medical equipment.
Some examples of durable medical equipment that Medicare covers may include, but isn’t limited to: Hospital beds, infusion supplies, oxygen equipment, patient lifts, and blood sugar monitors. If you have questions about whether a particular item or supply is covered, call 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. Medicare customer service representatives are available 24 hours a day, seven days a week.
It depends. Residents of the U.S., including citizens and permanent residents, are eligible for premium-free Medicare Part A if they have worked at least 40 quarters (10 years) in jobs where they or their spouses paid Medicare payroll taxes and are at least 65 years old. Legal immigrants who are age 65 or older who do not have this work history can purchase Medicare Part A after residing legally in the U.S. for five years continuously. Legal immigrants (non-citizen permanent residents) under age 65 with disabilities may also qualify for Medicare, but typically first must meet the same eligibility requirements for SSDI (disability benefits) that apply to citizens, which are based on work history, paying Social Security taxes on income, and having enough years of Social Security taxes accumulated to equal between 20 and 40 work credits (5-10 years). New immigrants are not eligible for Medicare regardless of their age. Once immigrants meet the residency requirements, eligibility and enrollment works the same as it does for others.
You will typically be automatically enrolled in Original Medicare, Part A and B, after you’ve received Social Security disability benefits (or certain Railroad Retirement Board disability benefits) for two straight years. Your Medicare coverage will start 24 months from the month you qualified for disability benefits. In some cases, this could be earlier than the month when you received your first check. You must be either a U.S. citizen or legal permanent resident of at least five continuous years to be eligible for Medicare.
Note that certain conditions may qualify you for Medicare under age 65, but have different enrollment details than those described above.
- If you have Lou Gehrig’s disease (Amyotrophic Lateral Sclerosis, or ALS), you’re enrolled in Medicare automatically the first month you receive disability benefits from Social Security or the Railroad Retirement Board.
- If you have end-stage renal disease (ESRD), you might qualify for Medicare, but you’re not automatically enrolled. If you’re on dialysis or you’ve had a kidney transplant, contact Social Security (information below).
You can get more information about Medicare and Social Security disability benefits from the Social Security Administration:
If you are happy with your coverage under traditional Medicare, you do not need to take any action during the Medicare Open Enrollment period. If you do nothing during the Medicare Open Enrollment period, your coverage under traditional Medicare will continue next year.
The timing of enrollment does not matter, as long as you enroll before the Medicare Open Enrollment period ends on December 7. Keep in mind that it can take some time to compare plans, and you may want to have a list of all the medications you take and the providers you see before you sit down to compare plans. If you wait until the end of the Medicare Open Enrollment period to enroll in a plan, you should still receive your new plan information before your new coverage takes effect on January 1.
You can, but generally only under special circumstances that qualify you for a Special Enrollment Period (SEP). These circumstances include (but are not limited to) moving to a new location that is outside of your current plan’s service area or where additional plan options are available, moving back into the U.S. after living abroad, moving into or out of a facility, or if Medicare terminates your current Medicare Advantage plan.
Some beneficiaries can change coverage on a quarterly basis. This includes enrollees who receive assistance from Medicaid and enrollees who receive Extra Help paying their Medicare drug plan premiums and cost sharing, who can switch Part D plans or Medicare Advantage plans once per calendar quarter in the first three quarters of the year, and during the Medicare Open Enrollment period that runs from October 15 through December 7 each year. Some beneficiaries can change coverage from month to month. This includes beneficiaries in certain institutions, such as nursing homes, who are allowed to switch Medicare Advantage or Part D plans once a month for as long as they are living there.
If you are currently enrolled in a Medicare Advantage plan and would like to switch to traditional Medicare, or switch to another Medicare Advantage plan, you may do so during the Medicare Open Enrollment period, which runs from October 15 through December 7 each year, or during the second Open Enrollment Period just for people in Medicare Advantage plans (the Medicare Advantage Open Enrollment period), which runs from January 1 through March 31. If you are in traditional Medicare, you can switch Part D plans or switch to a Medicare Advantage plan during the Medicare Open Enrollment period that runs from October 15 through December 7; you cannot use the Medicare Advantage Open Enrollment period (from January 1 to March 31) unless you are enrolled in a Medicare Advantage plan before January 1.
Hospice programs provide care and support people who are terminally ill. Their focus is on comfort, or “palliative” care, not on curing an illness. The National Hospice and Palliative Care Organization reports that 1.43 million Medicare beneficiaries were enrolled in hospice care for at least one day in 2016.
Medicare covers almost all aspects of hospice care with little expense to patients or families, as long as a Medicare-approved hospice program is used (in 2016, there were more than 4,300 Medicare-certified hospice programs in the US). When a Medicare beneficiary enters hospice the hospice benefits are provided via Original Medicare, even if the beneficiary had previously been enrolled in Medicare Advantage.
But if a Medicare Advantage enrollee who is in hospice care needs treatment for something that isn’t part of the terminal illness or related conditions, they can choose to use Original Medicare or their Medicare Advantage coverage.
To qualify, a patient must be eligible for Medicare Part A, and a doctor must certify that the patient is terminally ill and has six months or less to live. Medicare-approved programs usually provide care in your home or other facility where you live, such as a nursing home or, in some cases, hospitals.
Medicare covers a full complement of medical and support services for a life-limiting illness, including drugs for pain relief and symptom management; medical, nursing and social services; certain durable medical equipment and other related services, including spiritual and grief counseling, which Medicare typically doesn’t cover. There’s no deductible for hospice care, and copays for covered medications related to the terminal condition won’t exceed $5 (note that if a hospice patient needs medications that aren’t related to the terminal condition, their Part D plan would still have to cover them with its normal cost-sharing requirements, and their medical provider has to notify the Part D plan that the medications are unrelated to the terminal condition. This can be complicated, but it’s important for beneficiaries and their families to understand).
Medicare will also cover respite care, which is a short-term stay at a qualified hospice facility. It gives the usual caregiver a chance to rest. Respite care may last up to five days at a time.
Typically, Medicare does not cover room and board in facilities like nursing homes, but in-patient hospice care is covered during respite care, or at other times if the hospice programs deems it necessary and arranges it. If a hospice patient receives respite care, the patient will be billed 5 percent of the Medicare-approved cost of the inpatient care, and Medicare will pay the other 95 percent. Medigap plans can help to cover the out-of-pocket costs associated with hospice care, including respite care.
Hospice care continues as long as the hospice medical director or doctor recertifies that you’re terminally ill.
In general, once you’re enrolled in Medicare, you don’t need to take action to renew your coverage every year. This is true whether you are in Original Medicare, a Medicare Advantage plan, or a Medicare prescription drug plan. As long as you continue to pay any necessary premiums, your Medicare coverage should automatically renew every year with a few exceptions as described below.
There are some exceptions where you will need to take action to continue your coverage. Some situations where your Medicare Advantage or stand-alone Medicare Part D prescription drug plan coverage won not be automatically renewed include, but aren’t limited to:
- Your plan reduces its service area, and you now live outside of its coverage area.
- Your plan doesn’t renew its Medicare contract for the upcoming year.
- Your plan leaves the Medicare program in the middle of the year.
- Medicare terminates its contract with your plan.
If your Medicare plan doesn’t renew its contract with Medicare for the coming year, your Special Election Period will run from December 8 to the last day of February of the following year. If you have Medicare Advantage and don’t enroll in a new plan by the date that your current plan ends its contract with Medicare, you’ll be automatically returned to Original Medicare.
Keep in mind that your new coverage starts on the first day of the month after you submit your enrollment application, meaning if you apply on February 8, your new Medicare plan wouldn’t begin until March 1.
You’ll also get a three-month Special Election Period if your Medicare Advantage or Medicare Part D Prescription Drug Plan terminates its contract with Medicare. This period starts two months before the contract ends and runs an additional month after the contract ends. If Medicare terminates your plan’s contract, you will have a Special Election Period that begins 1 month before the termination effective date and ends 2 months after the effective date of the termination.
While you may not need to renew your Medicare coverage, it’s still a good idea to review your coverage annually. Benefits, provider and pharmacy networks, drug formularies, and cost sharing can all change from year to year and affect how much you pay out of pocket. Comparing plans annually is one way to make sure your coverage continues to meet your health needs and budget.
During the Medicare Open Enrollment period, from October 15 to December 7, you can make many changes to your Medicare coverage, depending on the coverage you already have. You can change from traditional Medicare to a Medicare Advantage plan (or vice versa). If you prefer Medicare Advantage, you can choose among the Medicare Advantage plans offered in your area during this period. If you are in traditional Medicare, and want prescription drug coverage, you can choose among Medicare prescription drug plans.
Medicaid is a joint federal and state program that helps pay medical bills for people with low income and limited resources. Eligibility for Medicaid depends on income level and family size.
Medicaid coverage differs from state to state. In all states, Medicaid pays for basic home health care and medical equipment. Medicaid may pay for homemaker, personal care, and other services that are not covered by Medicare. There are Medicaid programs that pay some or all of Medicare’s premiums and may also pay deductibles and coinsurance for certain people who qualify for Medicare and need financial assistance.
Absolutely not. Medicare is a federal health coverage program designed for the elderly and individuals with certain qualifying health conditions such as ESRD (End Stage Renal Disease). Medicaid is a state-run health coverage program that primarily targets low-income individuals that live within the state.