LearningCenter

Are you turning 65? Turns out, you’ll be joined by thousands of birthday buddies.

In fact, <a href="https://arc.aarpinternational.org/countries/united-states" target="_blank">10,000 Americans turn 65</a> every day - a real cause for celebration, whether it’s the milestone of retirement or your journey to the right Medicare coverage.

Still, many Americans are confused by Medicare: how to enroll, when their enrollment period is and what plan to even enroll in.
But the process doesn’t need to be so complex. Here’s your Medicare checklist for turning 65.

## 1. Make Sure You Qualify For Premium-Free Medicare Part A

Most people qualify for Medicare Part A because of their work history. If you’re a U.S. citizen or permanent legal resident, you qualify for premium-free Part A as long as you have paid payroll taxes for at least 10 years.

Call your local Social Security Office to see if you’re eligible for Medicare Part A. You may receive a paper statement from SSA <a href="https://www.ssa.gov/myaccount/assets/materials/SSA-7005-SM-SI%20Wanda%20Worker%20Young.pdf" target="_blank">[sample here]</a>  as a reference, or you can create an account online at ssa.gov.

### What If You Didn’t Work Enough?

You may still qualify for Medicare Part A through your spouse if you don’t (or won’t) have 40 quarters of work history. You’re eligible if your spouse qualifies for premium-free Part A, and:

- You have been married for at least one year and your spouse is eligible for Social Security benefits.
- You're divorced and your former spouse is eligible for Social Security benefits.  You must have been married at least 10 years, and you must be single now.
- You’re widowed, but were married for at least nine months, and you are currently single.
 
If you don’t meet any of these criteria, you can either continue working until you’ve logged 40 quarters, or pay for Part A. For 2022, the Part A premium is $499 per month, but this amount may be reduced if you have some work history.

## 2. Figure Out When You’re Going To Need Part B
 
If you are currently employed and you are covered by an employer health plan, and your employer has more than 20 employees, you don’t have to sign up for [Part B](https://www.healthinsurance.com/learning-center/article/understanding-medicare-part-b) until you retire and give up your employer-based health coverage.

Many people can’t take full Social Security benefits until age 66, so it’s common to delay retirement by a year. You can delay Part B as long as your employer coverage meets Medicare’s minimum requirements.

But if you work for a small company with less than 20 employees, you’ll probably need to enroll in Part B when you’re first eligible. Be sure to talk about this with your employer before your 65th birthday. There’s no reason to pay the Part B premium until you’ll actually need Medicare.

## 3. Decide When You’re Taking Social Security
 
There are a few nuances to receiving Social Security and how it impacts when you can enroll in Medicare Parts A and B:

- If you take Social Security at age 65, your enrollment in Medicare will be automatic.
- If you pass on Social Security at age 65, but want to sign up for Medicare, you’ll have to apply for it separately.
- You can use <a href="https://www.ssa.gov/" target="_blank">ssa.gov</a> to enroll if you choose to enroll before your 65th birthday.
- If you wait until after you’re 65, you’ll have to visit a Social Security office to sign up for Medicare.
 
## 4. Know Which Doctors You Want To See When You Have Medicare
 
Make sure the doctors you see, or want to see, accept Medicare. Finding out ahead of time can help you avoid surprises.

If you plan to move during your retirement, it’s wise to get recommendations for doctors in your new hometown and see if they accept Medicare patients.

## 5. Get A Firm Understanding Of Your Medications

When it comes to medications and aging into Medicare, there are 3 steps to take:
 
- You should always know your medications and their doses.
- Talk to your doctor about generic versions of your prescriptions to reduce costs.
- Find out if your doctor thinks you might need a new or different medication in the future.

## 6. Understand The Gaps In Original Medicare

Medicare doesn’t cover 100% of your health care costs. Instead, you’ll pay a portion out of your own pocket. The costs you pay for Part A differ from what you’ll pay for Part B.

### Gaps In Medicare Part A

Part A will cover you for inpatient type of events, like:

- Hospital stays
- Home health care
- Hospice
- Skilled nursing facilities

When you have a hospital stay, you’ll have to pay the Part A deductible. For 2022, the deductible is $1,556. You’ll pay this inpatient hospital deductible each time you are admitted to the hospital, provided you haven’t received hospital or skilled nursing facility services within the previous 60-day benefit period.

### Gaps In Medicare Part B

Part B of Original Medicare covers the services you’d receive in an outpatient setting, including:

- Doctors and therapy appointments
- Lab work and diagnostic imaging
- Outpatient surgeries
- Medical equipment like oxygen machines
- Some cancer treatments like chemotherapy
 
When you use Part B coverage, you can expect to pay out of pocket for each service. Your share of cost can include:

- **Part B deductible:** $233 for 2022 (you only pay the Part B deductible once each year).
- **Part B coinsurance:** 20% of the cost for each service or procedure.
- **Part B excess charges:** Up to 15% of the Medicare-approved charge if your doctor does not accept the Medicare-approved amount for a service (known as Medicare assignment).
 
The biggest Part B expense is the 20% coinsurance, which you’ll pay throughout the year. There are other costs you can expect to pay out of pocket with Original Medicare, including things like dental care, eye exams, hearing aids, and more.
 
Keep in mind that there is no cap on how much you can spend out of pocket with Original Medicare.

## How To Find The Right Medicare Plan For You

Make sure any Medicare plan you consider:

- Covers the doctors you want to see
- Covers the medications you need
- Has a premium you can afford
 
You can also narrow your choices down further by asking yourself:

- Do I intend to split my time between two or more States?
- Am I comfortable with an HMO-type arrangement, or using a set group of doctors and facilities?
 
If you spend a lot of time travelling or living in a second home, you’ll want to consider Medicare Supplement Insurance. But if you’re comfortable with a particular HMO-type medical group and plan to live in one place, then Medicare Advantage could be right for you.
 
## Your Options Beyond Original Medicare
 
There are Medicare plans available that help <a href="https://medicare.healthinsurance.com/" target="_blank">close the coverage gap</a> of what Original Medicare doesn’t cover. They include:

- Medicare Advantage
- Medicare Part D (Prescription Drug Plans)
- Medicare Supplement (Medigap)

### Medicare Advantage Plans

Medicare Advantage plans, also known as Medicare Part C, is a contract between a private insurer and Medicare. These plans must cover everything that Original Medicare covers.
 
[Medicare Advantage plans](https://www.healthinsurance.com/learning-center/article/medicare-advantage-guide) work like traditional private health insurance, so you may see certain out-of-pocket costs with Medicare Advantage, including:

- Monthly premium: Many Part C plans don’t have a monthly premium.
- Annual deductible: Most plans don’t have a deductible.
- Copayments or coinsurance for services and procedures.
 
Medicare Advantage plans also offer a number of added benefits, which vary by state and health plan. Some benefits include:

- **Fitness programs** like Silver Sneakers or free memberships to local gyms.
- **Vision coverage** for exams, lenses, and sometimes frames.
- **Hearing coverage** for exams and discounted hearing aids.
- **Dental coverage** for basic dental services.
- **Transportation** to and from medical appointments
- **Prescription drug coverage** (some plans)
 
[Medicare Advantage](https://www.healthinsurance.com/learning-center/article/the-difference-between-medicare-advantage-and-medigap) plans can also provide emergency coverage outside the United States. With the international coverage, out of pocket maximum protection, and a wide range of extra benefits, you can see why many people choose Medicare Advantage plans.

### Prescription Drug Plans
 
Prescription Drug plans [(PDPs or Medicare Part D)](https://www.healthinsurance.com/learning-center/article/medicare-part-d-guide) help with the cost of prescription drugs. Each company creates their PDPs differently, but you can expect to pay these costs for coverage:

- Monthly premium, which varies based on income
- Annual deductible (although many plans don’t have a deductible)
- Copayment or coinsurance per filled prescription
 
The copayments and coinsurance costs increase as the total amount your plan pays rises above certain thresholds, also known as coverage stages:

**Coverage Stage 1 – Deductible Stage:** You pay full price until you’ve spent $480 (for 2022).

**Coverage Stage 2 – Initial Coverage Stage:** You pay small copayments or coinsurance for each prescription.

**Coverage Stage 3 – Coverage Gap Stage:** Also known as the Medicare “Donut Hole.” Once your total drug costs (what you’ve paid plus what your plan has paid) exceed $4,020, you hit the coverage gap. You’d then pay 25% of the cost of prescriptions.

**Coverage Stage 4 – Catastrophic Stage:** Once your total drug costs (excluding what your plan has paid) exceed $6,350, you pay no more than 5% for medications
 
These coverage stages reset on January 1 each year. But it’s important to know that there is no out-of-pocket cap on drug costs under Part D.

### Medicare Supplement Insurance

Medicare Supplement Insurance, also known as Medigap, is designed to fill the gaps in Original Medicare. Medigap supplements Original Medicare by paying some or all of the expenses that you’d normally have to pay out of pocket.

Medigap policies are issued in 10 standardized plans: A, B, C, D, F, G, K, L, M, and N. Each of these plans cover a slightly different portion of the Original Medicare gaps.

Plan G is a popular Medigap option that covers every gap except for the Part B deductible. If you have Plan G, you can expect to pay for the first $198 in Part B expenses (like doctor’s visits). Plan G will then cover every penny of any Medicare-approved service or procedure.

Several Medicare supplements provide some international coverage, including plans C, D, F, G, M, and N.

Medigap plans also give you maximum flexibility, so you can see any doctor or use any facility that accepts Medicare patients, anywhere in the United States. You’re not bound to a network, or reliant upon referrals.

Medicare Supplement Insurance plans don’t cover prescription drugs, so you’ll need to enroll in a stand alone Prescription Drug plan to get drug coverage.

## Considerations Before Choosing A Plan

Make sure any Medicare plan you consider:

- Covers the doctors you want to see
- Covers the medications you need
- Has a premium you can afford
 
You can also narrow your choices down further by asking yourself:

- Do I intend to split my time between two or more States?
- Am I comfortable with an HMO-type arrangement, or using a set group of doctors and facilities?

If you spend a lot of time travelling or living in a second home, you’ll want to consider Medicare Supplement Insurance. But if you’re fine with HMO-type medical groups and plan to live in one place, then Medicare Advantage could be right for you.
 
As you approach age 65, it’s important to start your research sooner rather than later. Make sure you know what plans your doctors will accept, and which plans cover your medications.
 
Comparing Medicare plan features and costs doesn’t have to be complicated though. You can get Medicare quotes <a href="http://medicare.healthinsurance.com" target="_blank">through our site</a>. Or you can **call 800-620-4519**  to reach one of our licensed Medicare agents who can guide you through your Medicare plan options. 

If you’re aging into Medicare you may be confused about what you need to do or the different Medicare options available to you. We’re here to help.

6 Tips for Aging Into Medicare: A Step-by-Step Guide

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Healthinsurance.com 6 Tips for Aging into Medicare

Your Guide to Aging Into Medicare

Once you’ve enrolled in Medicare, do you have to take action to renew it each year? While there is an [annual open enrollment period](https://medicare.healthinsurance.com/learning-center/article/guide-to-medicare-annual-enrollment-period) (AEP) every year from October 15th to December 7th, you generally don’t have to do anything unless you want to make changes.

There are a few exceptions, though. This guide will help you understand when you need to renew your Medicare coverage and when you can let it renew on its own. 


##Medicare Renewal - When You Might Have to Renew

There are some circumstances in which your coverage will not automatically renew. These are generally limited to [Medicare Part D](https://medicare.healthinsurance.com/learning-center/article/medicare-part-d-guide) (prescription drug coverage) and [Medicare Advantage](https://medicare.healthinsurance.com/learning-center/article/medicare-advantage-guide) plans. 

For example, you’ll have to choose a new plan at renewal if:

- Your existing plan reduces its coverage and doesn’t include your area anymore
- Your plan leaves Medicare or does not renew its Medicare contract for the next year
- Medicare terminates the contract with your existing plan
- Your insurer decides not to continue your current plan

In these cases, you may get a [special election period](https://medicare.healthinsurance.com/learning-center/article/medicare-special-enrollment-period) along with the normal enrollment period. That means you’ll have time to choose a new plan. 

If you don’t choose a different plan option, you might be automatically enrolled in a different Medicare Advantage plan offered by the insurer, or you may be returned to Original Medicare. If the affected plan is Medicare Part D and you don’t make a new choice, you might lose Medicare Part D coverage.

###How Do You Renew Your Medicare?

If you want to stay with the same plan and it’s still offered and contracted with Medicare, you shouldn’t need to do anything to renew. However, if you need to elect a new plan, you’ll want to take action right away.

####Medicare Part A and B (Original Medicare) Renewal

Your Medicare Part A and B will continue from one year to the next. However, there may be [changes in monthly premiums](https://medicare.healthinsurance.com/learning-center/article/2021-changes-to-medicare), cost-sharing, or other parts of the program. As a result, it’s important to review your Original Medicare plan each year during the enrollment period.

If you decide you don’t like the changes, you’ll have time to review different Medicare Advantage plans to see if they offer a better option for your needs.

####Medicare Part C (Medicare Advantage) Renewal

Medicare Advantage is the type of plan that is most likely to change from one year to the next. You might see a plan discontinued, in which case you need to choose different coverage. Or, there could be a significant change in monthly premiums, coverage levels, and cost-sharing.

It’s important to compare Medicare Advantage coverage every year during annual enrollment so that you are sure that you’re getting the best coverage at the right price for your needs.

If you want to stay with the same plan and have reviewed the premiums, benefits, and provider network, you can let the plan renew automatically.

####Medicare Part D (Drug Coverage) Renewal

Do you have to renew Medicare Part D every year? Like most insurance coverage, it’s important to review the price and coverage during the enrollment period to make sure nothing has changed that negatively affects you. 

If the plan is no longer offered or isn’t contracted with Medicare anymore, you’ll need to choose a different Medicare Part D plan. If you don’t, you could lose prescription drug coverage when the plan period ends.

If the plan is continuing and you aren’t concerned about the changes, you can allow the plan to renew automatically.

####Does Medicare Part G (Medigap or Medicare Supplement) Automatically Renew?

Do [Medicare supplement plans](https://medicare.healthinsurance.com/learning-center/article/medicare-supplement-101) automatically renew each year? Most supplement plans, known as Medigap, are designed to continue indefinitely as long as you make your payments. Even if that particular plan isn’t offered to new members anymore, existing enrollees with the plan can continue it.

It’s important to ensure you make your Medigap payments on time! If you don’t, the plan will terminate and you might not be able to get it back.

If you’re asking “Do I have to renew my Medicare supplement every year?” rest assured that it will continue as long as payments are made on time.


##Does Medicare Expire?

All insurance plans have a start and end date, but Medicare doesn’t expire unless you stop making payments or cancel the coverage yourself. 

Medicare does not expire. It continues from year to year unless your plan is canceled or you stop making payments. If your plan is canceled and you don’t make a different selection, you may be returned to Original Medicare coverage.

### Do Medicare Benefits Run Out?

In some cases, there are limits to how much Medicare will pay for specific services in each year or over your lifetime. For example, inpatient hospital stays beyond 90 days in a year can be limited and you may be required to pay your own medical costs beyond that point.

However, Original Medicare benefits do not run out — they continue to renew year after year. If you fail to make your Medicare monthly payment, you might face cancellation for non-payment. But the benefits themselves do not run out.


##Learn More About Medicare Enrollment and Renewal

Reviewing your insurance coverage during the different [Medicare enrollment periods](https://medicare.healthinsurance.com/learning-center/article/medicare-enrollment-periods) is essential to make sure you’re still getting the coverage you expect at a price you can afford. However, you usually don’t need to take action to renew Medicare unless you want to change plans.

Curious if you have the right plan to meet your needs? Talking to a licensed insurance agent can help. Contact us today to [compare plans](https://medicare.healthinsurance.com/) or learn more about Medicare renewal.

Most people don't need to renew or sign up for Medicare every year. But there is some important renewal information you should know. Learn more here.




Does Medicare Automatically Renew? | Medicare Renewal Info

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Does Medicare Automatically Renew? Do You Need to Sign Up Every Year?

In 2010, the Affordable Care Act (ACA) became law. It took effect over a period of the next few years, but now it’s fully operational. The ACA is also known as Obamacare because President Obama championed the law.

Because the ACA changed a lot of the requirements for health insurance, it’s common for people to wonder about the differences between Obamacare vs. Medicare. This article will help you understand the difference and show you how your Medicare coverage may have been affected by this law.


##Is Obamacare the Same as Medicare?

When comparing the Affordable Care Act vs. Medicare, it’s important to understand that they aren’t the same thing. The ACA is a law that made changes in the way health insurance is required to operate for consumers under the age of 65. Medicare is health insurance itself, managed by the federal government, for qualifying individuals. 

While some proponents describe Obamacare as “Medicare for all” , the slogan makes things more confusing. The idea behind the slogan was to capture  the impact the ACA would have on medical coverage, by providing access to health insurance to  everyone, regardless of pre-existing conditions.e.

Don’t let Obamacare vs. “Medicare for All” confuse you. Obamacare is not the same as Medicare.


##What is Obamacare?

Obamacare is a law that made significant and widespread changes to how health insurers have to operate. For example, to be compliant with the ACA, a long-term health plans must offer ten minimum essentiall benefits including  mental health and substance abuse treatment benefits as an essential benefit. Health insurance companies can also no longer deny someone health coverage due to a pre-existing condition. 

In general, the law expands coverage for individuals by making Obamacare compliant plans more similar to the types of group plans employers offer. . Most Americans receive health insurance from their employer, but some do not. For example, individuals who are not employed, freelancers, or work in the gig economy, generally do not have access to group plans. The ACA created a federal marketplace (some states built their own exchanges)  so that individuals without comprehensive health coverage could compare plans and buy a policy that made sense. They could also qualify for government help through tax subsidies to pay the monthly premium  if their income was below a certain threshold.

When people say they “are covered by Obamacare,” they usually mean that they have purchased a health insurance plan that meets the ACA’s requirements,  from a federal or state insurance marketplace.


##What is Medicare?

[Medicare](https://medicare.healthinsurance.com/learning-center/article/what-is-medicare) is a federal health insurance program that is for those 65 and older or those who have specific health conditions. It consists of multiple parts, each of which covers a different section of your medical needs.

[Medicare Part A](https://medicare.healthinsurance.com/learning-center/article/medicare-part-a) (hospital insurance) and [Part B](https://medicare.healthinsurance.com/learning-center/article/understanding-medicare-part-b) (medical insurance), together, are known as Original Medicare. You can also add Medicare Part D to get coverage for prescription drugs.

Medicare Part C is known as [Medicare Advantage](https://medicare.healthinsurance.com/learning-center/article/medicare-advantage-guide) and is a full replacement for Parts A and B. You’ll get at least the same coverage level as you would with Original Medicare, often with additional benefits and prescription drug coverage included as well. 


##Does Obamacare Affect Medicare?

Does the ACA affect Medicare? Obamacare affects all health insurance policies, including Medicare. The primary impact on Medicare was the expansion of preventive health benefits, which are defined as [essential health benefits](https://www.healthcare.gov/coverage/what-marketplace-plans-cover/) under the law. These screenings and tests are covered 100%, with no copayment or deductible.

The ACA also helps lower prescription drug costs for Medicare beneficiaries. There is a coverage gap in Part D that starts when you hit the maximum coverage for the year and ends when you spend enough on prescriptions to qualify for catastrophic coverage. In the past, you had to pay the full cost of your prescription drugs during that time. Learn more about catastrophic coverage and the [phases of Medicare Part D](https://medicare.healthinsurance.com/learning-center/article/phases-medicare-part-d) here. Thanks to the ACA, you pay 25% of the cost of covered drugs instead. 


##Can I Stay on Obamacare Instead of Medicare?

Obamacare is a law that affects health insurance, not a health insurance policy itself. People who say they are “on Obamacare” usually mean that they bought an individual or family policy through the federal or state designated  health insurance exchange and may be getting assistance with the premium costs.

Once you are eligible for Medicare, you cannot use an Obamacare plan instead. The only way you can delay your enrollment into Medicare is if you have a qualifying group plan, which generally means a plan offered by your employer.

That’s not bad news — Medicare plans are generally less expensive than individual or family plans in your state’s marketplace.


##Is Medicare Advantage Part of the Affordable Care Act?

Medicare Advantage, like all health insurance plans, is impacted by the ACA. There are also laws that require Medicare Advantage plans to offer at least as much coverage as Original Medicare, so you won’t suffer any loss of benefits with an Advantage plan.

The biggest difference between Medicare Advantage and Original Medicare is that an Advantage plan will have a specific network of providers that you will need to use. Often, there is no coverage outside the network except for emergency care.

Most Medicare Advantage plans also offer additional benefits that Original Medicare does not cover. That’s why it’s important to compare plans so you can ensure that the costs and benefits meet your needs before you enroll.


##More On Obamacare/ACA and Medicare

The Affordable Care Act had a big impact on all health insurance, including Medicare. Addressing the [Part D “donut hole”](https://medicare.healthinsurance.com/learning-center/article/what-is-the-medicare-donut-hole) and expanding preventive benefits helps Medicare beneficiaries no matter what their situation is.

Understanding your Medicare options is essential to choosing the right plan for your needs. Often it helps to talk to a licensed agent that can help you compare plans. If you have additional questions or would like to look at your options, [contact us today!](https://medicare.healthinsurance.com/)


Obamacare (ACA) and Medicare are not the same thing. Learn about their key differences here from the Medicare experts!


The Key Differences Between Obamacare and Medicare

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Obamacare/ACA vs Medicare

When you use your Medicare coverage to get medical care, your doctor generally submits a claim for reimbursement to Medicare. Sometimes, you’ll need to do this yourself.

Understanding how Medicare reimbursement and claims work is an important part of using your Medicare benefits to their full advantage. This guide will help you understand what reimbursement is and in what situations you might need to take action.


##What is Medicare Reimbursement?

In order for a doctor or medical provider to get paid by Original Medicare for providing services, the doctor’s office needs to submit a claim to Medicare. Usually, this is done automatically and you, as the patient, don’t need to do anything.

However, sometimes a doctor might not accept Original Medicare as payment. This could be because the amount Medicare agrees to pay is too low, or the paperwork is too difficult and frustrating. In this case, your doctor will either be non-participating or opt-out.

A non-participating doctor can charge you up to 15% more than what Medicare pays. You pay that amount upfront, and then file a reimbursement with Medicare to have them send you the approved payment amount. You file a reimbursement claim using form CMS-1490.

An opt-out doctor doesn’t accept Medicare payments and Medicare won’t reimburse you for care if you see them. As a result, you’ll pay the full amount yourself.

Keep in mind that Medicare Part C (Medicare Advantage) plans operate differently because they are issued from private insurance companies rather than managed by the Federal government like Original Medicare is.


##Medicare Reimbursement Rates 2022

How much does Original Medicare pay doctors for specific services? The answer is based on a variety of factors. There’s a base rate that Medicare pays depending on the service provided. Then the base rate is adjusted based on the zip code, complexity of the patient’s health needs, and more.

When a doctor bills Medicare, they use a CPT billing code that represents the service they are billing for. There are thousands of different codes, each with its own reimbursement rate. 

In order to get the Original  Medicare-approved amounts for the care your doctor recommends, ask the provider what codes will be used and what the reimbursement amounts are for those codes.

###Medicare Part A and B (Original Medicare) Reimbursement

If you have Original Medicare, you’ll use Medicare Part A for inpatient hospital stays and Medicare Part B for doctor’s visits and other medical needs.

###How much is Medicare Part A reimbursement? 

As we mentioned, it will vary significantly depending on the services you receive and the complexity of your case. Fortunately, your out-of-pocket cost does not change. After a deductible of $471, you’ll pay $0 for the first 60 days of hospitalization in the year, and then $371 per day for days 61-90 in the year. 

For [Medicare Part B](https://medicare.healthinsurance.com/learning-center/article/understanding-medicare-part-b) reimbursement, again, it depends on your needs and the complexity of your healthcare. The Medicare Part B coinsurance is 20% of the Medicare-approved amount. That means it’s important to know how much the care will cost, so be sure to ask your provider.

###Medicare Part C (Advantage) Reimbursement

Medicare Part C is a full replacement for Original Medicare and is provided by private insurance companies. When you have Medicare Part C, you never need to file a reimbursement with Medicare. Instead, contact the insurer if there are any concerns about claims or payments.

The important thing to remember about Medicare Part C plans is that most of them do not provide coverage for care that you receive outside the medical network. That means that if you see a doctor that doesn’t accept the coverage, you have to pay the full amount yourself.

###Medicare Part D (Drug Coverage) Reimbursement

Generally, the pharmacy where you pick up your medication will take care of your [Medicare Part D](https://medicare.healthinsurance.com/learning-center/article/medicare-part-d-guide) reimbursement filing. They will file directly with the plan to receive the payment they are due.

If you paid out-of-pocket for a medication that should have been covered, you’ll need to file a reimbursement claim with the Part D plan provider, not Medicare itself. Contact the insurer to find out what the process is.


##Medicare Reimbursement Rules

In most cases, you won’t have to worry about the reimbursement rules because the provider or pharmacy will file the claim for you.

However, if you are filing for reimbursement from Original Medicare, you need to do so within 12 months of the service being provided. If you wait longer than that, you can no longer get payment from Medicare. You also need to send in a specific form, along with a copy of the itemized bill from the provider.

If you have Medicare Advantage, the rules may be different. You’ll need to contact your insurer to find out how to get reimbursement if your provider doesn’t file the claim.


##Who is Eligible for Medicare Reimbursement?

To be eligible for reimbursement from Original Medicare, you either need to be a medical provider who has accepted the assignment or an individual with Medicare coverage. 

For individuals, you can only ask for reimbursement for Medicare-covered services or services that are covered by your Medicare Advantage plan. In addition, the services need to be completed by a medical provider that is part of the plan — not an opt-out or out-of-network doctor.

As we’ve mentioned, it’s rare for a Medicare patient to need to get reimbursed from Medicare. In general, you’ll pay your copayment or coinsurance amount and the doctor will bill Medicare for the rest.


##How Does Original Medicare Reimburse Physician Services?

There are a wide variety of CPT or HCPCS codes that apply to physician services. Each specific service has its own code, and the doctor’s office will use these codes when billing Medicare for your care.

If you receive a bill from the doctor that you did not expect, the first thing to do is contact the doctor’s office and ask them if they sent it through to Medicare with the right codes. Explain that you only pay your deductible and coinsurance or copayment amounts. 

You can also call Medicare or your insurance provider directly to explain the situation. The goal is to get the billing corrected so you don’t pay more than you need to.


##Have More Questions About Reimbursement and Claims?

Because there are thousands of service codes that can be billed to Medicare by your doctor, it’s hard to know exactly what the doctor will receive from Medicare. However, most of the time the only [Medicare costs](https://medicare.healthinsurance.com/learning-center/article/medicare-costs) you need to worry about are your monthly premium, deductible, and copayment or coinsurance.

If you have more questions about Medicare reimbursement and claims, it might be helpful to talk to a licensed insurance agent. We can help you [compare plans](https://medicare.healthinsurance.com/) and answer any questions you have. Contact us today!



If you are worried about filing a Medicare claim or getting reimbursed, read here for how to handle those situations and how reimbursement works.


Understanding Medicare Reimbursement & Claims FAQs Answered

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Understanding Medicare Reimbursement & Claims

In general, those who [qualify for Medicare](https://medicare.healthinsurance.com/learning-center/article/who-qualifies-for-medicare) are 65 and older. The program was created to help older Americans get health insurance coverage. However, there are some people who are able to get Medicare if they are under 65.

Often, these people are disabled or have specific health conditions. This guide will help you understand what disabilities allow you to qualify for Medicare early and [how to enroll](https://medicare.healthinsurance.com/learning-center/article/how-do-i-apply-for-medicare) in coverage if you are eligible.


##What Disabilities Qualify For Medicare Under 65?

In order to get Medicare for a disability, you have to have received Social Security Disability Income (SSDI) payments or railroad disability annuity checks for at least 24 months. At that point, you will automatically be enrolled in both Medicare Part A and B.

That means that the disabilities that qualify you for Medicare under age 65 are the same ones that qualify you for SSDI. According to Social Security, you must earn under $1,310 per month and have a condition that significantly limits your ability to do basic activities of work for at least 12 months. Also, your condition must be listed by Social Security as severe or considered as severe as one on the list. If it’s not on the list or comparable, there must be little to no other work available to you due to your condition.

Examples of disabilities that qualify for early Medicare eligibility include:

- Blindness
- Cerebral palsy
- Chronic respiratory disorders that test at certain levels

You can also get Medicare if you have Lou Gehrig’s disease (ALS), pancreatic cancer, or acute leukemia. There are additional conditions that may allow you to qualify before 65, visit the Social Security website for more information.

###Do You Pay For Medicare If You Are On Disability?

If you qualify for Medicare due to disability, you still pay the monthly premiums the way other Medicare enrollees do. That means that Part A will only be premium-free if you worked for at least 40 quarters in a job paying Medicare taxes. Otherwise, you’ll pay a monthly premium.

However, if you have a lower income and asset level, you may qualify for a [Medicare Savings Program](https://medicare.healthinsurance.com/learning-center/article/what-is-medicare-savings-program) that can help you pay for your premiums and out-of-pocket costs. You might also qualify for Medicaid as well as Medicare, meaning you will be dual-eligible and pay less.


###Is Medicare Part B Free If You Are Disabled?

All Medicare enrollees pay a monthly premium for Medicare Part B. If you are disabled, the amount will be deducted from your SSDI check or railroad disability payment. 

Just like with Medicare Part A, if you have a low income and assets, you may qualify for additional help with your premiums and out-of-pocket costs. Being dual-eligible for Medicare and Medicaid can also reduce your costs.


##What Medicare Benefits Are Available For People With Disabilities?

Americans with disabilities get all of the same benefits from Medicare that other Medicare beneficiaries receive. That means they can choose between [Original Medicare and Medicare Advantage](https://medicare.healthinsurance.com/learning-center/article/original-medicare-vs-medicare-advantage), shop for prescription drug plans (Part D), and more.

It’s important to ensure that you choose a plan that provides the coverage you need. For example, if you choose a [Medicare Advantage](https://medicare.healthinsurance.com/learning-center/article/medicare-advantage-guide) (Part C) plan, you’ll want your doctors to be part of the insurer’s network so that you can get coverage. If you stay with Original Medicare, you might consider a [Medigap plan](https://medicare.healthinsurance.com/learning-center/article/medicare-supplement-101) when you are first eligible to help you with your coinsurance.
 

##Health Insurance For Disabled Under 65

It can be difficult for those who are disabled and under 65 to find health insurance outside of Medicare. If you are able to work, you can likely get health insurance coverage from your employer. If you are not working, you might qualify for Medicaid.

However, if you are able to qualify for Medicare, that can give you an important option that will give you broader coverage than Medicaid alone. Medicare is a great option for those who are disabled and cannot work.


##What Medical Conditions Qualify For Early Medicare?

You can get Medicare if you are under 65 for a variety of disabilities and medical conditions. These health conditions are the same ones that qualify you to receive Social Security Disability Income (SSDI) payments.

You need to receive SSDI for 24 months before you qualify for Medicare. That waiting period may be waived for certain health conditions, such as Lou Gehrig’s disease (ALS).


##Learn More About Medicare Coverage for People with Disabilities

If you’re disabled and qualify for Medicare, it’s important to take advantage of this coverage so you can get the care you need. That means having the right Medicare plan and assistance programs in place.

If you’re interested in learning more about Medicare plans, we can help. Contact us today to talk to a licensed insurance agent and [compare plans](https://medicare.healthinsurance.com/).





Some people with disabilities, under the age of 65, could qualify for Medicare. Discover who qualifies and benefit options here.



Medicare Coverage For Disabled People Under 65

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Can You Get Medicare Early If You Are Disabled?

If you have a lower income, you might wonder how you can afford your Medicare costs. For example, your [Medicare Part D](https://medicare.healthinsurance.com/learning-center/article/medicare-part-d-guide) prescription drug coverage has a monthly premium, deductible, and copayment for prescriptions. 

If you need help paying for those costs, you should consider the Medicare Extra Help program. This guide will help you understand how to use this program and answer common questions that many Medicare beneficiaries have.


##What is Medicare Extra Help?

The Extra Help program helps those who struggle to afford their Medicare Part D prescription drug plan. In order to apply, you have to be enrolled in Medicare Part D. You might qualify for either full extra help or partial assistance.

The enrollment you qualify for depends on your monthly income, assets, and other programs you qualify for. 

If you qualify for Medicaid, SSI, or a Medicare Savings Program, you automatically receive Extra Help on your Medicare Part D plan. You don’t need to enroll, you simply need to send a copy of the qualifying notice to your drug plan.

Qualifying for Extra Help provides you with a special enrollment opportunity each quarter (except 4th quarter) to change Part D plans to make sure the plan you are in fits your needs. 


##What Does Medicare Extra Help Pay For?
Medicare Extra Help allows you to get assistance paying for your monthly premium, and deductibles. ,

The extra help you receive includes:

- Paying your Part D monthly premium and deductible
- Pay a lower copayment for prescription drugs
- Removes any Part D late enrollment penalty you might have

The specifics of how much you pay will depend on the level of Extra Help you qualify for. 

For example, partial Extra Help allows you to pay no more than 15% of the cost of the drug, and full Extra Help gives you a copayment of $9.20 in 2021 for name-brand drugs, ($9.85 in 2022) and $3.70 in 2021 for generics ($3.95 in 2022). 

Of course, if your normal Part D copayment is lower than that, you pay the lower amount.


##Medicare Extra Help Income Limits

Many people ask, “What are the income limits with Extra Help with Medicare?” These income limits change from year to year and are based on whether you live alone or as a couple. You also must live in one of the 50 states or the District of Columbia.

###What are the income limits for Extra Help with Medicare in 2021? 

For 2022, our resource limits must be below $27,950 for a couple, and $14,010 if you are not married or living alone. Your primary residence, vehicles, personal property, life insurance, and burial plots are not included in this total. 

 Government assistance such as food stamps, housing assistance, and utility help is not counted in the income.


##Medicare Extra Help Benefits

The primary benefit of Medicare Extra Help is to make your Medicare Part D plan more affordable. There are a lot of Medicare beneficiaries who struggle to make ends meet due to being on a fixed income or losing a spouse who was a source of income. 

With Medicare Extra Help, you can receive partial or full assistance paying for your Medicare Part D monthly premium and deductible, along with adjustments to your copayment for specific drugs. It’s a major benefit, especially for those who need a lot of prescription medication.


##Medicare Savings Programs (MSP)

In addition to Extra Help with Medicare Part D, you may qualify for Medicare Savings Programs (MSP) that help you with costs you may have for [Medicare Parts A and B](https://medicare.healthinsurance.com/learning-center/article/difference-between-medicare-part-a-part-b). There are four programs, each one with different qualifying criteria when it comes to income and assets.

1. The Qualified Medicare Beneficiary program provides the most assistance, paying for Part A and B premiums, deductibles, and coinsurance or copayments. 
2. The Specified Low-Income Medicare Beneficiary Program pays for Part B premiums only.
3. The Qualifying Individual program helps pay for Part B premiums. 
4. The Qualified Disabled and Working Individuals Program helps pay the Part A premium if you lose premium-free Part A because you went back to work and you have a qualifying disability.

You can learn more about these programs in our [Medicare Savings Programs guide](https://medicare.healthinsurance.com/learning-center/article/what-is-medicare-savings-program).


##Learn More About Medicare Extra Help Programs

Medicare Extra Help can allow you to save thousands of dollars for costs related to your Medicare Part D plan. This guide addressed many common questions, but you might still need more information. Talking to a licensed insurance agent can help. Contact us today to discuss your Medicare options with a licensed professional.


Some Medicare beneficiaries qualify for Extra Help for premiums, deductibles & co-payments. Learn more about who qualifies & the benefits of Medicare Extra Help.

Medicare Extra Help Programs: Income Limits and Benefits

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The Medicare Annual Enrollment Period (AEP), sometimes called Medicare Annual Open Enrollment or the Medicare Annual Election Period, runs from October 15 to December 7 each year. This is the time period in which Medicare beneficiaries can make certain changes to their Medicare plans, which we will cover below. Those plan changes would then become effective on January 1. 

But if Medicare beneficiaries are satisfied with their current Medicare plans, they don't have to take any action during Medicare AEP and there are no penalties involved. Medicare plan details can change annually, though, so it's wise to review your Medicare coverage each year.

##View Our 2022 Medicare Annual Enrollment Guide

The experts at TogetherHealth have developed a 2022 AEP Readiness Guide to help you prepare for the Medicare Annual Enrollment Period so you can make an informed choice for your healthcare needs next year.
   <p style="text-align:center;"><a href="https://cms.healthinsurance.com/Medicare_Annual_Enrollment_Period_Guide_for_2022_16a80ab0da.pdf" alt="
The Medicare Annual Enrollment Period (AEP) - also called the Medicare Open Enrollment Period - is an election period that allows you to make changes to your Medicare coverage each year. Your new coverage would take effect January 1 of the following year.">
<img src="https://cms.healthinsurance.com/Medicare_open_enrollment_period_9b2556b3f8.png">
</a></p>

##Overview of Medicare Enrollment Periods 

It's important to know that the Medicare Annual Enrollment Period is different from other Medicare enrollment periods. Here’s a quick overview of the differences:

- **Annual Enrollment Period (AEP):** Any changes to Medicare or Medicare Advantage plans
Initial Enrollment Period (IEP): Only happens around your 65th birthday, any changes to Medicare or Medicare Advantage plans
-  **Open Enrollment Period (OEP):** Applies only to those with Medicare Advantage, who can change Medicare Advantage plans or drop them and return to Original Medicare
- **General Enrollment Period (GEP):** Open enrollment period to join Medicare Part A and B.
- **Special Enrollment Period (SEP):** Occurs if you have eligible life changes that mean you need to change your plan before the next annual enrollment period.

**Be sure to visit our [guide to different enrollment periods](https://medicare.healthinsurance.com/learning-center/article/medicare-enrollment-periods) to learn more.**

## What’s the Difference Between Medicare AEP and the Medicare General Enrollment Period?

The Medicare Annual Enrollment Period is sometimes confused with the Medicare General Enrollment period, which is January 1 to March 31 each year. It’s important to understand the differences between the two enrollment periods.

The Medicare General Enrollment Period is for Medicare beneficiaries who didn’t sign up for [Medicare Part A](https://www.healthinsurance.com/learning-center/article/medicare-part-a)) or Part B when they first became eligible and aren’t eligible for a [Medicare Part B special enrollment period](https://www.healthinsurance.com/learning-center/article/understanding-medicare-part-b). The AEP, however, is for beneficiaries who are already enrolled in Medicare and want to change their Medicare coverage.

##What Changes Can I Make During the Medicare Annual Enrollment Period?

The first thing to know is that you cannot use the Medicare Annual Election Period to enroll in Medicare Part A or Part B for the first time.

If you’re enrolled in Medicare Part A and Part B and you’d like to change your Medicare coverage, here are some things you can do during the Medicare AEP:

- Change from Original Medicare to a Medicare Advantage plan.
- Change from one Medicare Advantage plan to another.
- Disenroll from your Medicare Advantage plan and go back to Original Medicare.
- Change from one prescription drug plan (Medicare Part D) to another.
- Enroll in a prescription drug plan.
- Cancel your prescription drug coverage.


##5 Tips to Prepare for the Medicare Annual Enrollment Period

There are many Medicare insurance carriers and plan options, but there are several steps you can take to be a savvy shopper and choose the right plan for your unique needs.

###1. Mark Your Calendar

This may seem like an obvious tip, but it’s worth mentioning: Mark your calendar for October 15 through December 7 if you’d like to make a change to your Medicare plan.

You might even set aside a few hours to research and compare Medicare Advantage plans and Prescription Drug plans ahead of October 15. These plans announce their benefits for the next year starting on October 1.

Writing down these Medicare AEP dates and to-dos will help you to commit to these priorities.

###2. Review Your Medicare Annual Notice of Change

You’ll receive lots of information over the next month or so prior to and during AEP, so if you’re currently enrolled in a Medicare Advantage or Prescription Drug Plan, the Annual Notice of Change (ANOC) is one piece of mail you’ll want to read.

Your Medicare plan will mail your Annual Notice of Change letter to you by September 30. The ANOC letter will inform you of most changes to your Medicare health plan, including coverage and benefits that will take effect on January 1, 2022.

Each year, your Medicare health plan sets the amounts it will charge you for premiums, deductibles and other services. Medicare doesn’t set these rates - but your insurance company does. With this in mind, the amounts you pay could change each year.

While evaluating your current Medicare plan, you may want to ask yourself questions like:

- Did the plan cover the services I needed?
- Did I use out-of-network providers?
- Did I spend more out of pocket than I originally anticipated?
- Has something changed with my health (new diagnosis, new prescriptions, etc.)?

The ANOC will also provide a side-by-side comparison of your current plan and next year’s plan benefits, costs and other changes (if any).

Moral of the story: Don’t toss this piece of mail aside. Always review your ANOC to ensure your plan continues to meet your needs on an annual basis. And if you don’t receive your ANOC by September 30, contact your Medicare insurance company.

###3. Make a List of What’s Important to Your Health

Keeping a list of what’s important to your health is an invaluable way to prepare for the Medicare Annual Enrollment Period.

Start by writing down all of your doctors, preferred health care facilities and hospitals, and prescription drugs, if you take any.

We also recommend making a list of value-added benefits that may fit your health, lifestyle and budget.

For example, you may be someone who likes to keep active and have social interaction. So a fitness program like SilverSneakers, which gives you access to a network of gyms and other programs, might be a good fit for you. A Medicare Advantage plan may provide these types of fitness or wellness programs.

Another thing to consider is whether or not you have an elective surgery planned for 2022. If so, you’ll want to check your hospital-specific benefits under your current Medicare Advantage plan.

###4. Check Your Plan’s Drug Formulary

Your Medicare plan’s drug formulary will not be included in your Annual Notice of Change, so be sure you call your insurance customer service representative to see if your prescription drugs will be covered for the 2022 plan year.

If your prescription drugs aren’t covered, it’s wise to use the Medicare Annual Enrollment Period to find a plan that does cover them.

###5. Talk To Your Doctor

Another “Medicare must-do” is to make sure all of your doctors and healthcare facilities will remain in network with your current Medicare plan. If they aren’t, you may want to take advantage of the Medicare Annual Enrollment Period.

So be sure to ask your doctor if he or she plans on changing health plan affiliations over the next year.


##What Changes Can I Make During the Medicare Annual Enrollment Period?

The first thing to know is that you **cannot** use the Medicare Annual Election Period to enroll in Medicare Part A or Part B for the first time. 

But if you’re enrolled in Medicare Part A and Part B and you’d like to change your Medicare coverage, here are some things you can do during the Medicare Annual Election Period:

- Change from Original Medicare to a Medicare Advantage plan.
- Change from one Medicare Advantage plan to another.
- Disenroll from your Medicare Advantage plan and go back to Original Medicare.
- Change from one [prescription drug plan (Medicare Part D)](https://www.healthinsurance.com/learning-center/article/medicare-part-d-guide) to another.
- Enroll in a prescription drug plan.
- Cancel your prescription drug coverage.


## What Are The Benefits of a Medicare Advantage Plan?

Understanding your Medicare plan options - starting with a [Medicare Advantage plan](https://www.healthinsurance.com/learning-center/article/medicare-advantage-guide) - is a smart first step to take because you can switch, enroll into or dis-enroll from Medicare Advantage plans during AEP.

Medicare Advantage plans, otherwise known as “[Medicare Part C](https://www.healthinsurance.com/learning-center/article/medicare-advantage-guide)” or “MA Plans,” bundle Original Medicare (Parts [A](https://www.healthinsurance.com/learning-center/article/medicare-part-a) and [B](https://www.healthinsurance.com/learning-center/article/understanding-medicare-part-b)) services into one plan. While Original Medicare offers you a number of benefits, it [may not cover](https://www.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage) health and medical services you might need. 

One major change happening for the 2021 plan year is that people with End Stage Renal Disease (ESRD), also known as kidney failure, will now have the option to enroll in a Medicare Advantage plan. The Centers for Medicare & Medicaid Services (CMS) estimates that <a href="https://www.ahip.org/medicare-advantage-what-is-changing-for-beneficiaries-with-end-stage-renal-disease-esrd-in-2021/" target="_blank">more than 80,000 people living with ESRD</a> will enroll in a Medicare Advantage plan by 2026 - a significant increase of 63%.


## What Are Medicare Advantage Special Needs Plans?
 
Medicare beneficiaries also have access to Medicare Advantage plans designed for unique needs. These are called <a href="https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/special-needs-plans-snp" target="_blank">Special Needs Plans</a> (SNPs). Like other types of Medicare Advantage plans, SNPs vary based on location.

You may be able to switch to a Special Needs Plan during the Medicare Annual Enrollment Period if one of these situations apply: 

- You’ve been diagnosed with a serious medical condition by a doctor. There are SNPs for certain chronic conditions, such as kidney and heart failure, diabetes and dementia. Services are tailored to the specific condition the plan covers.
- You need or have received skilled nursing care for at least 90 days at your home or at an institution, such as a nursing home or long-term care facility.
- You qualify for both Medicare and Medicaid. Medicaid eligibility is based on your income and assets. If you qualify, Medicaid will pay most of the costs for your Medicare Special Needs Plan.

Special Needs Plans include all the same benefits as regular Medicare Advantage plans, plus some expanded coverage. 

For example, all Special Needs Plans must include prescription drug coverage, which is usually tailored to the specific condition the plan covers. Although most regular Medicare Advantage plans include prescription drugs, some do not.

Some SNPs also provide a care coordinator to help you stay on track with your doctor appointments and treatment plan. 


## Changes in Income Due to Coronavirus (Covid19)?

The coronavirus crisis has [affected the financial well-being of many Americans](https://www.healthinsurance.com/learning-center/article/coronavirus-economic-impact), including those on Medicare. If you’ve experienced a decrease to your income or assets, the Medicare AEP 2020 season is a great time to switch to a more affordable plan.

If you have limited income, you might qualify for extra savings on Medicare costs through these programs:
- **Medicare Savings Programs.** These programs help pay for some of your Medicare Part A and Part B out-of-pocket costs, such as copays, deductibles and premiums. Most programs are for Medicare beneficiaries who also qualify for Medicaid. And as mentioned, Medicaid covers the majority of your costs when you join a Medicare Advantage Special Needs Plan. You can check if you qualify through your <a href="https://www.medicaid.gov/about-us/contact-us/contact-your-state-questions/index.html" target="_blank">local Medicaid office</a>. 
- **Medicare Extra Help.** Extra Help reduces your Medicare prescription drug plan costs. You should contact Social Security to <a href="https://www.ssa.gov/benefits/medicare/prescriptionhelp/" target="_blank">check your eligibility for Extra Help</a> if you have an existing Medicare drug plan or you join one during AEP.


## How To Enroll During the Medicare Annual Enrollment Period

To enroll in an eligible plan during the Medicare Annual Enrollment Period, you can visit [our comparison tool](https://www.healthinsurance.com/medicare/quotes).  Or, you **call (855) 651-5094** to talk to a licensed insurance agent to get help enrolling in Medicare.

Whatever option you choose, be sure to have **3 items** handy before you enroll in a plan or make changes to your current plan during AEP:

- Your Medicare card
- Your list of doctors, prescriptions and what is important to your health
- Pen and paper to take notes


## How To Find A Medicare Advantage or Prescription Drug Plan Before AEP

You don’t have to go it alone when choosing a Medicare Advantage plan or Prescription Drug Plan. We’re here to help you navigate the Medicare Annual Enrollment Period through a number of ways, including:

- [Our Medicare plan comparison tool](https://medicare.healthinsurance.com/)
- [Our online Medicare resources](https://www.healthinsurance.com/learning-center/medicare)

You can also **call 800-620-4519** to speak to a licensed insurance agent about your options.

You can also read through some of our articles to learn more about Medicare.

- [Medicare 101 Guide](https://www.healthinsurance.com/learning-center/article/medicare-supplement-101)
- [What is Medigap](https://www.healthinsurance.com/learning-center/article/medicare-advantage-guide)
- [Understanding Original Medicare vs. Medicare Advantage](https://www.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage)




Get ready for Medicare AEP with our 2022 guide to Medicare Annual Enrollment Period. Learn about Medicare enrollment changes, tips, Medicare resources & more.






UPDATED Medicare Annual Enrollment Period 2022 | Healthinsurance.com

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Healthinsurance.com Guide to the Medicare Annual Enrollment Period

UPDATED: Medicare Annual Enrollment Period 2022

As a veteran, you’ve earned the right to have excellent healthcare, and we thank you for your service! 

At the same time, when you approach the age of 65, you’ll also qualify for Medicare. You can carry both VA benefits and Medicare, but they don’t work together. Instead, some of your care will be covered by the VA and other medical needs by Medicare.

This guide will help you understand how to use both VA benefits and Medicare and when each coverage will apply. Let’s get started!


##VA Benefits vs Medicare

Both VA Benefits and Medicare provide comprehensive medical coverage for a variety of needs. However, they work in different places. 

If you go to a VA facility for your medical care, your VA medical benefits will apply. However, outside that system, you have to pay the full cost yourself, even in an emergency.

With Medicare coverage, if you get care outside the VA but at a Medicare-certified provider, you can use your Medicare benefits. As a result, Medicare can be a vital coverage if you don’t live close to a VA facility or if you travel frequently.

It’s important to keep in mind that VA care is based on your priority level. If you have a lower assigned priority level and VA funding drops, you may not be able to get VA medical benefits anymore. That’s why having Medicare if you’re eligible is an important backup.

###How Do VA Benefits Work With Medicare?

You might be wondering “Does the VA bill Medicare?” or “Does the VA bill Medicare Advantage plans?” The answer in both cases is no, they do not work together. 

Instead, your coverage will depend on what medical facility you go to. If you go to a VA facility, your VA benefits will take care of your needs. Any non-VA but Medicare-certified care will be covered by Medicare.

Sometimes the VA will authorize care at a non-VA facility. This generally means that they will cover the costs of those services, but if they don’t, Medicare may pay for the Medicare-eligible services left over.

###Is Medicare Primary Over VA Benefits? 

Medicare only applies to non-VA doctors. So in the VA, your VA benefits are primary. Everywhere else, Medicare is primary.

###Are VA Benefits Better Than Medicare?

In general, you’ll get the same benefits from both Medicare and VA benefits, though your coverage amounts, copays, and other factors may differ. 
Your access to VA care, along with the out-of-pocket costs you have in the form of copayments, can vary depending on your priority level. If you have a lower priority number, you might have to wait for care at the VA or have to pay more for services or medications.

Medicare gives you another option that isn’t dependent on your VA priority. Instead, you can get non-VA care when you need it. You can also choose a [Medicare Advantage plan](https://medicare.healthinsurance.com/learning-center/article/medicare-advantage-guide ) that brings additional benefits, such as vision, dental, and other care. However, Medicare Advantage plans have a limited network, so you’ll have to see the approved providers.

Instead of thinking about which coverage is better, it’s best to consider the benefits of combining Medicare and VA benefits.


##VA Medicare Eligibility

VA eligibility and Medicare eligibility are separate. To qualify for VA care, you need to be a veteran and meet the VA benefit requirements.

For Medicare, you need to be a U.S. resident or citizen who has lived in the country for at least five years, along with being 65 years of age or older, or having specific health conditions. You can qualify for VA but not Medicare, or you might qualify for both.

As we’ve mentioned, VA benefits are only applicable to VA medical centers. That’s why having Medicare as a secondary coverage can help.

###Do I Have to Enroll in Medicare if I Have VA Benefits?

You don’t have to, but you may face penalties if you don’t enroll during your initial enrollment period but decide to sign up later. 

Most Americans get Part A automatically and it’s free. For Medicare Part B, you might be automatically enrolled or you may have to sign up. There is a monthly fee for Medicare Part B, but it will be higher if you skip enrollment and then change your mind later on. We put a guide together that explains the [difference between Medicare Part A and Part B](https://medicare.healthinsurance.com/learning-center/article/difference-between-medicare-part-a-part-b) in further detail. 

We highly recommend signing up for Medicare when you are initially eligible. It expands your available medical options and can bring peace of mind if you have a lower VA priority level.


##Do I Need Medicare If I Have VA Benefits?

Do VA patients need Medicare? It’s a common question. You might think it’s unnecessary to carry two forms of health coverage.

However, those with VA benefits can only go to VA medical centers. Anything else isn’t covered. With Medicare, you have a much wider range of care available, which can be essential if you’re traveling or live far from a VA center.

If you wait to enroll in Medicare Part B because you have VA benefits, you may have to pay a late-enrollment penalty when you do decide to sign up. VA benefits don’t give you a [special enrollment period](https://medicare.healthinsurance.com/learning-center/article/medicare-special-enrollment-period ) or an exemption from the late-enrollment fees. 


##Can You Have VA Benefits and Medicare Advantage?

[Medicare Advantage](https://medicare.healthinsurance.com/learning-center/article/medicare-advantage-guide), or Medicare Part C, is a full replacement for Original Medicare. Often you get additional benefits, such as discounts on health memberships, vision care, or dental coverage. 

### Does the VA Bill Medicare Advantage Plans?

It does not. Instead, you use the plan that applies to the medical provider you see.

If you are eligible for Medicare, you can sign up for Medicare Advantage, even if you have VA benefits. As we’ve noted, VA benefits only apply at a VA health center. Medicare Advantage can be used anywhere within the plan’s medical network.

Keep in mind that, unlike Original Medicare, a Medicare Advantage plan will have a limited network of providers, generally within a single geographical area. Make sure your non-VA doctors are part of the network and that the plan covers the prescriptions you need.


## More Questions About Medicare for Veterans?

This guide has covered the most commonly asked questions that veterans have about Medicare coverage, but you might have additional concerns. That’s not a problem! We’re here to make it easy for you to understand your VA and Medicare options. 

Often it helps to talk to a licensed insurance agent that can review your specific situation and help you find the coverage that works for you. If this is something you’d like to do, contact us today!


You can have VA Benefits and Medicare, but they do not work together. Learn more about the two here and get your comparison and eligibility questions answered.


VA Benefits & Medicare | Guide to Medicare for Veterans

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VA Benefits and Medicare

Medicare is a health insurance plan for Americans 65 and older, and those under 65 with specific health conditions. Those who don’t meet these criteria often have a private plan, either a group health plan through their employer, or an individual plan they obtain directly  through a health insurance exchange, agency, or carrier. 
As you get older, you might wonder if it’s a good idea to stay with your private insurance plan instead of switching to Medicare. How does private insurance compare to Medicare? Can you delay your enrollment?

This guide will help you understand the differences between private insurance and Medicare coverage and when you should enroll in Medicare.


##Medicare vs Private Insurance After 65

As you approach age 65, you’ll qualify for Medicare. If you qualify for premium-free Medicare Part A, you’ll get that automatically. 

If you have a group insurance plan, you can delay enrolling in Medicare Part B until your group coverage ends. You won’t have to pay a late enrollment fee as long as your group coverage qualifies.

However, if you have  individual private insurance, you should enroll in Medicare Part B as soon as you are eligible. An individual private insurance plan does not allow you to delay your Part B enrollment — you will end up paying a late enrollment penalty when you do get your Part B coverage.

###Private Insurance Benefits

Individual private insurance offers a variety of benefits, depending on the plan you choose. If you have an Affordable Care Act compliant plan, then you will be covered for the ten minimum essential benefits, which includes maternity and mental health services. 
There are a variety of types of insurance. You might have a Health Maintenance Organization (HMO) plan, where you need a primary care doctor to authorize specialty care. You also need to get your medical care within the provider network to have coverage.

A usually more expensive private insurance option is a Preferred Provider Organization (PPO), where you don’t need a primary care doctor and can see specialists if you’d like. You pay less if you go to an in-network provider, but you can receive coverage outside the network as well.

Learn more about how [HMOs and PPOs work with Medicare](https://medicare.healthinsurance.com/learning-center/article/medicare-hmo-vs-ppo).

###Private Insurance Deductibles

A deductible is the amount that you pay for medical care before your insurance plan kicks in. For example, if you had a $1,000 deductible and a medical bill of $3,000, you’d pay the first $1,000 and the plan would generally pay the rest. 

After the deductible is paid for the year, you may only have to pay copayments or coinsurance for covered medical care.

The deductibles for private insurance vary widely. Some plans have a deductible as low as $500 for an individual and $1,000 for a family, but usually deductibles are closer to $2,000 or even more. For ACA compliant private insurance, the highest your out-of-pocket costs can be for a private insurance plan is $8,700, and $1700 for a family in 2022.

Generally, a lower deductible plan has a higher monthly payment, and a higher deductible plan costs less per month.

###Medicare Benefits

Medicare is a national program that covers health care needs for those that qualify. One of the biggest benefits of Original Medicare is that you can see any Medicare-approved provider, and the vast majority of doctors accept the coverage.

That means if you live in New York and are traveling to Florida, you can get care from a Medicare-approved provider in Florida even though it’s not your home state. Most private insurance plans have limited provider networks that are in one geographic area.

Another benefit is that Medicare Part A, for inpatient hospitalization, is premium-free for most Americans. Medicare Part B is also affordable, with a low monthly premium compared to most private insurance plans. The 2022 monthly Part B premium is $170.10

Medicare Advantage , also known as Medicare Part C, is an alternative to Original Medicare. When you enroll in a Medicare Part C plan, your benefits are offered and administered by a private insurance company and these private insurance companies must comply with many rules and regulations set by the Medicare program. If you are already in a Medicare Advantage plan, curious about them, or you’ve never heard of them, [our in depth guide](https://medicare.healthinsurance.com/learning-center/article/medicare-advantage-guide ) is for you.

###Medicare Deductibles

The Medicare deductibles depend on which part you’re using. For [Medicare Part A](https://medicare.healthinsurance.com/learning-center/article/medicare-part-a), hospital insurance, you have a $1,484 deductible for the year in 2021; the deductible is increasing to $1,556 in 2022. After that, you pay a copayment per day depending on the length of your hospital stay.

For Medicare [Part B](https://medicare.healthinsurance.com/learning-center/article/understanding-medicare-part-b), which is used for doctor’s appointments and medical equipment, the deductible is $203 in 2021; this is increasing to $233 in 2022.  After the deductible, you pay 20% of the Medicare-approved amount for any medical services you receive, and Medicare pays the rest.

If you have a [Medicare Advantage Plan](https://medicare.healthinsurance.com/learning-center/article/medicare-advantage-guide) (Medicare Part C), your deductible will depend on the plan you choose. Be sure to compare the monthly premiums and deductibles so that you choose the Advantage Plan that makes the most sense for you.


##Private Insurance Reimbursement Rate vs Medicare

All health insurance plans set their own reimbursement rates for various medical services. In order to be in the insurance plan’s network, the provider has to agree to accept these payments.

In general, a private insurer will pay significantly more for a covered service than Medicare does. A 2020 study found [private insurers pay almost 200% of Medicare rates]( https://www.kff.org/medicare/issue-brief/how-much-more-than-medicare-do-private-insurers-pay-a-review-of-the-literature/) on average. That means that private insurance is more attractive to medical providers. However, that doesn’t stop doctors from accepting Medicare — in fact, 93% of primary care physicians accept Medicare.


##Start Comparing Medicare Plans Today

If you’re eligible for Medicare, it often doesn’t make sense for you to continue using private insurance unless you’re in a qualifying group plan. Instead, you should consider switching to Original Medicare or choose a Medicare Advantage plan. 

Making the right choice can be difficult because you have so many options. Talking to a licensed insurance agent can help. Contact us today if you have further questions or want to compare [Medicare plans](https://medicare.healthinsurance.com/)!

Discover the key differences between private insurance and Medicare, and learn which is best for you after you turn 65.

Private Insurance vs Medicare: Benefits, Deductibles, and more

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Private Insurance vs. Medicare

Many older Americans wonder how they’ll pay for long-term care in the future if they aren’t able to live at home. There are limited circumstances where a short-term stay in a nursing home is covered by Medicare. However, a lot of nursing home care is not covered by Medicare. 

This article will help you understand when Medicare covers nursing homes, when it doesn’t, and what options are available to you.


##How Much Does Medicare Pay For Nursing Home Care?

[Medicare Part A](https://medicare.healthinsurance.com/learning-center/article/medicare-part-a) covers limited nursing home care for medical needs. If custodial care is your only health need, then Medicare coverage does not apply.

For example, Medicare Part A may provide coverage if you need to stay in a certified skilled nursing facility for a short period of time to recover from a fall or an illness after a qualifying hospital stay. There are a number of requirements before this coverage is available, such as having Part A coverage days left, a doctor saying you need skilled nursing care, and more.

If you have [Original Medicare](https://medicare.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage) coverage, you’ll pay a $0 copayment for days 0-20 in each benefit period, a $194.50 per day copayment for days 21-100, and you’ll be responsible for all costs from day 100 onward.


##How Long Does Medicare Pay For Nursing Home Care?

Medicare does not pay for long-term care at a nursing home. If you have medically-required care at a skilled nursing facility and Medicare Part A provides coverage, you can receive coverage for up to 100 days.

Beyond 100 days, you will have to pay all of the costs associated with treatment at the skilled nursing facility. 


##Does Medicare Cover Nursing Homes For Dementia?

As we mentioned, long-term nursing home care is not covered by Medicare. However, [Medicare Part A and B](https://medicare.healthinsurance.com/learning-center/article/difference-between-medicare-part-a-part-b) can help with coverage for some home health services that can assist an Alzheimer’s patient that is still living at home.

If an Alzheimer’s patient needs intermittent skilled nursing care for less than 21 days, Medicare can help provide coverage for this need. 

However, Medicare does not provide coverage for:

- Round-the-clock home care
- Homemaking services, like cleaning or laundry, when this is all the care you need
- Custodial or personal care, like bathing, grooming or getting dressed when this is the only care you need
- Meal delivery


##Does Medicare Cover Nursing Home Rehabilitation?

Medicare Part A will help cover the cost of being in a skilled nursing facility for rehabilitation for a short time after a qualifying hospitalization. There are conditions that must be met, such as having Medicare Part A days available and receiving medically-necessary care.

For the first 20 days, you don’t pay a copayment. From day 20-100, you’ll pay a daily copayment for nursing home rehabilitation. Day 101 and beyond are not covered by Medicare, so you’ll need to pay those costs yourself.

Services covered include a semi-private room, meals, physical or occupational therapy, medications, and more. The goal is to provide short-term care so that you can recover fully and live successfully at home again.


## Does Medicare Cover Hospice?

Medicare Part A does include coverage for hospice. In order to receive coverage, a hospice doctor and the patient’s doctor must certify that the patient is terminally ill, which means there is a life expectancy of six months or less. 

Hospice care is designed to make the patient comfortable, not cure an illness. Benefits include pain relief and symptom management services, medical and nursing services, medication and durable medical equipment as needed, homemaker and aide services, and spiritual and grief counseling for loved ones. 

You pay nothing for approved hospice care, but there may be a small copay for outpatient drugs for pain management. You may also pay 5% of the Medicare-Approved amount for respite care.

###How Many Days Will Medicare Cover Hospice?

Those approved for hospice care generally have less than six months to live. If the care lasts longer than six months, the doctors must re-certify that you are still terminally ill. 

There isn’t a hard limit for hospice care, but the expectation is that the care will not exceed a year. If the doctors do not recertify that the patient has six months or less to live, then hospice benefits will end.


##Learn More About Medicare and Nursing Homes

Medicare only covers short-term skilled nursing care, not long-term care in a nursing home. However, there are other payment options for nursing homes, such as Medicaid, long-term care insurance, or personal funds.

If you’d like to learn more about Medicare and nursing homes or need help [comparing Medicare plans](https://medicare.healthinsurance.com) to choose the best option, talking to a licensed agent may help. Contact us today for more information!


All your Medicare and nursing home questions answered in one place. If you still have questions, you can contact one of our licensed agents for help.

Does Medicare Cover Nursing Homes? Coverage & Cost Questions

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Does Medicare Cover Nursing Homes?


If you qualify for Medicare, you’re probably wondering how much you’ll pay. The answer can be confusing because there are a variety of expenses you are responsible for, including a monthly premium, deductibles, and copayments. 

Also, the cost of each part of Medicare is different. For example, [Part A](https://medicare.healthinsurance.com/learning-center/article/medicare-part-a) is premium-free for most Americans but [Part B](https://medicare.healthinsurance.com/learning-center/article/understanding-medicare-part-b) has a monthly premium. Understanding what you’ll pay for different plans is an important part of making the right choices for your needs.

This guide will help you understand the costs of Medicare so you can choose the best coverage for you.


## Is Medicare Actually Free?

Medicare is made up of different parts, most of which are not free. However, there are ways to get help paying for your Medicare costs if you have a lower income and assets.

[Original Medicare](https://medicare.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage) is made up of Parts A and B, and many people choose to add [Part D](https://medicare.healthinsurance.com/learning-center/article/medicare-part-d-guide) as well. Part A is hospital insurance, Part B is medical coverage for doctor’s visits and medical supplies, and Part D covers prescription medication. Each of these parts has its own costs.

[Medicare Advantage](https://medicare.healthinsurance.com/learning-center/article/medicare-advantage-guide), or Medicare Part C, is an alternative to Original Medicare. These plans provide at least as much coverage as Original Medicare and often include drug coverage and additional benefits. Medicare Advantage has a variety of costs as well.

Regardless of which Medicare plan you choose, you will have at least some out-of-pocket costs.


## What is the Cost of Medicare for 2022?

The costs of Medicare change slightly from year to year to account for inflation in the price of care and medical supplies. CMS just released the latest information on Medicare costs for 2022. This guide to 2022 changes to Medicare outlines the new rates for premiums and deductibles as well as other changes you should be aware of.

When it comes to Medicare costs, each part is different, so we’ll look at each one individually.

If you have a [Medicare Supplement Plan](https://medicare.healthinsurance.com/learning-center/article/medicare-supplement-101) (Medigap) you may pay less out of pocket, and if you qualify for a [Medicare Savings Program](https://medicare.healthinsurance.com/learning-center/article/what-is-medicare-savings-program) you might have lower costs as well. 

###How Much is Medicare Part A?

For most people, Medicare Part A doesn’t have a monthly premium. In 2021, if you use your insurance for an inpatient hospital stay, you’d pay a deductible of $1,484. This deductible is increasing for 2022 and will now be $1,556.

After the deductible, the first 60 days of inpatient hospital care in a year have a $0 coinsurance bold text. For days 61 - 90 in a year, the coinsurance is $389 per day. Day 91 and beyond are $7778 a day, up to 60 days in your lifetime. 

Once those 60 days are used up, you have to pay the full costs of your medical care each time you go beyond 90 days in a hospital stay.

###How Much is Medicare Part B?

Medicare Part B has three types of costs — a monthly premium, a deductible, and coinsurance.

In 2021, the monthly premium for most Americans was $148.50 but this amount increased to $170.22 in 2022. The deductible was $203 in 2021 and increased to $233 in 2022. Following these costs, you pay a coinsurance of 20% of the Medicare-Approved amount for the care you receive. 

###How Much is Medicare Part D?

Similar to Medicare Part B, Part D has a monthly premium, a deductible, and a copayment for medications you need. 

The specific Part D premium will depend on the plan you choose. Medicare Part D is offered by different private insurance companies, so you’ll want to compare plans. The average 2022 premium for Part D will be $33 per month in 2022. 

When selecting a Part D plan, ensure that your required medications are part of the plan. Then, at your premium, deductible, and copayment amounts before you make a decision. 


##Who Actually Pays for Medicare?

Medicare is funded through two trust funds held by the Treasury, which get money from social security taxes and money authorized from Congress. Everyone pays 1.45% of their income into FICA, and employers pay another 1.45%, totaling 2.9%. 

Other funds come from income taxes paid on Social Security benefits, interest earned from the investments the trust fund makes with available funds, and Medicare Part A premiums paid by those who don’t get the coverage for free.

Also, when you enroll in Medicare, you pay part of the costs yourself through monthly premiums, deductibles, and copayments or coinsurance.

###How Much is Taken Out of Your Social Security Check for Medicare?

In general, the only amount automatically deducted from your Social Security payment each month is your  Medicare Part B premium. 

If you’ve chosen to enroll in Medicare Part D as well, you can opt to have that automatically deducted from your Social Security payment. If you select a Medicare Advantage plan instead of Original Medicare, you can choose to pay that separately or have it automatically deducted from your Social Security check. You’ll need to arrange automatic payments for Part D or Part C with the insurer. 

If you start receiving Medicare before you get Social Security benefits, you will be billed by Medicare every quarter. That means you’ll be responsible for paying three months at a time, so be sure to budget for the expense.

###How Much Does the Average Senior Pay for Medicare?

How much does Medicare cost at age 65? The truth is there’s no single answer. The costs of Medicare vary widely depending on how much medical care you need. If you need a lot of medical procedures or medication, you could pay a lot more than someone else who needed less medical attention. 

Most individuals pay  a monthly premium for Medicare Part B. However, those with higher incomes may pay a higherPart B premium, and those with lower incomes may get help from the State in paying some, or all, of their Medicare premiums, Part D plans also have different premium, deductible, and copayment structures. And similar to Part B, those with higher incomes are subject to pay more; those with lower incomes may get extra help in paying Part D costs.  If you choose Part C instead of Original Medicare, you’ll have a variety of options for coverage and out-of-pocket costs.

That’s why it’s so important to understand Medicare coverages and compare them carefully. When you make the right choices for your needs, you can get the most out of your Medicare costs.


##Learn More About Medicare Costs

This article answered many common questions about Medicare costs, but many times talking to someone helps you get a better understanding of the options available. We have licensed agents available to help you [compare plans](https://medicare.healthinsurance.com/) and answer any other questions you have. 

Contact us today to learn more about Medicare costs and choose a plan!


How much does Medicare cost and does it depend on the type and your specific medical needs? We answer these questions and more in this guide.

A Guide to Medicare Costs

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How Much is Medicare?

Does Medicare cover dental implants? As we get older, we often lose teeth and need to get implants to replace them. It’s important to know whether your Medicare coverage will help you get this type of care.

As you might know, Medicare has several different parts. Part A and B are known as [Original Medicare](https://medicare.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage), while Medicare Part C is known as [Medicare Advantage](https://medicare.healthinsurance.com/learning-center/article/medicare-advantage-guide). We’ll take a look at whether each of these parts can help cover the cost of dental implants.

###What Are Dental Implants?

Before we move forward, it’s essential to define dental implants so it’s clear what we’re discussing. When you have a tooth removed, leaving an open gap in your mouth can cause a variety of problems, including shifting teeth, bone loss, and more.

An implant replaces your missing tooth with a metal post and an artificial tooth that looks and functions just like a real one. This dental surgery helps you regain your normal smile and tooth function. It’s a great alternative to dentures or bridges.


##Does Original Medicare (Part A and B) Cover Dental Implants?

Original Medicare includes both Part A and Part B. Part A is inpatient hospital insurance, so it won’t cover dental work unless it’s medically required and related to a condition you are getting Part A coverage for.

Does Medicare Part B cover dental implants? Unfortunately, no. Dental coverage is not part of Original Medicare, although Medicare Part B may help treat conditions related to the implant surgery. For example, if you have an infection due to your implant, your Medicare coverage would help you get medical care for the infection.

Some people wonder, “Does Medicare supplement cover dental implants?” A [Medicare supplement plan](https://medicare.healthinsurance.com/learning-center/article/medicare-supplement-101), or Medigap, does not add additional coverage to Original Medicare. Instead, it helps you pay for out-of-pocket costs related to covered care.


##Does Medicare Advantage (Part C) Cover Dental Implants?

Because Medicare Advantage plans often add additional coverage above Original Medicare, it’s common to ask, “Does Medicare Advantage cover dental implants?” The good news is that depending on the plan, you may be able to get coverage for implants and other dental care.

Not all Medicare Advantage plans cover dental, but many do. You’d have to look at whether the plan you want offers coverage only for cleanings and routine exams, or if there’s also coverage for complex dental procedures as well. 

It’s important to compare various Medicare Advantage plans to get the benefits you want at a cost that makes sense for your budget.


##Does Medicare Part D Cover Dental Implants?

[Medicare Part D](https://medicare.healthinsurance.com/learning-center/article/medicare-part-d-guide) is drug coverage, designed to help recipients afford the prescription drugs they need. Because it only covers prescription drugs, it does not offer coverage for dental implants or other dental care.

However, if you are prescribed pain medication or antibiotics after the implant surgery, your Medicare Part D plan will likely cover these medicines.


##Learn More About Medicare and Dental Coverage

If you think you might need dental care and are concerned about Medicare coverage, it can help to talk to a licensed agent who can help you compare your options. We’re here to help you learn more about [Medicare and dental coverage](https://medicare.healthinsurance.com/learning-center/article/does-medicare-cover-dental), as well as to help you [compare Medicare plans](https://medicare.healthinsurance.com/) and so you can select the best option for your needs.


Discover if Medicare covers dental implants and where to find more Medicare and dental coverage information.

Does Medicare Cover Dental Implants?

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A colonoscopy is an important exam that can help detect health problems while they are still highly treatable. Doctors can detect and remove polyps before they have a chance to grow or become cancerous.

Does Medicare cover colonoscopies? How much do they cost? This page will help answer common questions about Medicare coverage and this essential exam. 


##Does Medicare Cover Colonoscopy Cost?

Medicare Part B will cover a colonoscopy regularly, depending on your needs and risk factors. If you’re considered at high risk for colon cancer, Medicare will cover the exam every two years. 

However, if you have a normal or low risk of colon cancer, Medicare covers a colonoscopy every 10 years. There’s no minimum age requirement to get coverage for a colonoscopy, although doctors often recommend the exam for those 50 and over.

###How Much Does a Colonoscopy Cost Out Of Pocket?

For most medical care under Medicare Part B, you’re responsible for your annual deductible and a copayment. However, a colonoscopy exam is different. It’s considered preventive care, so your deductible does not apply.

If the doctor accepts the Medicare assignment, you don’t pay anything for the colonoscopy exam. However, if a polyp is found and has to be removed, the exam moves from being preventive to diagnostic. As a result, you may be billed for your normal Medicare Part B coinsurance, which is 20% of the Medicare-approved amount for the procedure.

If you’re curious about how much your test and potential polyp removal will cost, be sure to talk to your doctor. Factors such as whether the provider accepts the Medicare assignment, how much the doctor charges and more may impact your out-of-pocket costs.

##Does Medicare Cover Colonoscopy Prep?

Colonoscopy prep involves taking specific medication to clear your system, allowing the exam to be completed. Medicare Part B does not cover the medication. However, if you have Medicare Part D for prescription coverage, the prep kit should be covered with your normal Part D deductible and copayment. 

If you have Medicare Part C, or Medicare Advantage, drug coverage is often included with the plan. In general, colonoscopy prep kits are covered under Medicare Advantage drug plans. However, you might have a deductible or copayment.


##Does Medicare Cover Anesthesia for a Colonoscopy?

Most people don’t experience a colonoscopy while awake. Instead, they are put under anesthesia for the exam. The anesthesia used for a colonoscopy is covered under Medicare Part B, along with other relevant costs for the procedure.

Your out-of-pocket expenses will still be $0 if the test is preventive, and you’ll still pay 20% of the allowed costs for all aspects of the procedure, including anesthesia if polyps are found and removed.


##Does Medicare Require Prior Authorization for Colonoscopy?

Many insurance plans require pre-authorization before they will cover a medical service. In general, Original Medicare does not require pre-authorization for a colonoscopy.

However, your Medicare Part D plan might require pre-authorization for the colonoscopy prep kit before you obtain it, so be sure to check with your specific plan. Also, if you have a Medicare Advantage plan, you will likely need prior authorization before you move forward with your exam.

Because a colonoscopy is very routine, it’s unlikely that you will have any trouble getting the authorization you need. To avoid headaches, be sure to check with your insurance company before moving forward if you have a Medicare Advantage plan. 

###More Questions About Medicare and Colonoscopy Coverage?

If you have more questions about how colonoscopies are covered by Medicare or want to compare different Medicare coverage options, we’re here to help. Simply contact us to talk to a licensed agent today!

Medicare covers colonoscopies once every 24 months. Learn more about prep, anesthesia, and authorization here first before scheduling an appointment.

Does Medicare Cover a Colonoscopy? Coverage & Cost Questions

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Does Medicare Cover a Colonoscopy? 

If you’ve decided to choose a [Medicare Advantage plan](https://medicare.healthinsurance.com/learning-center/article/medicare-advantage-guide) for your Medicare coverage, it’s important to know what kind of plan you’re working with. Private health insurance plans can be structured in different ways, each with its own requirements.

Two of the most common Medicare Advantage types are Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). In addition, each Medicare Advantage plan will have its own network of doctors and providers. 

To get the maximum benefit from your Medicare Advantage plan it’s important to understand these insurance plan structures and how they work. Let’s dive in!


##What is a Medicare Advantage HMO Plan?

A Medicare Advantage HMO plan has a medical network of doctors and providers and only provides coverage within that network. 

If you want to go to a doctor or provider outside the network, you won’t be able to use your insurance plan unless it’s emergency care, out-of-area urgent care, or out-of-area dialysis. 

An HMO also requires you to have a designated Primary Care Provider (PCP) to coordinate your care. Specialist appointments generally require a referral from your PCP and may also require preauthorization from the insurance company as well.

###Does a Medicare HMO Plan Replace Original Medicare?

A Medicare Advantage Plan HMO is an alternative to Original Medicare. All Advantage plans must offer at least as much coverage as Original Medicare, and many offer additional benefits as well.

###What is a Medicare HMO Risk Plan?

An HMO Risk Plan is a type of health insurance arrangement that an insurance company makes with the government. The insurance company agrees to provide medical services to each member of the plan, and the government pays the insurance company a flat fee per enrollee.

Most Medicare Advantage HMOs operate this way. A few get reimbursed from the government based on actual costs, but most get a flat fee per member.

###What is a Medicare HMO-POS Plan?

HMO-POS stands for “Health Maintenance Organization - Point of Service.” These are hybrid plans that allow members to get some coverage for medical care outside the HMO network. If you use out-of-network care, you will pay more than you would for normal in-network benefits.

An HMO-POS still requires you to have a PCP coordinate your care, but you may not need a referral to see a specialist. However, getting a referral may allow you to get coverage more quickly. You may still have to preauthorize some services with the insurance company.

With an HMO-POS, there are separate deductibles for the in-network (HMO) and out-of-network (POS) parts of the plan. 


##What is a Medicare Advantage PPO Plan?

What is the difference between an HMO and PPO? In a Preferred Provider Organization (PPO) plan, you have more choices in your medical care. However, you may pay a higher monthly premium for these types of plans.

A PPO still has a medical provider network and you may pay less for medical services within the network. However, you can receive care outside the network as well. You don’t have to choose a PCP to coordinate your care, although it may still help you to have a single provider who understands all of your needs.

You won’t need a referral to see a specialist, but you’ll need to set up specialist appointments yourself. You also won’t need insurance authorization for services provided outside the medical provider network. Finally, there’s only one deductible for the whole plan, rather than separate ones for in-network and out-of-network care.

When choosing a plan, it’s important to compare Medicare Advantage PPO vs HMO plans. That way you can get the coverage you need with a premium you can afford.


##Pros and Cons of PPOs and HMOs

<br>
<table>
  <tr>
    <th>Plan</th>
    <th>Pros</th>
    <th>Cons</th> 
  </tr>
  <tr>
    <td><strong>Medicare HMO</strong></td>
    <td>A Medicare HMO has lower monthly premiums while providing a strong level of care and benefits. You get a dedicated doctor coordinating your care and may pay less for medical services because everything is provided within the network.</td> 
    <td>Medicare HMOs limit care to the network only, so if you are traveling, you can only receive emergency care. You also have to get referrals to see a specialist and need to preauthorize certain services before they will be covered.</td>
  </tr>
  <tr>
    <td><strong>Medicare PPO</strong></td> 
    <td>Medicare PPOs generally allow you to see whomever you would like without a referral or preauthorization. You don’t have to stick to one PCP, and you can receive medical services outside the provider network.</td>
<td>Medicare PPOs are more expensive in terms of a monthly premium and there may be fewer plan options available in your area. You may have higher out-of-pocket costs for care outside the network and may pay more overall than you would with an HMO.</td>
  </tr>
</table>
<br>


##Get Expert Assistance on Your HMO and PPO Options

Now that you understand the general differences between Medicare PPOs and HMOs, you might wonder “Is Original Medicare a PPO or HMO?” The truth is it isn’t either one. Original Medicare uses a nationwide network of participating doctors and doesn’t require a PCP or preauthorization. If you get care from a doctor that’s opted out of Medicare, you’ll need to pay the full price out-of-pocket.

Choosing the right plan can be challenging, but it’s much easier when you have a licensed agent helping you understand your options. If you’d like to compare plans or have more questions, we’re here to help. Simply [contact us today](http://medicare.healthinsurance.com/)!



Learn the difference between Medicare Advantage HMO and PPO plans and see which may be the best for you!


What Is the Difference Between Medicare HMO vs. PPO

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What is the Difference Between Medicare HMO vs. PPO?

What are special needs plans? If you have a specific disease or set of health needs, you may qualify for a Medicare Special Needs Plan (SNP). These plans are offered through [Medicare Advantage](https://medicare.healthinsurance.com/learning-center/article/medicare-advantage-guide) and can help you focus your benefits and drug coverage to meet your specific healthcare needs.

There are three kinds of SNP plans. This article will describe each one and help you determine if you qualify.

##What Are the Three Types of Special Needs Plans?

The three Medicare SNP plans are chronic conditions special needs plans (C-SNP), dual-eligible SNP plans (D-SNP), and institutional SNP plans (I-SNP). Each one is designed to meet a specific need by providing tailored healthcare.

To qualify for a special needs plan, you need to have Medicare [Part A](https://medicare.healthinsurance.com/learning-center/article/medicare-part-a) and [Part B](https://medicare.healthinsurance.com/learning-center/article/understanding-medicare-part-b), live in the plan’s service area and meet the specific plan’s eligibility requirements.

###Chronic Conditions SNP (C-SNP)

C-SNP plans are tailored to meet the needs of people with specific chronic conditions. These plans help group providers and specialists that can best attend to your needs. 

For example, there might be a special needs plan for Medicare in your area that focuses on people with congestive heart failure. The providers, drug formulary, and case management would all be focused on helping patients with this illness.

A C-SNP plan can focus on one or several chronic conditions. Some of the conditions that qualify for a C-SNP include:

- Autoimmune disorders
- Cancer
- Chronic alcohol or other substance dependence
- Chronic heart failure
- Cardiovascular disorders
- Diabetes mellitus
- Dementia
- End-stage liver disease
- End-stage renal disease requiring dialysis
- Severe hematologic disorders
- Chronic lung disorders
- HIV/AIDS
- Stroke
- Neurological disorders
- Chronic and disabling mental health conditions

When looking for SNP plans, it’s important to compare your options. There will be different costs and types of coverage available for different plans. Understanding your unique needs and the plans available in your area will help you choose the best coverage for you.

###Dual Eligible SNP (D-SNP)

When you are eligible for both Medicare and Medicaid, you are considered dual-eligible. The specific coverage for your D-SNP Medicare plan will depend on the specific state you live in since Medicaid is state-specific.

All categories of Medicaid eligibility are included in the dual-eligible SNP definition. Features of D-SNP plans will be similar to regular Medicare Advantage plans, but they are designated as either a Medicare Zero-Dollar Cost-Sharing Plan or a Medicare Non-Zero Dollar Cost-Sharing Plan. 

As with any health coverage, you’ll want to compare D-SNP options to ensure you get the best benefits for your specific needs.

###Institutional SNP (I-SNP)

To qualify for an institutional SNP plan, you need to qualify for a Medicare Advantage plan and need at least 90 days of care in a qualified institutional setting. This could include long-term care, a skilled nursing facility, a care facility for individuals with intellectual disabilities, or an inpatient psychiatric facility.

Each plan provides a model of care (MOC) to the Center for Medicare Services, which lays out how the plan takes care of members in the institution. This includes having professional case managers and providing individualized care plans. In an I-SNP, providers can see patients based on preventative care, rather than medical necessity, so visits happen more often to prevent issues and decline. 

##Contact Us to Learn More About Medicare SNP Plans

The good news is that you have a wide range of healthcare options available when it comes to Medicare addressing specific health needs. Unfortunately, it can be hard to understand all of the available plans. 
Talking to a licensed insurance agent can help. If you’re interested in comparing your Medicare options, contact us today!


SNP plans are offered through Medicare Advantage. Learn how to apply and who qualifies in this guide.

A Guide to Medicare Special Needs Plans (SNP)

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Medicare Special Needs Plans (SNP)

Home health care is an important service for many older Americans. It can help you save money compared to needing to go to the doctor or hospital, and it allows you to grow older at home instead of in a facility.

Many people wonder, “Will Medicare pay for home health care?” This article will take a look at exactly what home health care is and help you understand which home health care services are covered by Medicare.


##What Is Home Health Care?

Home health care covers a wide range of services that are administered to patients at home. This care is just as effective as services you receive at a hospital or skilled nursing facility, but it saves you significant money — and you don’t have to travel!

What does home health care do? Some examples include administering injections, monitoring serious illness, helping with wound care, and more.

The focus of home health care is usually to treat an illness or injury. The goal is to keep you as independent and self-sufficient as possible, for as long as possible.


##Who Qualifies For Home Health Care Services?

Does Medicare pay for in-home care services? In certain circumstances, it does.

To be eligible for Medicare coverage for home health care, you have to have Medicare Part A and/or Part B, while also meeting all of the following requirements:

- You must be under the care of a doctor and your services need to be part of a plan of care regularly reviewed by your doctor
- Your doctor certifies that you need intermittent skilled nursing care, physical therapy, occupational therapy, or speech-language pathology
- Your doctor must certify that you’re homebound 

For physical or occupational therapy or speech-language pathology, your condition needs to be expected to improve in a predictable and reasonable timeframe, and you must require the therapist to do the therapy.


##Does Medicare Part B Cover Home Health Care Services?

Normally, home health care services are covered by Medicare Part B. To receive coverage, you need to be homebound and in need of skilled care. You don’t need a previous hospital stay to qualify.

The good news is that if you need these services and qualify for coverage, you are covered 100%. There is no coinsurance or copayment for Part B-covered home health services. 


##Does Medicare Part C Cover Home Health Care Services?

Medicare Part C, known as Medicare Advantage, is a full replacement for [Original Medicare](https://medicare.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage). They are required to offer at least as much coverage as Medicare Part A and B, but often go beyond and have additional coverage.

For instance, if you need non-skilled in-home care, like medication assistance, grooming, mobility assistance, or other services, many Part C plans will offer some coverage.

You’ll need to research your Medicare Advantage plan to find out exactly what coverage is available and what your copayments and deductibles are. However, you will never get less coverage than you would with Original Medicare.


## Does Medicare Supplement (Part F) Cover Home Health Care Services?

[Medicare Supplement](https://medicare.healthinsurance.com/learning-center/article/medicare-supplement-101) plans help cover costs in [Original Medicare](https://medicare.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage) that are not covered by Medicare Part A and B. This might include assistance with coinsurance or copayment amounts or excess charges.

Because home health care services are 100% covered with Medicare Part B, with no coinsurance or copay, a Medicare Supplement plan does not affect how much you pay for home health care with Medicare.


##Medicare for Home Health Care: Compare Medicare Plans 

Choosing the right Medicare plan can be challenging. There are a lot of options and the best choice for you will depend on your specific health needs. 

If you’d like to talk to a licensed insurance agent to [compare Medicare options](https://medicare.healthinsurance.com/), we’re here to help. Contact us today!


Discover which Medicare plans cover home health care services and which plans do not. Plus, learn who qualifies!

Does Medicare Cover Home Health Care?

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When you are eligible for Medicare, you have two primary options. One is Original Medicare, which includes Part A and Part B. The other option is Medicare Advantage, known as Part C.

You can’t have Part C and Original Medicare. When you choose Part C, you are choosing to get your Medicare Part A and B coverage through the Medicare Advantage plan.  That means you have to choose between them, which can be a challenge. This article will help you understand Original Medicare vs. a Medicare Advantage plan so you can choose the right one for your needs.


##Difference Between Original Medicare and Medicare Advantage

[Original Medicare](https://medicare.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage) is administered by the government and it can be used at any doctor in the U.S. who accepts Medicare. Generally, most folks get [Part A](https://medicare.healthinsurance.com/learning-center/article/medicare-part-a) for free and pay a monthly premium for [Part B](https://medicare.healthinsurance.com/learning-center/article/understanding-medicare-part-b).

Original Medicare coverage will not vary depending on which state or area you live in. Your out-of-pocket costs, after your deductible, are generally 20% of the Medicare-approved costs for services. Original Medicare does not cover hearing, vision, or [dental care](https://medicare.healthinsurance.com/learning-center/article/does-medicare-cover-dental). If you want prescription drug coverage, you have to add [Medicare Part D](https://medicare.healthinsurance.com/learning-center/article/medicare-part-d-guide) and pay a separate premium. 

[Medicare Advantage](https://medicare.healthinsurance.com/learning-center/article/medicare-advantage-guide) is sold by private insurance companies who have a contract with the Federal government. Theremay be limitations on the medical providers you can use depending on where you live. Most Medicare Advantage plans include prescription drug coverage and additional benefits. You might be able to get vision coverage or a discount to a local health club.

Most importantly for many beneficiaries, Medicare Advantage has more predictable out-of-pocket costs. Instead of paying a percentage of the service cost, which is impossible to know in advance, you generally pay specific [deductibles and copayments](https://medicare.healthinsurance.com/learning-center/article/2021-changes-to-medicare). 

You can often get Medicare Advantage for the same cost as Original Medicare, although some Advantage plans cost more.

###Is Original Medicare Better Than Medicare Advantage?

Like any choice, there are pros and cons of Medicare Advantage plans vs. Original Medicare. For instance, Medicare Advantage plans can be better for those who want more predictable out-of-pocket costs or are looking for additional benefits. 

However, Original Medicare is better for those who travel frequently or use doctors who are not in the same medical network. You won’t need referrals to see specialists  and being able to see any doctor you choose can bring peace of mind. You can make Original Medicare out-of-pocket costs easier to manage if you add a [Medigap](https://medicare.healthinsurance.com/learning-center/article/medicare-supplement-101) policy.

It’s important to think about your specific needs before you choose between Medicare Advantage and Original Medicare. Only you can decide which is best for your situation.

###Cost Difference Between Original Medicare and Medicare Advantage

When you have Original Medicare, you’ll pay a monthly premium for Part B  and there is also a deductible each year.  If you need prescription drugs, you may need Part D as well.. 

Once you reach the deductible for Part B, you’ll pay 20% of the Medicare-approved cost of the medical care you receive. There is no out-of-pocket maximum. For prescription drugs, after the deductible, there are specific copayments each time you need medication.

While Medicare Advantage may also have  a monthly premium, there are many plans with $0 premiums. Therefore, many plans won’t cost any more than you already pay for Medicare Part B, and they already include prescription drugs. 

Each Medicare Advantage plan has its own out-of-pocket costs, including deductibles, copayments, and coinsurance. You’ll want to compare plans before making your final decision. Most Medicare Advantage plans also have an out-of-pocket cost maximum each year, after which the plan covers 100%.

###Can You Switch From Medicare Advantage to Original Medicare?

You can switch from Medicare Advantage and Original Medicare in two different enrollment periods each year. The first is Open Enrollment, which is between October 15th and December 7th each year. You can make any changes to your Medicare plan that you like during this timeframe.

The second time you can switch plans is during the Medicare Advantage Annual Enrollment Period, which is between January 1st and March 31st each year. If you have a Medicare Advantage plan during this time, you can choose a different Medicare Advantage plan or switch from Medicare Advantage to Original Medicare. 

Some circumstances create a special enrollment period, where you can make changes to your Medicare coverage outside of the normal windows. For instance, if you move out of your Medicare Advantage coverage area, you have an opportunity to choose a new plan or switch to Original Medicare.

###Learn More About Original Medicare vs. Medicare Advantage

Understanding the differences between Medicare Advantage and Original Medicare is essential to making the right decision for your needs. However, it often helps to talk to a licensed insurance agent as well. If you have questions about your Medicare coverage and want to [compare plans](https://medicare.healthinsurance.com), contact us today!




Understand the difference between Original Medicare and Medicare Advantage so you can choose the plan that's right for your needs.

Original Medicare vs. Medicare Advantage: Which One is Right for You?

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Original Medicare Vs. Medicare Advantage

If you’re on Medicare and know that you may need more exercise, but aren’t sure how to go about it, the SilverSneakers program is a great way for you to get started with fitness or take your fitness goals to the next level.

In this guide to Medicare and SilverSneakers, we’ll review all the basics of the SilverSneakers program, including what it is, what it covers, how much it costs, and how it works with Medicare. We’ll also cover the wonderful benefits of fitness and exercise, especially for those who are [aging into Medicare](https://www.healthinsurance.com/learning-center/article/tips-for-aging-into-medicare) .


##What Is SilverSneakers? 

SilverSneakers is a complete fitness and wellness program focused on physical health for adults 65 and older. SilverSneakers programs are only available with certain Medicare plans. Classes and activities aim to improve the overall well-being of seniors at all levels and abilities.

Although SilverSneakers is traditionally known for offering access to gyms and health clubs, they have expanded to offer a complete range of fitness and wellness activities and programs. 

###What is Included in the SilverSneakers Program?

SilverSneakers currently offers:

- Free gym membership for seniors with <a href="https://tools.silversneakers.com/LocationSearch?_ga=2.13160816.615417601.1618407218-77505151.1618407218" target=" _blank">access to more than 17,000 gyms</a> across the U.S.
- Online classes
- On-demand classes
- FLEX community classes

The FLEX component of SilverSneakers has really brought their wellness offerings into the forefront of fitness for seniors. The FLEX community classes don’t resemble the gym at all. For people who don’t enjoy  gyms, or prefer alternatives to lifting weights or riding an exercise bike, FLEX is an intriguing option.

The FLEX program offers a <a href="https://www.silversneakers.com/learn/community-fitness/" target=" _blank">variety of senior workouts and fitness options</a> in friendly, no-stress settings including:

- Parks
- Recreation centers
- Churches

Activities and classes offered in the FLEX programs include:

- Tai Chi
- Yoga
- Boot camps

All classes are led by certified coaches and trainers. With FLEX, you can get out of your house, while staying out of the gym, and engage in any level of exercise you’d like. Plus, you still have access to all of the in-gym and online classes offered by SilverSneakers.

Something that isn’t included, though, is personal coaching or one-on-one training. All of the SilverSneakers classes and programs are geared either towards open-access gyms (you have the run of the gym) or group classes.

### Who Is Eligible For SilverSneakers?

The only eligibility requirement for SilverSneakers is that you’re covered by a participating Medicare plan. 
Although there’s a common assumption that you have to be 65 or older, SilverSneakers eligibility is not based on age. So if you’re in Medicare before age 65, rest assured that you can use SilverSneakers as long as your plan offers it. 


##How Does SilverSneakers Work?

For you as a user, SilverSneakers membership is very simple. If you qualify for it, you simply enroll online. Once you’re enrolled, you have access to 100% of the program and benefits offered by SilverSneakers.

For starters, you could look for a gym. This has historically been what SilverSneakers is known for. You can use their <a href="https://tools.silversneakers.com/LocationSearch?_ga=2.13160816.615417601.1618407218-77505151.1618407218" target=" _blank">fitness club locator</a> to find the gyms or facilities that are closest to you. 

You get the benefits of a gym membership, without having to pay for it. Instead, SilverSneakers has a payment arrangement with the gyms and facilities in their network. Wonderfully, you don’t have to be involved with those details.

You simply show up at the gym or facility of your choice and start working out. 

**Here are some things to keep in mind:**
- It might be a good idea to chat with the staff to see how the facilities are laid out.
- You might also want to ask the staff which classes and other privileges are included in your free membership. 
- One last thing to check is their COVID-19 policies regarding occupancy, masks, and other safety protocols. But you don’t need to complicate this. Simply sign up, get the necessary info, and then show up.

###Is the SilverSneakers Program Free?

The SilverSneakers program is included free of charge with many Medicare Advantage plans, along with some Medigap plans. Medicare recipients with these plans don’t have to pay for SilverSneakers services, which include a basic membership to some gyms, live online fitness classes, and more. However, if you want services the program doesn’t cover, such as personal training at the gym, supplements, or other products, you’ll have to pay for those.

### Does SilverSneakers Pay for Gym Membership?

SilverSneakers members may be able to get a free basic membership at thousands of participating gyms, fitness locations, and community centers across the country. However, not all gyms are part of the program. That means you’ll need to check with specific gyms in your area to ask if they honor the SilverSneakers membership.

If you are eligible, some benefits of SilverSneakers include the use of gyms who participate in the program. Some plans cover the SilverSneakers program and members will be able to join select gyms. 

The good news is that because there are SilverSneakers partners across the country, you can use your SilverSneakers membership at participating gyms when you travel as well.

###SilverSneakers Classes Online

There are many other benefits of SilverSneakers besides the ability to use “in-person” facilities. This is especially true as a result of the [Coronavirus](https://www.healthinsurance.com/learning-center/article/what-is-coronavirus) pandemic. 
SilverSneakers has responded to the perils of quarantine and lock down by expanding their online offerings. The aim is to help counteract adverse health consequences due to isolation, immobility, and negative emotions. 

**SilverSneakers makes two kinds of online fitness content available:**

- Live classes via Zoom
- On-demand classes directly on the SilverSneakers website
- The live classes are just what they sound like: classes that you can take as they happen. SilverSneakers has a <a href="https://tools.silversneakers.com/Search/OnlineClasses" target=" _blank">schedule of upcoming classes</a> on their website. There is no additional fee for using the live classes.
- As for the on-demand classes, these are also viewed on the device of your choice using an internet connection. You can simply search for a class that interests you and play it whenever you want. You don’t have to wait for the class to go “live.”
- For the on-demand and live programs, you can find a great variety of offerings, including:
- Yoga
- Movement
- Cardio
- Strength training


##Medicare and SilverSneakers

How do Medicare and SilverSneakers work together? This section will help you understand the specifics of how you can get SilverSneakers through Medicare. 

###Does Medicare Cover SilverSneakers?

Original Medicare, the basic government program, does not cover SilverSneakers. However, if you use a Medicare health  or Supplement plan offered by a private insurance plan contracted with the government, private insurance option, you might have access to the program.

SilverSneakers is available to people who use either:

- [Medicare Advantage plans](https://www.healthinsurance.com/learning-center/article/medicare-advantage-guide), or
- Medicare Supplement Insurance (Medigap)

###Does Medicare Automatically Include SilverSneakers?

If you have a Medicare plan that includes SilverSneakers, you are automatically enrolled. You can check your eligibility on the SilverSneakers website, or contact your Medicare plan provider. SilverSneakers is available through specific Medicare Advantage plans or Medigap plans. 

###SilverSneakers And Medicare Advantage

For Medicare Advantage plans, SilverSneakers will come as an “AdditionalExtra Benefit.” AdditionalExtra benefits are those offered by the plan beyond what’s covered by Original Medicare [Part A](https://www.healthinsurance.com/learning-center/article/medicare-part-a) and [Part B](https://www.healthinsurance.com/learning-center/article/understanding-medicare-part-b). Other Medicare Advantage additional extra benefits often include vision and hearing coverage, rides to appointments, and dental coverage.

SilverSneakers is either included with your Medicare Advantage plan, or it’s not. You won’t be able to add SilverSneakers as an option. 

If using this benefit is important to you, you’ll want to specifically look for a Medicare Advantage Plan that offers SilverSneakers.

### Can I Join SilverSneakers if I Don’t Have a Medicare Advantage Plan?

Usually, a Medicare recipient gets SilverSneakers through a Medicare Advantage plan. However, if you don’t have an Advantage plan, you may still be able to get SilverSneakers through a Medicare Supplement Plan, known as Medigap. Medigap is additional coverage you can purchase alongside Original Medicare that helps you pay for out-of-pocket expenses.

Not all Medigap plans offer SilverSneakers, and if you don’t sign up for a Medigap plan during your initial enrollment period you aren’t guaranteed acceptance. However, getting Medigap does make it possible to have SilverSneakers with Original Medicare.

###SilverSneakers And Medicare Supplement

[Medicare Supplement plans](https://www.healthinsurance.com/learning-center/article/medicare-supplement-101), which work with Original Medicare, sometimes offer SilverSneakers as an incentive for you to sign up. Once again, this isn’t an a la carte option; your plan either offers SilverSneakers, or it doesn’t. You can find out in advance whether or not a Medicare Supplement Insurance plan offers SilverSneakers.

**NOTE**: SilverSneakers is an additional benefit. It is not a part of the core, required benefits of these plans. Insurance companies can change or eliminate extra benefits, including SilverSneakers. So make sure to choose your Medicare coverage based on other healthcare needs, too.


##Why Should I Take Advantage of SilverSneakers?

SilverSneakers is a great way to maintain a healthy lifestyle through physical activity. Studies show that even <a href="https://www.psychologytoday.com/us/blog/the-athletes-way/201505/very-small-amounts-exercise-can-reap-huge-benefits" target=" _blank">small amounts of exercise</a> can lead to better health and longevity. 
SilverSneakers eliminates one of the obstacles to physical health: the cost of a gym membership or private workout equipment. By making so many types of exercise for seniors available, SilverSneakers allows you to find an activity that appeals to you - making you much more likely to stick with it.

Among the many benefits of physical activity are:

- Reduced risk of dying from [coronary heart disease](https://www.healthinsurance.com/learning-center/article/cardiovascular-disease-cvd-medicare-coverage) 
- Reduced risk of developing diabetes, lung disease, and colon cancer
- Reduced symptoms of anxiety and depression, lifting overall feelings of well-being
- Can lower blood pressure
- Improves flexibility, reducing stiffness, and joint swelling
- As we age, we’re much more likely to be sedentary and inactive. SilverSneakers is an easy and affordable tool to combat these tendencies and stay vital, active, and healthy.


##How To Join SilverSneakers

If your Medicare plan offers SilverSneakers, you’ll want to use your Medicare plan’s member ID card to sign up. You’ll do this online at the SilverSneakers website.  If you’re not sure if your plan includes this benefit, you can <a href="https://tools.silversneakers.com/Eligibility/CheckEligibility" target=" _blank">check your eligibility</a> on their site as well.

**If your plan doesn’t offer SilverSneakers, you won’t be able to get it.** You can consider switching to a plan that does offer SilverSneakers. Keep in mind though that you probably can’t switch plans in the middle of the year.

Instead, you’ll want to take advantage of one of the enrollment periods allowed by Medicare. 
**For Medicare Advantage, you can use two enrollment periods:**
The Medicare Annual Election Period (AEP), and
The Medicare Advantage Open Enrollment Period (MA-OEP)

The [Medicare Annual Enrollment Period](https://www.healthinsurance.com/learning-center/article/guide-to-medicare-annual-enrollment-period) is from October 15th to December 7th of each year. If you switch to a new plan, your new coverage is effective on January 1st of the following year. 

The MA-OEP is from January 1st to March 31st of each year. Any changes to your coverage are effective on the first day of the month after your enrollment change.

NOTE: It’s important to make sure that any plan you switch to will meet your other healthcare needs. At a minimum, you’ll want to make sure that any Medicare Advantage plan covers your doctors and [medications](https://www.healthinsurance.com/learning-center/article/tips-to-reduce-your-prescription-drug-costs). Don’t switch just to get a fitness benefit.

Changing Medicare Supplement plans can be much more complicated. After your Medigap Open Enrollment Period, you usually have to apply for coverage, and you can be turned down, or charged more for pre-existing conditions. This makes choosing your first Medicare Supplement plan an important decision. 

**Here are some tips when choosing Medicare Supplement Insurance:**
If you’re shopping for coverage, try to find a Medigap plan that currently has SilverSneakers because you may not be able to switch Medigap plans later.

You can, however, move from [Medicare Supplement to Medicare Advantage](https://www.healthinsurance.com/learning-center/article/the-difference-between-medicare-advantage-and-medigap) during the Annual Election Period (AEP). If you do this, look for a new plan that has SilverSneakers coverage.

Remember that there are no age restrictions for SilverSneakers. So if you have a qualifying Medicare Insurance plan, you’re eligible for SilverSneakers.

To find a participating gym or facility in the SilverSneakers network, just use their <a href="https://tools.silversneakers.com/LocationSearch?_ga=2.13160816.615417601.1618407218-77505151.1618407218" target=" _blank">locator tool</a>.


##Additional SilverSneakers FAQs 

Still have questions about SilverSneakers? No problem, we can help. Take a look at these commonly-asked questions and answers.

###Is SilverSneakers Free?

SilverSneakers is available without any extra charge. In addition, the individual classes and services are free of charge. You pay a monthly premium for Medicare Advantage (some plans have $0 monthly premiums) and Medicare Supplement plans, though. And you must continue to   pay your Part B premium when you enroll in either of these plans.

###Who Pays For SilverSneakers?

Your Medicare health plan insurance company pays for SilverSneakers access.

###Can I Join SilverSneakers Without Insurance?

No. You must have a participating Medicare health insurance plan to get SilverSneakers.

###Does Tricare Cover SilverSneakers?

No. You must have a private Medicare plan like Medicare Advantage or Medicare Supplement Insurance[jla1] .

###Does Medicaid Cover SilverSneakers?

No, not by itself. If you have [Medicaid and a Medicare plan](https://www.healthinsurance.com/learning-center/article/whats-the-difference-between-medicare-and-medicaid) like Medicare Advantage or  Medicare Supplement, then you might be able to have access to SilverSneakers.

##Final Thoughts On SilverSneakers

SilverSneakers is a versatile service that connects you to a multitude of fitness options. Using SilverSneakers can help reduce your risk for certain diseases and improve your mental well-being. Because of the lifestyle benefits, it’s worth [looking for a Medicare plan](https://www.healthinsurance.com/learning-center/article/10-medicare-frequently-asked-questions) that comes with SilverSneakers.

**Medicare Advantage plans may offer SilverSneakers, a way to work out at home or at participating fitness locations. <a href="https://tools.silversneakers.com/Eligibility/CheckEligibility?utm_campaign=2021aep_benefytt_resourcecenter|AEP21-B&utm_medium=referral&utm_source=benefytt" target="_blank">Click here</a> to check your eligibility, or call our licensed insurance agents at 1-800-620-4519 (TTY 711) to see if you qualify for a Medicare Advantage plan that may include SilverSneakers as a benefit.**



Learn how Medicare works with the SilverSneakers program. We’ll cover costs, eligibility, how to join, and more.

A Guide to Medicare and SilverSneakers

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Medicare and the SilverSneakers Program

Medicare Advantage, or Medicare Part C, often offers additional  benefits and sometimes savings on out-of-pocket costs. However, Medigap can also help you save on your costs and pay less for coinsurance, copayments, and deductibles.

It’s important to know the difference between Medicare Advantage and Medigap, along with the pros and cons of each. After that, you may be wondering, “Can I switch from Medicare Advantage to Medigap?” This article will help you understand if you can, and when it’s possible.


##What's the Difference Between Medicare Advantage and Medigap?

[Medicare Advantage, or Medicare Part C,](https://medicare.healthinsurance.com/learning-center/article/medicare-advantage-guide) is an all-inclusive alternative to [Original Medicare](https://medicare.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage). It generally encompasses Medicare Parts A, B, and D. However, because your coverage is provided by a private insurer and not the government, there are limitations on your provider network. You can also expect different — and sometimes lower — copayments, deductibles, and coinsurance.

People choose Medicare Advantage because they enjoy getting additional benefits, such as low-cost health club memberships, vision and [dental coverage](https://medicare.healthinsurance.com/learning-center/article/does-medicare-cover-dental), and more. They also prefer the predictable out-of-pocket costs rather than a percentage coinsurance.

[Medigap](https://medicare.healthinsurance.com/learning-center/article/the-difference-between-medicare-advantage-and-medigap) is an add-on to Original Medicare and helps you pay for healthcare costs like your deductible, copayments, and coinsurance. There are several plans, lettered from A to N. However, some are not available to beneficiaries after a certain date.  Medigap is sold by private insurers, and the only difference between providers offering the same letter is cost — every Plan A will be the same as every other Plan A.

Medicare beneficiaries choose Medigap because it lowers or eliminates a lot of out-of-pocket costs. Medigap has to pay its share when Medicare covers its part. You can see any doctor in the U.S. that accepts Medicare, and you don’t need referrals for specialist appointments. 

In general, no one can sell you a Medigap plan if you have Medicare Advantage. In order to get Medigap, you have to disenroll from Medicare Advantage and return to Original Medicare.


##Switching From Medicare Advantage to Medigap FAQ

People have a lot of questions about switching from Medicare Advantage to Medigap. This section will answer some of the most frequently asked questions.

###Can You Switch From Medicare Advantage to Medigap Without Underwriting?

If you choose Medigap with Original Medicare during your initial enrollment period around your 65th birthday, you were guaranteed acceptance even if you had known health conditions. After that initial period, if you want to join a Medigap plan, they generally use underwriting to review your health risk before they decide to accept you.

If you want to avoid this underwriting, you’ll need a special enrollment period that has guaranteed issue rights. For instance, if you decide to switch out of a Medicare Advantage plan within the first 12 months, you can get Medigap without underwriting. 

Other times you can get Medigap without underwriting include:

- If you move out of your Medicare Advantage service area
- If you’re in one of four states that require Medigap to be freely available at certain times of year (Maine, Massachusetts, Connecticut, and New York)

###Can I Switch From Medicare Advantage to Medigap During Open Enrollment?

In order to switch to Medigap, you need to disenroll in Medicare Advantage and go back to Original Medicare. You can do this during two enrollment periods. 

The first is Open Enrollment, which occurs from October 15th-December 7th each year. During this time you can make any changes you’d like, including returning to Original Medicare and getting Medigap.

You might wonder about Medicare Advantage’s Annual Enrollment period, from January 1-March 31 each year. While you can leave your Medicare Advantage plan during that time and return to Original Medicare, you won’t be able to sign up for Medigap until the next Open Enrollment period. 

###Contact us to Learn More About Medicare Plans

Understanding your rights under Medicare can be challenging. It’s often easier when you speak to a licensed insurance agent about your situation. If you’d like to discuss your options and see whether Medicare Advantage or Medigap is better for you, we’re here to help. [Contact us today!](https://medicare.healthinsurance.com/)



If you're contemplating switching from Medicare Advantage to Medigap it's important to understand the pros and cons and differences between each plan. We answer these questions and more to help you make an informed decision.

Can I Switch From Medicare Advantage to Medigap

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Can You Change From Medicare Advantage to Medigap?

Individuals have an initial enrollment period available to them to first enroll in Medicare. However, Medicare also allows those in certain circumstances to enroll in Medicare Part B at a later point. 

In addition, Medicare also offers special enrollment periods to those already enrolled in Medicare. Each year, Medicare beneficiaries have a chance to change their Medicare plan choices during the [annual enrollment](https://medicare.healthinsurance.com/learning-center/article/guide-to-medicare-annual-enrollment-period) period (AEP). Those with [Medicare Advantage](https://medicare.healthinsurance.com/learning-center/article/medicare-advantage-guide) can also change their Medicare Advantage plan, or return to [Original Medicare](https://medicare.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage), during the Medicare Advantage open enrollment period (MA OEP).

But what if you need to make a change to your Medicare plan outside of those dates? The government allows special enrollment periods (SEPs) for specific types of events where you will need immediate coverage before the next annual enrollment.

This guide will help you understand what SEPs are available and how each one works.


##Medicare SEP FAQ

It can be very challenging to keep up with which life events qualify for an SEP, especially if you’re in the middle of a move, job change, or other stressful situation. Plus, each SEP has its own rules. That’s why it’s important to know how each one works ahead of time, if possible.

###Medicare Special Enrollment Periods for Premium-Free Medicare Part A

Generally, you sign up for [Medicare Part A](https://medicare.healthinsurance.com/learning-center/article/medicare-part-a) automatically when you turn 65.

Not everyone retires at or before age 65. If you’re still working after age 65 and are covered under a group health plan, you don’t have to sign up for Medicare right away. 

Once you retire and stop working, you have an eight-month special enrollment period to sign up for premium-free Medicare Part A, along with a drug plan (Part D) or Medicare Advantage (Part C) if you prefer.

If you qualify for premium-free Medicare Part A, . you can sign up for it anytime because you don’t pay a premium, although you may have a gap in coverage. 

However, if you have to pay a premium for Medicare Part A, you can only sign up during approved enrollment periods or if a special enrollment period is triggered. 

###Special Enrollment Period for Medicare Part B

[Medicare Part B](https://medicare.healthinsurance.com/learning-center/article/understanding-medicare-part-b) carries a monthly premium, and if you sign up after your initial enrollment period you usually will face a penalty. There are exceptions, though, and many of them apply to events that cause a special enrollment period.

If you’re still working after age 65 and are covered under a group health plan, you may choose to delay signing up for Part B. Once you retire and stop working, you have an eight-month special enrollment period to sign up for Medicare Part B, along with a drug plan (Part D) or Medicare Advantage (Part C) if you prefer.

You get a special enrollment period for Part B if

- You have group health plan coverage
- You or your spouse (or a family member if you’re disabled) is working for the employer that provides your health coverage
- Generally, this SEP lasts for eight months from the above events.

###Special Enrollment Period for Medicare Advantage and Part D Plans

When you have a Medicare Advantage (MA)plan or a Prescription Drug Plan (also known as Medicare Part D), you can make changes during the normal annual enrollment period. However, there are times when you need to make immediate changes, and a special enrollment period can let you do that.

You can get a special enrollment period for an MA or Part D plan if:

- You lose group or union health coverage; this SEP lasts for two (2) months after that coverage ends.You move out of your plan's area, or to an area with new plan offerings; this SEP generally lasts from one month before your move until two months afterward
- You move back to the U.S. from abroad; this SEP lasts for two months after you return to the U.S.
- You move into or out of an institution; this SEP lasts as long as you live in the institution and for two full months afterward
- You are no longer eligible for Medicaid; this SEP lasts for three months from the date you’re notified or no longer eligible, whichever is later
- You are no longer eligible for a Special Needs Plan (SNP); this SEP lasts for three months after your disenrollment from the SNP
- You’re released from jail; this SEP lasts for two full months after you’re released
- If your MA or drug plan decides not to renew its contract for the next year, this SEP starts December 8th and ends on the last day in February of the following year
- You qualify for extra help with drug coverage - you qualify for an SEP every three months for the first 9 months of the year  

This is not an exhaustive list. If you have questions about Medicare enrollment or want to review your plan options, contact us today!

###Medicare Special Enrollment Period for a Disaster

If there is a Federal, State or locally declared emergency or disaster, the Center for Medicare Services (CMS) will designate a special enrollment period for those who missed their chance to enroll due to that event. 

The special enrollment period starts the date the declaration was made and continues for two full months following the end of the declaration.  This SEP also applies to those who don’t live in the affected area but rely on people in that area for help with healthcare decisions.


### Learn More About Medicare Special Enrollment Period (SEP)

There are a lot of life events that can impact your need for Medicare, and sometimes they happen outside of the normal enrollment timeframes. Special enrollment periods exist to help you get the coverage you need at the right time.

If you have questions about Medicare enrollment or want to review your [Medicare Advantage plan](https://medicare.healthinsurance.com) options, contact us today!


Understanding the Medicare special enrollment period is critical to know when and why you can make changes to your plan. We answer all your SEP questions in this guide.

Everything You Need to Know About Medicare Special Enrollment Periods

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Understanding Medicare Special Enrollment Period (SEP)

If you choose to have [Original Medicare](https://medicare.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage) with [Medicare Part D](https://medicare.healthinsurance.com/learning-center/article/medicare-part-d-guide) added, you’ll receive prescription drug coverage through Medicare Part D. However, there can sometimes be a gap in the coverage of your prescriptions.

This gap is known as the “donut hole,” and it’s a period of time where you pay out-of-pocket for your medications. However, you don’t pay the full amount, and once your out-of-pocket costs hit a specific level Medicare will resume coverage.

What is the Medicare donut hole? This page will help you understand the donut hole and how to navigate it.


##How Does the Donut Hole Work in Medicare?

The Medicare donut hole is a period of time where you’ve reached the limit of your Medicare Part D coverage, but haven’t hit the “catastrophic coverage” level where Medicare resumes assisting you with your prescription drug coverage.

With Medicare Part D, the first portion of the year you’ll be paying toward your deductible. The deductible varies but can be up to $445 in 2021. Once you reach your deductible, your drug plan will kick in and you’ll pay your copayment or coinsurance for your medication.

If the amount you and your plan pay toward prescription drugs reaches a certain level, you’ll enter the donut hole. Keep in mind that not everyone gets to the prescription donut hole — the gap was designed to encourage Medicare recipients to seek out lower-cost drugs and generics. The Medicare donut hole in 2021 starts at $4,130. 

###When Does the Medicare Donut Hole End?

The coverage gap ends when you reach the catastrophic coverage limit for the year. In 2021, this amount is $6,550. 

The good news is that the donut hole essentially closed in 2020, so that even when you hit the coverage gap, you won’t pay more than 25% of the cost of prescription drugs. However, around 95% of the cost will count toward moving you out of the hole.


##Do Medicare Advantage Plans Cover the Donut Hole?

Medicare drug coverage — Part D — works the same in a Medicare Advantage plan as it does with a "Stand-alone” Part D plan. However, some [Medicare Advantage](https://medicare.healthinsurance.com/learning-center/article/medicare-advantage-guide) plans offer more generous benefits during the donut hole than a stand-alone Part D plan does.

Understanding your prescription drug coverage is essential so that you know if you’re likely to approach a coverage gap based on the price of your medication. If so, make sure you know what the costs will be during the donut hole period.

###Medicare Part D Plans Without the Donut Hole 

There are no Medicare Part D plans — including Medicare Advantage plans — without a coverage gap. However, some prescription plans have additional coverage options during the donut hole.

For instance, your Medicare Advantage plan might include coverage for some generic medications even in the gap. Or, they may offer some drugs at a lower cost than 25%. It all depends on your plan and provider.

The best way to avoid the donut hole is to work with your doctor to keep the cost of your medication low. If that’s not possible, the fact that you will pay no more than 25% of the full cost even in the coverage gap will help ease your mind.

###How Do I Get Out of the Medicare Donut Hole?

If you’re in the Medicare Part D donut hole, the only way to get out is to spend enough to reach the catastrophic coverage threshold. The good news is that while you’re paying no more than 25% of the cost of the medication, close to 95% of the cost of the drugs is going toward your spending total.

One way to manage the  coverage gap “donut hole” is to work with your doctor to find effective low-cost and generic medications that will help you maintain your physical health.

Here are some tips that can help:

- Use a generic or find a similar drug that has a generic
- Talk to your doctor about drug costs and whether specific prescriptions are really needed
- Shop around — different pharmacies offer different drug prices
- Compare Medicare plans each year to make sure you have affordable drug coverage


###Learn More About Medicare Costs and Plans

Medicare costs can be confusing, especially when there is the possibility of a coverage gap in the middle of the year. Fortunately, even during the Medicare donut hole, you don’t have to pay more than 25% of a prescription drug price, and you may even pay less. 

If you’re interested in comparing Medicare plans to make sure your drug coverage meets your needs, talking to a licensed insurance agent can help. Learn more about your options and [compare Medicare plans](https://medicare.healthinsurance.com/) today!


The Medicare donut hole applies to cost gaps for prescription drugs. Learn about how the donut hole works and what you can do to offset prescription drug costs.

What is the Medicare Donut Hole? 

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Everyone can enroll in Medicare in the seven-month period around their 65th birthday through the Medicare Initial Enrollment Period (IEP). It starts three months before your birth month, includes your birth month, and ends three months afterward. If you don’t enroll in Medicare (either Medicare Part A or Part B) during your IEP, you can enroll enroll in either during the General Enrollment Period that occurs annual from January 1 through March 31 of each year.  

After you enroll in Medicare when can you change your Medicare coverage options? 

There are three main enrollment periods that allow you to make changes to your coverage. Everyone with Medicare can make changes during the annual enrollment period (AEP).  If you have certain qualifying events happen in your life, you may also have a special enrollment period (SEP) to allow changes. And if you are enrolled in a Medicare Advantage (MA) plan, you will also have an opportunity to make changes during the MA open enrollment period (OEP) that happens at the beginning of the year. .

This article will cover these enrollment periods in more detail so you know exactly when you can make changes to your Medicare plan.


##Special Enrollment Period SEP for those enrolled in Medicare Advantage or Prescription Drug Plans

If you have special circumstances in your life, , you may qualify for a Medicare SEP to change your Medicare Advantage or Part D plan coverage. The special enrollment period options and length will be different for each circumstance. 

For example, you could qualify for an SEP if you:

- Retire from a job after age 65
- Move 
- Become eligible for Medicaid
- Have your Medicare plan terminated by the insurer
- Lose other medical or drug coverage

To learn more about Medicare SEPs, check out our guide on special enrollment periods.


## Medicare Advantage Open Enrollment (MA OEP) vs. Annual Enrollment (AEP)
Both Medicare annual enrollment period (AEP) and Medicare Advantage Open Enrollment  period (MA OEP) happen each year. However, there are some important differences. This will help you understand Medicare AEP vs Medicare Advantage OEP.

The Medicare annual enrollment period is between October 15th and December 7th of each year. During this time everyone with Medicare can join, switch, or drop any Medicare Advantage or Prescription Drug plan (“Part D). Your coverage will begin on January 1st, as long as you make your choice by December 7th. 

The Medicare Advantage open enrollment period applies only to those enrolled in Medicare Advantage plans. From January 1st to March 31st each year, you can switch to a different Medicare Advantage plan, or switch from Medicare Advantage to Original Medicare and join a separate drug plan. 

To summarize the Medicare annual enrollment period vs Medicare Advantage open enrollment period:

Dates: Oct 15 - Dec 7 for AEP, Jan 1 - March 31 for Medicare Advantage OEP
Costs: None beyond your plan’s monthly premiums
Eligibility to Enroll: AEP — any Medicare beneficiary; OEP — Medicare Advantage enrollees only
Form of Medicare Available: AEP — any; MA OEP — Change Medicare Advantage plans or Medicare Advantage to Original Medicare

###Medicare Enrollment Periods Chart

This chart can help you understand Medicare open enrollment vs annual enrollment, along with special enrollment periods.
<br>
<table>
  <tr>
    <th></th>
    <th>Medicare Annual Enrollment (AEP)</th>
    <th>Medicare Advantage Open Enrollment (OEP)</th> 
    <th>Medicare Advantage & Part D Special Enrollment (SEP)</th>
  </tr>
  <tr>
    <td>Start Date</td>
    <td>October 15th</td> 
    <td>January 1st</td>
    <td>When a qualifying even occurs</td>
  </tr>
  <tr>
    <td>End Date</td>
    <td>December 7th</td> 
    <td>March 31st</td>
    <td>Varies</td>
  </tr>
  <tr>
    <td>Notes</td>
    <td>Any Medicare beneficiary can make any changes</td> 
    <td>Medicare Advantage enrollees only, limited changes</td>
    <td>Details depend on the qualifying event</td>
  </tr>
</table>
<br>
###Learn More About Medicare Enrollment Periods

Now that you understand the different enrollment periods, you might decide you want to make a change. Making the right choice for your needs is easier when you talk to a licensed insurance agent. Contact us today for any questions about enrollment periods or [comparing Medicare plans](https://medicare.healthinsurance.com)!



Between OEP, AEP, and SEP, Medicare enrollment periods can be confusing. Learn about the different enrollment windows and what you need to do to qualify for Medicare benefits.

Understanding Medicare Enrollment Periods

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[Medicare Part D](https://medicare.healthinsurance.com/learning-center/article/medicare-part-d-guide) offers important prescription drug coverage and is part of both Original Medicare and Medicare Advantage. As a result, it’s important to understand the Medicare Part D phases that occur each year.

There are four Medicare Part D stages. Depending on your drug costs, you may not reach all four in a given year. However, it’s still vital to know what to expect in case your prescription drug needs increase over time.

Here’s what you need to know.


##What are the 4 Stages of Medicare Part D?

What are the Medicare Part D stages of coverage? As we mentioned, there are four of them. They start with the deductible period, then initial coverage, followed by the donut hole, and then catastrophic coverage. We’ll go in-depth into each stage so that you can fully understand how they work for you.

###Deductible Period

During the deductible period, you pay the full price of your prescription drugs until you meet your Medicare Part D deductible. The deductible may vary from one plan to another, but Medicare does set a maximum limit. 

####Medicare Part D Deductible 2021

In 2021 the deductible limit for Medicare Part D is $445. 

Some plans have a $0 deductible, meaning that you skip the first of the Medicare Part D payment stages and move straight into initial coverage.

Other plans have a deductible that only applies to certain tiers of medications, while other medications are covered right away. For instance, generic medications may be covered immediately while name-brand medications have a deductible. 

Make sure you review the Medicare Part D deductible when you compare plans each year so you can choose the plan that’s best for your needs.

###Initial Coverage

Once your deductible is met, you move into initial coverage. This is where your Medicare Part D plan covers your medication, and you only pay a copayment or coinsurance each time. Each plan will have a different list of covered medications and different out-of-pocket costs, so be sure to carefully review the details of your plan.

The initial coverage period lasts until you hit $4,130 in total drug costs, which includes both the amount you have paid during the year and the amount your plan paid. Depending on your medical needs, you may not hit the limit, but if you do, you enter the coverage gap known as the Medicare donut hole.

###Medicare Part D Donut Hole

Once you hit the Medicare Part D initial coverage limit, you enter a gap in coverage known as the donut hole. In the past, you had to pay a significant amount of your drug costs during this gap. The coverage gap for all drugs essentially closed in 2020, meaning your share of costs in the “donut hole” is limited to 25% of the drug cost (both brand-name and generic).

This percentage will replace the copayment or coinsurance you were paying during the initial coverage period. S For a generic drug that costs $100, you would pay $25 for that drug during the donut hole.  For brand-name drugs, even though you only pay 25% of the cost, around 95% of the cost will count toward your out-of-pocket total to move you out of the coverage gap.

Once you have paid $6,550 in out-of-pocket costs for prescription drugs, you’ll exit the donut hole and enter catastrophic coverage.

###Medicare Part D Catastrophic Coverage

The final stage of Medicare Part D is catastrophic coverage. What is catastrophic coverage in Medicare Part D? It’s a phase designed to help those who have especially high prescription drug costs.

During catastrophic coverage, you’ll pay significantly lower copayments or coinsurance for your remaining prescriptions for the year. For Medicare Part D catastrophic coverage in 2021, you’ll pay 5% of the cost of drugs, and the plan pays for the remainder. 


##Does Medicare Part D Have an Out-of-Pocket Maximum?

There is no out-of-pocket maximum for Medicare Part D, but once you hit catastrophic coverage, your out-of-pocket costs drop significantly. Generally, you’ll pay a a minimum of $9.20 for brand-name medication and $3.70 for generic drugs, or 5% of retail costs, whichever is higher.  

###Learn More About Medicare Part D Coverage Stages

Medicare Part D is important coverage for many Medicare beneficiaries. That’s why it’s vital to understand the various Part D phases and whether you will enter them in a specific year. Comparing plans is easier with a licensed insurance agent by your side. Contact us to learn more or use our [plan comparison tool](https://medicare.healthinsurance.com/) to learn about plans in your area.




Understanding the stages of Medicare Part D can help you determine how much you will pay for prescription drugs. Learn more about the four coverage stages.

The 4 Phases of Medicare Part D 

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what are the phases of medicare part d?

Medicare Part D Phases 

Not all Medicare beneficiaries can afford to pay their premiums, copayments, and coinsurance. If you have a lower income, it’s possible that you’ll qualify for a Medicare Savings Program to help with your out-of-pocket expenses.

Are you asking, “Do I qualify for a Medicare Savings Program?” If so, this article will help. This page is designed to help you understand the Medicare Savings Program income limits and other requirements.

Read on to find out if you qualify.

##What Does the Medicare Savings Program Cover?

There are four different Medicare Savings Programs that you may qualify for. Each one has different requirements and benefits. In general, there are income limits and resource limits to qualify for each program, and they may help pay your premiums, deductibles, copayments, and coinsurance.


###Qualified Medicare Beneficiary

The first program is known as the “Qualified Medicare Beneficiary” program. If your income is 100% of the <a href="https://www.healthcare.gov/glossary/federal-poverty-level-fpl/" target="_blank">Federal Poverty Level</a> or below and you are below the resources threshold, you can qualify for assistance with Part A premiums (if applicable), Part B premiums, deductibles, copayments, and coinsurance. Providers are not allowed to bill you for services or items covered by Medicare, and you pay very little for prescription drugs as well.

###Specified Low-Income Medicare Beneficiary

You may be eligible for the Specified Low-Income Medicare Beneficiary (SLMB) program if you make less than 120% of the Federal Poverty Level and are below the resources threshold for the program. 

This program covers your [Part B](https://medicare.healthinsurance.com/learning-center/article/understanding-medicare-part-b) premium but does not cover any other out-of-pocket expenses from Medicare. You will still be responsible for your deductible, copayments, and coinsurance. 

However, you will qualify for Extra Help with prescription drugs under [Medicare Part D](https://medicare.healthinsurance.com/learning-center/article/medicare-part-d-guide) automatically, which will help you save money on needed medication.

###Qualified Individual Program

The Qualified Individual (QI) program is state-based and helps pay Part B Medicare premiums for those with Medicare Part A and limited resources. This limited program is available on a first-come, first-serve basis and has limited spots each year. You also need to reapply each year.

You can qualify for the QI program if you make 135% or less of the Federal Poverty Level income and are below the resources limit for the program.

###Qualified Disabled Working Individual

If you qualified for Medicare due to a disability but recently returned to work, you may no longer be able to get <a href="https://medicare.healthinsurance.com/learning-center/article/medicare-part-a">Medicare Part A</a> premium-free. You can qualify for this assistance if you make as much as 400% of the Federal Poverty Limit if your income is from working. 

The Qualified Disabled Working Individual (QDWI) program may help you if the following apply:

- **You’re a disabled working person under 65**
- **You lost Social Security benefits and premium-free Medicare Part A due to returning to work**
- **You’re not getting medical assistance from your state through Medicaid**
- **You meet the income and resource requirements set by the state**

QDWI will help pay your Medicare Part A premiums.


##Who Qualifies for the Medicare Savings Program?

There are two qualifications for the Medicare Savings Programs. One is based on your income, and the other is your resources. The requirements may vary depending on the state you live in, and whether any of your income comes from working. Let’s take a deeper look.

###What is the Income Limit for the Medicare Savings Program?

The Medicare Savings Program income limit varies by location; most states base it on a percentage of the Federal Poverty Limit, which shifts slightly each year.

In 2021, here are the monthly income limits for each program. Limits for Hawaii and Alaska are slightly higher.

- Qualified Medicare Beneficiary: Individual $1,094 and Married Couple $1,472
- Specified Low-Income Medicare Beneficiary: Individual $1,308 and Married Couple $1,762
- Qualified Individual: Individual $1,469 and Married Couple $1,980
- Qualified Disabled Working Individual: Individual $4,379 and Married Couple $5,892

There are also resource limits for each program. Counted resources include stocks, bonds, and money in your checking or savings account. The resource limit for the QMB, SLMB, and QI programs is $7,970 for an individual and $11,960 for a married couple.

For the QDWI program, the resource limit is $4,000 for an individual and $6,000 for a married couple.

###What Counts as Income for Medicare Savings Program?

When looking at your income, how do you know what counts? The good news is that if you are working, around half of your working income is excluded. Worker’s compensation and disability benefits are also excluded.

If your income, after these adjustments, is close to the limit, it’s worth applying for the program. If approved, you could save a considerable amount of money on out-of-pocket expenses. Contact your <a href="https://www.medicare.gov/talk-to-someone" target="_blank">state’s Medicaid office</a> if you have questions about your eligibility.


##Medicare Savings Program vs. Medicaid

The Medicare Savings Program is administered by each state, often through the Medicaid office. However, it is not the same as Medicaid. 

[Medicaid](https://medicare.healthinsurance.com/learning-center/article/whats-the-difference-between-medicare-and-medicaid) is specifically designed for low-income families and individuals and covers medical care with little to no out-of-pocket expenses. There is no monthly premium to be on Medicaid, you qualify based on your income and assets. 

The Medicare Savings Program is designed to help Medicare beneficiaries, who are disabled or over 65, pay for their out-of-pocket costs with Medicare. This may include your Part B premium, your Part A premium (if any), and other costs. 

It is possible to be eligible for both Medicare and Medicaid at the same time. These folks are known as “Dual Eligible,” and generally qualify for a Medicare Savings Program automatically, along with Extra Help for prescription drugs.


##Learn More About the Medicare Savings Program

If you’re ready to learn more about Medicare and the Medicare Savings Program, it’s helpful to talk to a licensed insurance agent. Contact us to learn more and [compare plans](https://medicare.healthinsurance.com/) to find the one that’s right for you.

Medicare Savings Programs help individuals pay for premiums, deductibles, copays, drug costs, and more. Learn more about coverage and who qualifies in this guide. 

What is the Medicare Savings Program?

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For most Americans, enrollment in Medicare is automatic around the time you turn 65. If you’re already receiving retirement benefits from Social Security or the Railroad Retirement Board, you will automatically start receiving Medicare benefits on the first day of the month you turn 65.

But what if you’re still working, or you don’t want to sign up for Medicare right away? Is it mandatory to go on Medicare when you turn 65? This page will help you understand your options.

##Do You Automatically Get Medicare When You Turn 65?
If you are already receiving Social Security retirement benefits, you will automatically get Medicare at age 65 if you qualify for premium-free Medicare Part A. If you have to buy [Medicare Part A](https://www.healthinsurance.com/learning-center/article/medicare-part-a), you will need to sign up manually online or by contacting your local Social Security office.

You’ll know if you were automatically enrolled because you’ll receive a “Welcome to Medicare” package in the mail. This package includes details about Medicare Part A and Part B, along with your Medicare card. It will also help you answer the question, “How much will I have to pay for Medicare when I turn 65?” If you are uncertain or have questions about your Medicare eligility, you can contact Social Security direction, either via phone, online or visiting a local SSA office.  

You have the option to reject Medicare [Part B](https://www.healthinsurance.com/learning-center/article/understanding-medicare-part-b) if you don’t want it. However, if you change your mind and enroll later, you may have to pay a late enrollment penalty.

##What Happens If You Don't Sign Up For Medicare At 65?
Do you have to sign up for Medicare when you turn 65? Unless you are covered by an employer group or union health insurance plan, if you don’t and enroll later, you will have to pay higher premiums. So while you don’t “have” to sign up, it will likely cost you more if you delay.

If you’re not automatically enrolled and you also decide not to enroll for Medicare during your initial enrollment period near your 65th birthday, you won’t have coverage. If you change your mind, you will need to manually enroll in Medicare Part A and Part B by contacting your local Social Security office. And you may have to pay higher premiums if you didn’t enroll when you were first eligible.  Again, unless you were covered by your employer or union group coverage.  

If you qualify for premium-free Medicare Part A, you can enroll in that coverage anytime. However, for Medicare Part B, you can only enroll during specific enrollment periods. The General Enrollment Period (GEP) for Medicare occurs every January - March 31 and is an opportunity for individuals to apply for Medicare Part A or B if not automatically enrolled in Medicare or missed their Initial Enrollment Period. Enrollments during the GEP are effective July 1. If you don’t get Part B when you are first eligible, you could have to pay a late enrollment penalty. 

##Do You Have To Sign Up For Medicare At 65 If You Are Still Working?
If you have medical coverage under a group health insurance plan offered by an employer or a spouse’s employer, you generally do not have to sign up for Medicare at age 65. You are able to delay your enrollment until your group coverage ends, without paying a penalty. Medicare gives you a special enrollment period that lasts eight months after the group coverage ends. The exception is for employers with less than 20 employees, so check with your employer or Social Security because if you don’t enroll in medicare, your employer might pay less or not at all.  

You can also sign up for Medicare Parts A and B while you’re still working, if you choose to. As long as you were previously covered by a group health insurance plan, you won’t have to pay a penalty.

If you have Medicare Part B and return to work after the age of 65, you can drop Part B, as long as you have coverage under your employer’s group plan. When the group plan coverage ends, you can sign up for Part B again without paying a penalty.

###Understanding Your Medicare Option
Knowing exactly when to enroll in Medicare can be confusing, especially if you’re still working or not receiving retirement benefits. Also, it’s important to understand all of your options and decide whether [Original Medicare](https://www.healthinsurance.com/learning-center/article/how-to-fill-the-gaps-of-original-medicare-coverage) is right for you or if you want a different plan. 

The best way to find out is to talk to a licensed insurance agent. Contact us to find and compare plans today!


For a lot of people, Medicare used to start with retirement at 65. With more people working past 65, you may be wondering if Medicare is mandatory.