Medicare is the primary government health insurance program for U.S. citizens and lawful permanent residents age 65 and over. Most seniors are very happy with their Medicare insurance coverage; it covers hospital care, most outpatient doctor visits, diagnostic tests, and therapy, and there is a separate Medicare prescription drug plan to help pay for your medications.
If you are a new U.S. citizen, or permanent legal resident hoping to apply for citizenship soon, here’s what you need to know about the Medicare insurance program.
What are the different parts of the Medicare insurance program?
Your Original Medicare coverage includes Part A and Part B. Part A is your hospital insurance; it covers inpatient care in a hospital and short-term stays in a skilled nursing facility. It also covers hospice care and certain home health care services.
Part B is your health insurance and covers things such as doctor visits, outpatient tests, medical equipment and devices, and physical and occupational therapy.
Part C is the Medicare Advantage program. Medicare Advantage plans are offered by private insurance companies; you get both your Part A and Part B benefits in a Medicare Advantage plan. Most Medicare Advantage plans include Part D prescription drug coverage.
You cannot enroll in both Original Medicare and a Medicare Advantage plan; you have to choose one option for your Medicare coverage.
Part D is the Medicare Prescription Drug program. It is voluntary coverage that helps pay costs for prescription medications. There is a separate monthly premium for Part D.
If you are enrolled in Original Medicare, you may also buy a Medicare Supplement Plan, or Medigap plan. These are optional plans that help cover your out-of-pocket costs for Medicare- covered health care services under Part A and Part B. You cannot combine a Medigap plan with Medicare Advantage, however.
Who is eligible for Medicare?
You are eligible for Medicare when you turn 65 if you are a U.S. citizen or lawful permanent resident (green card holder) who has lived in the U.S. continuously for five years. If you are under age 65 and receiving Social Security disability payments, you may qualify for Medicare earlier.
If you or your spouse has a qualifying work history, you may qualify for premium-free Part A. Everyone enrolled in Part B pays a standard monthly premium, although those with higher incomes pay an additional premium supplement.
Even if you don’t qualify for premium-free Part A, you can enroll if you pay the monthly premium and meet other enrollment requirements.
You must be enrolled in Part A and/or Part B to purchase Medicare Part D prescription drug coverage.
Everyone who is eligible for Medicare coverage can enroll in Part A, Part B, Medicare Advantage, and Medicare Part D regardless of health status or pre-existing conditions. You do not have to pass a physical to enroll in a Medicare plan.
How do I apply for Medicare?
If you are already collecting Social Security benefits, you’ll be automatically enrolled in Original Medicare if you signed up for Medicare at the time you applied for Social Security. If you aren’t automatically enrolled, you can enroll up to three months before the month you turn 65, and for three months following your 65th birthday.
You can enroll online at www.SSA.gov, or in person at your local Social Security office. You can also call the Social Security Administration at 1-800-772-1213 to apply by phone.
If you want Medicare coverage, you should enroll when you are first eligible, because there is a late enrollment penalty if you sign up later. The penalty applies to your Part A premium, if you have to pay it, your Part B premium, and your Part D premium if you decide to enroll in prescription drug coverage.
If you choose Original Medicare and want to add Medigap coverage, it’s very important to buy a plan when you are first eligible. The Medicare Supplement Plan open enrollment period begins the month you are both enrolled in Part B and are 65 or over and lasts for six months. If you enroll during this period, you can buy any plan sold in your state at the lowest possible premium. If you wait to enroll and you have a pre-existing condition, you may be turned down for Medigap coverage.
How much does Medicare insurance cost?
In 2019, the Part A premium if you don’t qualify for premium-free Part A is $437. The standard Part B premium, which everyone must pay, even if you enroll in a Medicare Advantage plan, is $135.50.
Private insurance companies offer Part D, so premiums may vary, but the average monthly premium in 2019 is $33.
Part C is also private insurance, so premiums vary. You may be able to enroll in a $0 premium Medicare Advantage plan, which means there is no additional monthly premium on top of your normal Part B premium. If your plan has a monthly premium, you will send one payment to Medicare each month for your Part B premium, and a separate payment to your insurer.
The federal government sets Part A and Part B premiums each year. They may increase slightly from year to year.
What do I pay for with Medicare?
Both Part A and Part B have deductibles. With Part A, there is a $1,364 deductible for each benefit period; you may pay this deductible more than once in a year. The Part B deductible is only paid once per year and is currently $185.
You may also pay coinsurance for certain covered services. With Part B, you generally pay 20% of the allowable charges. There is a daily coinsurance amount under Part A for inpatient stays lasting longer than 60 days.
Some services have a flat copayment, which is due at the time you get care at the hospital outpatient department or doctor’s office. You will either pay a coinsurance amount or a copayment, but rarely both.
Medicare Advantage plans have different cost-sharing systems. You usually have just one annual deductible, and most plans have a copayment when you see the doctor or get outpatient services.
Part D plans usually have an annual deductible and charge a copayment amount each time you fill a prescription. Again, Medicare Advantage and Part D plans are private insurance plans, so you should check with each insurance company or a Medicare plan insurance agent for details about available plans.
Can I add my spouse and/or family to my Medicare plan?
Unfortunately, Medicare is individual coverage. You and your spouse will have to buy separate plans when you each become eligible. You can each enroll in a different plan or type of coverage if you like.
Children are not eligible for Medicare coverage.
Does Medicare cover all health care services?
Medicare covers most medically necessary services to diagnose and treat most illnesses and injuries. It also covers most preventive health care, including many vaccines, and annual wellness visits. Mental health services are also covered.
What it does not cover includes:
- Long-term care in a nursing home
- Routine dental care
- Routine vision care
- Routine hearing care
- Cosmetic procedures
- Most elective surgery
- Custodial care (custodial care is non-medical care for help with things such as eating, bathing, and dressing)
- Most prescription medications you take at home
Although you don’t lose any benefits with a Medicare Advantage plan, your coverage may be slightly different. Many plans include optional expanded benefits such as routine vision and dental care in addition to your Part A and Part B benefits.
What if I have more questions about Medicare insurance?
The Texas Health Information, Counseling and Advocacy Program has information about your Medicare insurance options and how to get help paying for Medicare if you are eligible. If you have questions about specific plans available in your area, contact an insurance agent specializing in Medicare plans near you.