An overview of Medicare and the Medicare enrollment process
Medicare is a federal entitlement program that provides affordable healthcare coverage for over 60 million people. Initially designed for America’s seniors, the program now covers people over the age of 65 as well as younger people with certain disabilities. Those are the basics.
This often misunderstood program can be confusing, even if you’ve been enrolled in it for years. That’s okay. You’re not alone if you’re not clear on what Medicare is or what it covers. To help you understand Medicare better, we’ve answered some commonly asked questions about the program below.
When can I enroll in Medicare?
First, let’s go over eligibility. Most people become eligible for Medicare when they’re 65. That’s the minimum age for Medicare benefits for the general population. Some younger people with disabilities can also enroll, though. This includes:
- People with end-stage renal disease (ESRD)
- People with ALS (Lou Gehrig’s disease)
- Those receiving disability benefits from Social Security or the Railroad Retirement Board
Enrollment falls into two categories: automatic and active.
Certain Medicare members will need to sign up for Medicare when they become eligible. Others will get enrolled automatically. Automatic enrollment applies to:
- People with ALS
- Those with a disability who’re under 65
- People receiving Social Security benefits at least 4 months before they’re eligible for Medicare
For these groups, enrollment is automatic, but it varies. For instance, people with ALS will get enrolled into Parts A and B once their disability benefits start. If you fall into one of these categories, check out Medicare.gov for specific information about enrollment and when your benefits start.
For everyone else, enrollment requires active participation. If you don’t get Social Security benefits and you don’t have a disability, then you’ll need to sign up for Medicare when you first become eligible. (This includes people with ESRD, who need to actively enroll as well.)
Your Initial Enrollment Period (IEP) to sign up for Medicare lasts for 7 months: 3 months before the month you turn 65, the month you turn 65, and 3 months after that month. So, for example, if you turn 65 on August 8th, your IEP runs from May 1st through November 30th.
It’s important to enroll in Medicare when you’re first eligible. The sooner you enroll, the sooner your coverage starts. Plus, if you miss your IEP and then later decide to enroll, you may pay a penalty for certain portions of Medicare. And those late enrollment penalties can last for as long as you have Medicare (i.e., forever).
What does Medicare cover?
Medicare is divided into four parts: A, B, C and D. Each of these parts covers different benefits, which we’ll highlight in this section.
Medicare Part A
Medicare Part A is hospital insurance. It covers the care you get during an inpatient hospital stay and/or skilled nursing facility. This portion of Medicare usually doesn’t have a premium because it’s paid for through work taxes.
If you accumulate 40 work credits over the course of your working life, you won’t have a Part A premium. About 99% of people get this portion without a monthly premium. You might hear it referred to as “premium-free Part A.”
Part A does include cost sharing, though, in the form of deductibles and coinsurance. So while there’s no monthly premium for most people, everyone will pay for a portion of their care.
Medicare Part B
Medicare Part B covers medical services. It’s what you probably think of when you think of typical medical benefits. This portion of Medicare covers things like routine trips to the doctor, flu shots, vaccines, X-rays, outpatient surgery and other medically necessary care and equipment.
Everyone pays a premium for Medicare Part B. Some higher-income members pay more, but everyone has a cost for this portion of Medicare. Along with the monthly premium, Part B has an annual deductible and 20% coinsurance — meaning you pay 20% of the cost of care, with no annual limit on out-of-pocket costs.
Medicare Part C (Medicare Advantage)
Medicare Part C is called Medicare Advantage. It covers all of the benefits of Medicare Parts A and B together (by law), plus added benefits that vary by plan. This portion of Medicare is sold by private companies, but it’s still regulated by the federal government.
Medicare Advantage is an increasingly popular way for Medicare members to get their benefits. About 45% of Medicare enrollees now choose private plans over Original Medicare. These plans cover a bevy of added benefits, including things that Original doesn’t, such as prescription drugs, dental and vision care, hearing aids and exams, and more.
Premiums and cost sharing vary widely with Medicare Advantage, but many plans have a $0 copay. Plus, Advantage plans cap what members pay out of pocket for medical care for the year.
Medicare Part D
Original Medicare (Parts A and B together) does not cover prescription drugs, with very few exceptions. In fact, the only exceptions are for drugs that you’d normally get in a hospital setting, like chemotherapy treatments.
If you need prescription drug coverage, you can buy a Medicare Advantage plan that covers prescriptions or a standalone Part D drug plan. Costs vary since these plans are also sold by private companies. But premiums tend to be low.
As with Part B, though, higher-income enrollees may pay more for Part D coverage. And if you sign up late (outside of initial enrollment), you may pay a penalty for not having what Medicare considers creditable drug coverage.
Can I change my Medicare coverage anytime?
The short answer is no. You can’t make changes to your Medicare coverage on a whim. There are certain times of the year, called enrollment periods, when you can make changes or switch to a different kind of coverage.
There are four major enrollment periods you should know about: General Enrollment, Open (or Annual) Enrollment, Medicare Advantage Open Enrollment, and Medigap Open Enrollment.
General Enrollment Period
The General Enrollment Period runs from January 1st through March 31st each year. During this time, you can sign up for Part A and/or Part B if you didn’t enroll when you first became eligible. If you use this enrollment period to sign up for Medicare, you may pay a late enrollment penalty because you didn’t sign up during your initial enrollment window.
If you sign up for Part A and/or Part B during the General Enrollment Period, your coverage will take effect on the first of the month after the month in which you enroll.
Medicare Open Enrollment
This is the major enrollment period for Medicare, whether you have Original Medicare (Parts A and B) or Medicare Advantage. From October 15th through December 7th each year, you can make changes to your current coverage. That means:
- Joining a Medicare Advantage plan if you have Original Medicare
- Switching to a new Medicare Advantage plan if you have an MA plan already
- Switching from an Advantage plan with drug coverage to one without it (or vice versa)
- Dropping Medicare Advantage and going back to Original Medicare
- Joining a new prescription drug plan (Part D)
- Switching your Part D drug coverage
- Dropping your Part D drug coverage altogether
This all boils down to the fact that Medicare Open Enrollment is your best (and sometimes only) chance to change your Medicare coverage.
Changes you make during this enrollment period will take effect on January 1st of the following year.
Medicare Advantage Open Enrollment
This relatively new enrollment period is available only to people currently enrolled in a Medicare Advantage plan when the enrollment window opens. Running from January 1st through March 31st each year, the Medicare Advantage Open Enrollment period allows people with Medicare Advantage plans to make a one-time change to their coverage. This is not the same as the Open Enrollment period. You can only make one change during this three-month period.
Once you make that change, your new coverage will start on the first day of the month after your new plan gets your request for coverage (according to Medicare.gov).
Medigap Open Enrollment
When you’re first eligible for Medicare, you’re also first eligible for Medicare supplement insurance. Also called Medigap, this supplement to Original Medicare covers some of your out-of-pocket costs under Parts A and B.
Once you turn 65 and enroll in Part B, you have six months from that date to enroll in any Medigap plan that’s available to you where you live.
Outside of this initial enrollment window for Medigap, you may not be able to get coverage. That’s because health insurers can use medical underwriting — taking a look at your health history and medical condition — to set rates or deny coverage altogether.
There are other enrollment periods for Medicare, including special enrollment periods if you’re still working when you turn 65 or a 5-star Medicare Advantage plan becomes available in your area. For specifics on other enrollment periods, check out Medicare.gov and navigate to your specific scenario. This is just a roundup of the most common enrollment periods.
Where can I learn more about Medicare?
The best place to start if you want to take a deep dive on anything related to Medicare is the program’s government website at Medicare.gov. This is where you’ll find detailed — and we mean very, very detailed — articles on everything from how to join a Part D drug plan to exemptions from the Part B late enrollment penalty.
Another web-based option is the Centers for Medicare and Medicaid Services, which oversees the Medicare program and offers a wide range of info about it on its website at CMS.gov.
And if you’ve got some time on your hands, consider calling your local Social Security office to set up an appointment. You can speak with someone directly about Medicare. The Social Security Administration also has a website, but its info on Medicare may not be as comprehensive as the other federal websites we’ve mentioned.
Questions about Medicare enrollment or Medicare Advantage? Call us toll-free at 1-800-485-6202 anytime to speak with a licensed health insurance agent.
Medicare ni mpango wa haki ya shirikisho ambao hutoa chanjo ya afya ya bei nafuu kwa watu zaidi ya milioni 60. Programu hiyo, ambayo awali ilikusudiwa kuwahudumia wazee wa Marekani, sasa inahusu watu wenye umri wa miaka 65 na zaidi na pia vijana wenye ulemavu fulani. Hizo ndizo mambo ya msingi. Programu hii ambayo mara nyingi hueleweka vibaya yaweza kuwa yenye kutatanisha, hata ikiwa umejiandikisha kwa miaka mingi. Hiyo ni sawa. Wewe si peke yake kama wewe si wazi juu ya nini Medicare ni au nini inashughulikia. Ili kukusaidia kuelewa Medicare vizuri, tumejibu maswali kadhaa yanayoulizwa mara nyingi kuhusu programu hapa chini. Ni lini ninaweza kujiandikisha katika Medicare? Kwanza, hebu tuangalie sifa za kuandikishwa. Watu wengi wanastahili kupata huduma ya Medicare wanapofikia umri wa miaka 65. Hiyo ni umri wa chini kwa ajili ya faida ya Medicare kwa ajili ya idadi ya watu kwa ujumla. Hata hivyo, vijana fulani wenye ulemavu wanaweza kujiandikisha. Watu wenye ugonjwa wa figo wa hatua ya mwisho (ESRD) - Watu wenye ALS (ugonjwa wa Lou Gehrig) - Wale wanaopokea faida za ulemavu kutoka kwa Usalama wa Jamii au Bodi ya Kustaafu ya Reli - Kujiandikisha huanguka katika makundi mawili: moja kwa moja na hai. Wanachama fulani wa Medicare watahitaji kujiandikisha kwa Medicare wanapopata haki. Wengine watajiandikisha moja kwa moja. Kujiandikisha moja kwa moja inatumika kwa: Watu wenye ALS, wale wenye ulemavu chini ya miaka 65, watu wanaopokea faida za usalama wa kijamii angalau miezi minne kabla ya kustahili Medicare, kwa makundi haya, uandikishaji ni moja kwa moja, lakini inatofautiana. Kwa mfano, watu wenye ALS watajiandikisha katika Sehemu A na B mara tu faida zao za ulemavu zitaanza. Ikiwa unaanguka katika moja ya makundi haya, angalia Medicare.gov kwa habari maalum kuhusu uandikishaji na wakati faida zako zinaanza. Kwa wengine wote, kujiandikisha huhitaji ushiriki wenye bidii. Kama huna kupata faida ya Usalama wa Jamii na huna ulemavu, basi unahitaji kujiandikisha kwa Medicare wakati wa kwanza kuwa na haki. (Hii inajumuisha watu wenye ESRD, ambao wanahitaji kujiandikisha pia.) Kipindi cha Uandikishaji wa Mwanzoni (IEP) ni kipindi cha miezi saba kabla ya mwaka wa 65 na miezi mitatu baada ya mwaka huo. Kwa mfano, ikiwa una umri wa miaka 65 tarehe 8 Agosti, IEP yako itaanza tarehe 1 Mei hadi 30 Novemba. Ni muhimu kujiandikisha katika Medicare wakati wewe ni kwanza haki. Kadiri unavyojiandikisha, ndivyo ukaguzi wako unavyoanza. Kwa kuongezea, ikiwa unakosa IEP yako na baadaye uamue kujiandikisha, unaweza kulipa adhabu kwa sehemu fulani za Medicare. Hizi ni adhabu za marehemu za kujiandikisha ambazo zinaweza kudumu kwa muda mrefu kama una Medicare (yaani, milele). Medicare inashughulikia nini? Medicare imegawanywa katika sehemu nne: A, B, C na D. Kila moja ya sehemu hizi inashughulikia faida tofauti, ambayo tutaonyesha katika sehemu hii. Medicare sehemu A ni bima ya hospitali. Inashughulikia huduma unayopata wakati wa kukaa hospitalini na au kituo cha uuguzi wa kitaalamu. Sehemu hii ya Medicare kwa kawaida haina malipo kwa sababu inalipwa kupitia kodi za kazi. Ikiwa una mkusanyiko wa mikopo 40 ya kazi katika maisha yako ya kazi, utakuwa na sehemu ya A. Karibu asilimia 99 ya watu wanafurahia huduma hii bila malipo ya kila mwezi. "Hii ni sehemu ya ""Premium-Free"" na ""Premium-Free"" sehemu A, ambayo inashirikisha pamoja na kugawana gharama, ingawa kwa njia ya deductibles na coinsurance." Kwa hiyo ingawa hakuna malipo ya kila mwezi kwa watu wengi, kila mtu atalipa sehemu ya utunzaji wake. Medicare sehemu B inashughulikia huduma za matibabu. Ni nini pengine kufikiri ya wakati wewe kufikiri ya faida ya kawaida ya matibabu. Sehemu hii ya Medicare inashughulikia mambo kama safari za kawaida kwa daktari, chanjo za mafua, chanjo, X-ray, upasuaji wa wagonjwa wa nje na huduma nyingine za matibabu na vifaa. Kila mtu hulipa malipo kwa ajili ya Medicare Sehemu B. Baadhi ya wanachama wenye mapato ya juu hulipa zaidi, lakini kila mtu ana gharama kwa sehemu hii ya Medicare. Pamoja na malipo ya kila mwezi, sehemu B ina deductible ya kila mwaka na 20% coinsurance, ikimaanisha unalipa 20% ya gharama ya huduma, bila kikomo cha kila mwaka kwa gharama za nje ya mfuko. Medicare sehemu C (Medicare Faida) ni sehemu ya Medicare sehemu C inaitwa Medicare Faida. Hii inashughulikia faida zote za Medicare sehemu A na B pamoja (kwa sheria), pamoja na faida za ziada ambazo hutofautiana kulingana na mpango. Sehemu hii ya Medicare inauzwa na makampuni binafsi, lakini bado inasimamiwa na serikali ya shirikisho. Medicare Advantage ni njia inayopendwa zaidi na zaidi kwa wanachama wa Medicare kupata faida zao. Karibu asilimia 45 ya wagombea wa Medicare sasa huchagua mipango ya kibinafsi badala ya Medicare ya awali. Mipango hii inashughulikia faida nyingi za ziada, ikiwa ni pamoja na mambo ambayo Original haina, kama vile dawa za dawa, huduma ya meno na maono, vifaa vya kusikia na mitihani, na zaidi. Kwa hivyo, malipo ya malipo ya Medicare na Medicare Advantage ni tofauti, na kuna mipango mingi ambayo inatoa $ 0 ya kulipia. Kwa kuongezea, mipango ya faida hupunguza kile wanachama hulipa kutoka mfukoni kwa huduma ya matibabu kwa mwaka. Medicare sehemu D (Mashirika ya Medicare ya awali) haifai dawa za dawa, isipokuwa chache sana. Kwa kweli, ubaguzi pekee ni kwa ajili ya dawa kwamba wewe <unk>d kawaida kupata katika mazingira ya hospitali, kama matibabu ya kemotherapy. Ikiwa unahitaji bima ya dawa za dawa, unaweza kununua mpango wa Medicare Advantage ambao unashughulikia dawa za dawa au mpango wa dawa ya sehemu ya D. Gharama hutofautiana kwa kuwa mipango hii pia huuzwa na makampuni ya kibinafsi. Lakini malipo ya bima huwa ya chini. Hata hivyo, kama ilivyo na Sehemu B, washiriki wenye mapato ya juu wanaweza kulipa zaidi kwa ajili ya sehemu D. Ikiwa utajiandikisha kwa muda mrefu (ndogo kuliko usajili wa awali), unaweza kulipa faini kwa kutokuwa na kile Medicare inachukulia kuwa chanjo ya dawa ya kuaminika. Je, naweza kubadilisha bima yangu ya Medicare wakati wowote? Jibu fupi ni hapana. Huwezi kufanya mabadiliko ya Medicare yako chanjo juu ya whim. Kuna nyakati fulani za mwaka, zinazoitwa vipindi vya kujiandikisha, wakati unaweza kufanya mabadiliko au kubadili aina tofauti ya chanjo. Kuna vipindi vinne vikuu vya uandikishaji unapaswa kujua kuhusu: Uandikishaji wa jumla, Uandikishaji wa wazi (au wa kila mwaka), Uandikishaji wa wazi wa Medicare Advantage, na Uandikishaji wa wazi wa Medigap. Kipindi cha Uandikishaji wa jumla ni kuanzia Januari 1 hadi Machi 31 kila mwaka. Wakati huu, unaweza kujiandikisha kwa Sehemu A na/au Sehemu B kama wewe si kujiandikisha wakati wa kwanza akawa na haki. Kama wewe kutumia kipindi hiki uandikishaji kujiandikisha kwa Medicare, unaweza kulipa penalty marehemu uandikishaji kwa sababu wewe si kujiandikisha wakati wa dirisha yako ya awali uandikishaji. Ikiwa utajiandikisha kwa Sehemu A au B wakati wa Kipindi cha Kujiandikisha kwa ujumla, chanjo yako itaanza kutumika tarehe 1 ya mwezi baada ya mwezi ambao utajiandikisha. Kujiandikisha kwa Medicare ni kipindi cha kwanza cha kujiandikisha kwa Medicare, ikiwa una Medicare ya awali (sehemu A na B) au Medicare Advantage. Kuanzia Oktoba 15 hadi Desemba 7, unaweza kufanya mabadiliko katika bima yako ya sasa. Kujiunga na mpango wa Medicare Advantage ikiwa una Medicare ya awali, kubadilisha kwa mpango mpya wa Medicare Advantage ikiwa una mpango wa MA tayari, kubadilisha kutoka kwa mpango wa Advantage na chanjo ya dawa hadi moja bila (au kinyume chake), kuacha Medicare Advantage na kurudi kwa Medicare ya asili, kujiunga na mpango mpya wa dawa ya dawa (Part D), kubadilisha chanjo yako ya dawa ya sehemu D, kuacha chanjo yako ya dawa ya sehemu D kabisa. Mabadiliko yoyote unayofanya wakati wa kipindi hiki cha usajili utaanza kutumika Januari 1 mwaka uliofuata. Medicare Advantage Open Enrollment (MTA) ni mpango wa Medicare Advantage ambao unapatikana kwa watu waliojiandikisha kwenye mpango wa Medicare Advantage wakati dirisha la uandikishaji linafunguliwa. Kuanzia Januari 1 hadi Machi 31, kipindi cha Uandikishaji wa wazi cha Medicare Advantage kinaruhusu watu wenye mipango ya Medicare Advantage kufanya mabadiliko ya mara moja kwa chanjo yao. Hii si sawa na kipindi cha Kujiandikisha wazi. Unaweza kufanya mabadiliko moja tu katika kipindi hiki cha miezi mitatu. Baada ya kufanya mabadiliko hayo, chanjo yako mpya itaanza siku ya kwanza ya mwezi baada ya mpango wako mpya kupokea ombi lako la chanjo (kwa mujibu wa Medicare.gov). Medigap Open Uandikishaji Wakati wewe ni kwanza kustahili kwa Medicare, wewe pia ni kwanza kustahili kwa Medicare bima ya ziada. Medigap ni kifungu cha Medicare cha awali ambacho kinajumuisha gharama za ziada za sehemu A na B. Baada ya kufikia umri wa miaka 65 na kujiandikisha katika sehemu B, una miezi sita kutoka tarehe hiyo kujiandikisha katika mpango wowote wa Medigap unaopatikana mahali unapoishi. Nje ya dirisha hili la uandikishaji wa awali kwa Medigap, huenda usiweze kupata chanjo. Hiyo ni kwa sababu wajasiriamali wa afya wanaweza kutumia udhamini wa matibabu - kuangalia historia yako ya afya na hali ya matibabu - kuweka viwango au kukataa chanjo kabisa. Kuna vipindi vingine vya uandikishaji kwa Medicare, ikiwa ni pamoja na vipindi maalum vya uandikishaji ikiwa bado unafanya kazi wakati unapofikia umri wa miaka 65 au mpango wa Medicare Advantage wa nyota tano unapatikana katika eneo lako. Kwa maelezo zaidi juu ya kipindi kingine cha uandikishaji, angalia Medicare.gov na uende kwenye hali yako maalum. Hii ni tu roundup ya vipindi vya kawaida ya uandikishaji. Ninaweza kujifunza zaidi kuhusu Medicare wapi? Mahali pazuri pa kuanza ikiwa unataka kupiga mbizi kwa kina juu ya chochote kinachohusiana na Medicare ni tovuti ya serikali ya programu katika Medicare.gov. Hii ni ambapo utapata maelezo <unk> na tunamaanisha sana, sana <unk> makala juu ya kila kitu kutoka jinsi ya kujiunga na Sehemu D mpango wa madawa ya kulevya kwa msamaha kutoka Sehemu B marehemu uandikishaji adhabu. Kituo cha Huduma za Medicare na Medicaid (CMS) ni kituo cha huduma za Medicare na Medicaid, ambacho kinasimamia programu ya Medicare na hutoa habari nyingi kuhusu programu hiyo kwenye tovuti yake ya CMS.gov. Na kama una muda wa kutosha, fikiria kupiga simu ofisi yako ya usalama wa kijamii ili kupanga miadi. Unaweza kuzungumza na mtu moja kwa moja kuhusu Medicare. Utawala wa Usalama wa Jamii pia una tovuti, lakini habari yake juu ya Medicare inaweza kuwa si kama kina kama tovuti nyingine za shirikisho tumetaja. Maswali kuhusu usajili wa Medicare au Medicare Advantage? Piga simu kwa 1-800-485-6202 na uongee na wakala wa bima ya afya.