Learn the Basics about Medicare Benefits and Insurance Options

Are you turning 65 soon? You may be wondering about Medicare–when you should enroll, how to enroll, and what options you have. Medicare is the United States government health insurance program for beneficiaries aged 65 and older. Medicare also covers people younger than 65 with qualifying medical conditions such as end-stage renal disease, Lou Gehrig’s disease, and certain disabilities.

Many beneficiaries who are new to Medicare get confused by its complexity. Medicare includes four major parts: Part A, Part B, Part C, and Part D. Medicare Part A and Part B are often referred to as Original Medicare, and these are the parts of the program that are administered by the federal government. Part C is Medicare Advantage and represents an alternative way of receiving Medicare benefits from a private insurance company approved by Medicare.  Part D refers to Medicare prescription drug coverage, which is also provided by Medicare-approved private insurance companies.

Original Medicare

Generally speaking, Part A covers in-patient hospitalization while Part B covers outpatient services and other medical care provided by doctors and other health care professionals, as well as durable medical equipment. Other parts of the program are available through private insurance companies that have contracted with Medicare. You may be enrolled in Medicare automatically if you are about to turn 65, are a United States citizen or legal permanent resident of at least five continuous years, and receive retirement benefits through either the Social Security Administration (SSA) or the Railroad Retirement Board (RRB). If you qualify for automatic enrollment, you’ll get a “Welcome to Medicare” packet in the mail before your 65th birthday.

If you don’t qualify for automatic enrollment, you can sign up during the Initial Enrollment Period (IEP), which begins three months before your birth month, includes your birth month, and lasts for three months after that (a total of seven months).

You may enroll manually by visiting your local SSA office or by registering online at ssa.gov. You can also sign up by phone:

  • Call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. Social Security representatives are available Monday through Friday, from 7AM to 7PM.
  • If you worked for a railroad, contact the RRB at 1-877-772-5772. TTY users should call 1-312-751-4701. Railroad Retirement Board representatives are available Monday through Friday, from 9AM to 3:30PM.

Medicare Advantage (Part C)

Medicare Part C also known as Medicare Advantage plans  are offered by private insurance companies contracted with Medicare to deliver Medicare Part A and Part B benefits to plan enrollees.

Medicare Advantage plans may include additional benefits not covered under Part A and Part B, such as routine vision, dental, and hearing coverage. Some plans may include prescription drug coverage as well; these are called Medicare Advantage Prescription Drug plans.

You can enroll in Medicare Advantage during the Initial Enrollment Period, provided you have already obtained Medicare Part A and Part B. You can also enroll in a Medicare Advantage plan or change plans  during the Annual Election Period, which runs from October 15 to December 7 each year. Under certain conditions, you may be able to enroll in a Medicare Advantage plan during a Special Election Period as well.

If you sign up for a Medicare Advantage plan, you continue to pay your Part B premium in addition to the Medicare Advantage plan’s premium, if any.

Medicare Part D

Part D is the Medicare prescription drug benefit program. Medicare prescription drug coverage is generally recommended, but it is optional coverage.  This coverage is available by enrolling in a  stand-alone Medicare Part D Prescription Drug Plan to work alongside your Medicare Part A and/or Part B coverage, or by enrolling in a Medicare Advantage Prescription Drug plan, which provides your Medicare Part A and Part B benefits, plus prescription drug coverage.

Your circumstances determine when you can enroll or change Medicare plans providing prescription drug coverage:

  • If you are turning 65, Medicare provides an Initial Enrollment Period for Medicare Part D, which lets you enroll in a stand-alone Medicare Part D Prescription Drug Plan or a Medicare Advantage Prescription Drug plan (if you have Part A and Part B) three months prior to the month of your 65th birthday up through three months following your birth month. In total, that provides you a window of seven months in which to enroll (the same period as the Initial Election Period). This is generally the best time to enroll in Part D.
  • If you’re already enrolled in a stand-alone Medicare Part D Prescription Drug Plan or Medicare Advantage Prescription Drug plan, you may change plans during the Annual Election Period.
  • You may have a change in your life that affects your coverage. A Medicare Special Election Period (SEP) allows you to enroll in Medicare or change your Medicare coverage outside of your Initial Enrollment Period or other enrollment periods without penalty.  Some of the types of life changes that may qualify for a Special Election Period include, but are not limited to:
    • Dual enrollment in Medicare and Medicaid begins or ends
    • Participation in “Extra Help” (a low-income subsidy program) begins or ends
    • Moving into (or moving out of ) a nursing home or skilled nursing facility
    • Loss of current coverage

If you don’t enroll in a stand-alone Medicare Part D Prescription Drug Plan (or a Medicare Advantage Prescription Drug plan) as soon as you’re eligible (during your Initial Enrollment Period), you could face a late enrollment penalty when you enroll at a later date.