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Understanding Medicare and Eligibility

SECTIONS

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Enrolling in Medicare Part A

If you aren’t receiving Social Security or Railroad Retirement Board (RRB) benefits (for instance, because you’re still working), you must sign up for Medicare Part A even if you’re eligible to get it premium-free. You should contact Social Security three months before you turn age 65. If you worked for a railroad, contact the RRB to sign up.

You can sign up for Medicare Part A during the following times:

  1. Initial Enrollment Period – When you’re first eligible for Medicare. This is a seven-month period that begins three months before the month you turn age 65, includes the month you turn age 65, and ends three months after the month you turn age 65.
  2. General Enrollment Period – Between January 1-March 31 each year. Your coverage will begin July 1. You may have to pay a higher premium for late enrollment.
  3. Special Enrollment Period – When you or your spouse (or family member if you’re disabled) is currently working, and you’re covered by a group health plan through the employer or union.
  4. Special Enrollment Period for International Volunteers – When you’re serving as a volunteer in a foreign country.

If you aren’t eligible for premium-free Medicare Part A, you may be able to buy it. However, if you don’t buy Medicare Part A when you’re first eligible, your monthly premium may go up 10%. You’ll have to pay the higher premium for twice the number of years you could have had Medicare Part A, but didn’t join. For example, if you were eligible for Medicare Part A, but didn’t join for two years, you’ll have to pay the higher premium for four years. You don’t have to pay a penalty if you’re eligible for a special enrollment period.

Some People are Automatically Enrolled in Medicare Part A

If you receive benefits from Social Security or the RRB, you automatically get Medicare Part A starting the first day of the month you turn age 65. If you’re under age 65 and disabled, you automatically get Medicare Part A after you get disability benefits from Social Security or certain disability benefits from the RRB for 24 months. You’ll get your Medicare card in the mail three months before your 65th birthday or your 25th month of disability.

For more information on Medicare Part A, call Social Security, or visit socialsecurity.gov. If you receive benefits from the RRB, call 1 877 772 5772.

If you have end-stage renal disease (ESRD), different rules apply. Visit your local Social Security office, or call Social Security at 1 800 772 1213 to sign up for Medicare Part A. For more information, visit www.medicare.gov/Publications/Pubs/pdf/10128.pdf to view the booklet, “Medicare Coverage of Kidney Dialysis and Kidney Transplant Services.”

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Signing Up for Medicare Part B

If you didn’t sign up for Medicare Part B when you first became eligible, you may be able to sign up during one of these times:

  1. General Enrollment Period – Between January 1–March 31 each year. Your coverage will begin on July 1. You may have to pay a late enrollment penalty.
  2. Special Enrollment Period – If you wait to sign up for Medicare Part B because you or your spouse is currently working, and you’re covered by a group health plan based on that work, or if you’re disabled and you or a family member is working, and you’re covered by a group health plan based on that work, you can sign up for Medicare Part B anytime while you have group health plan coverage based on current employment or during the eight-month period that begins the month after the employment ends, or the group health plan coverage ends, whichever happens first. If you have COBRA coverage, you must enroll during the eight month period that begins the month after the employment ends. This special enrollment period doesn’t apply to people with ESRD.
  3. Special Enrollment Period for International Volunteers– If you waited to sign up for Medicare Part B because you had health insurance while volunteering outside of the U.S. for a tax exempt organization for at least a year, you can sign up during the six-month period that begins the first month that any one of the following happens:
    • You’re no longer volunteering outside the U.S.
    • The sponsoring organization is no longer tax exempt
    • You no longer have health insurance coverage outside the U.S.

Some People are Automatically Enrolled in Medicare Part B

If you receive benefits from Social Security or the RRB, in most cases, you’ll automatically get Medicare Part B starting the first day of the month you turn age 65. If your birthday is on the first day of the month, your Medicare Part B will start the first day of the prior month. If you’re under age 65 and disabled, you’ll automatically get Medicare Part B after you get disability benefits from Social Security or certain disability benefits from the RRB for 24 months. You’ll get your Medicare card in the mail about 3 months before your 65th birthday or your 25th month of disability.

If you don’t want Medicare Part B, follow the instructions that come with the card, and send the card back. If you keep the card, you keep Medicare Part B and will pay Medicare Part B premiums. If you have amyotrophic lateral sclerosis (ALS, also called Lou Gehrig’s disease), you automatically get Medicare Part B the month your disability benefits begin.

If you have Medicare because of end-stage renal disease, you can sign up for Medicare Part B when you sign up for Medicare Part A. If you delay signing up for Medicare Part B, you can get it only during the general enrollment period, and you may have to pay a late enrollment penalty.

If you live in Puerto Rico, and you want Medicare Part B, you’ll need to sign up for it. Contact your local Social Security office for more information.

If you aren’t receiving Social Security or RRB benefits, and you want to get Medicare Part B, you’ll need to sign up for Medicare Part B during your initial enrollment period, which is the seven-month period that begins three months before the month you turn age 65, includes the month you turn age 65, and ends three months after the month you turn age 65.

If you don’t sign up for Medicare Part B when you’re first eligible, you may have to pay a late enrollment penalty for as long as you have Medicare. Your monthly premium for Medicare Part B may go up 10% for each full 12-month period that you could have had Medicare Part B, but didn’t sign up for it. Usually, you don’t pay a late enrollment penalty if you sign up for Medicare Part B during a special enrollment period.

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Medicare Part A Hospital Insurance

Medicare Part A helps cover the following:

  • Inpatient care in hospitals (such as critical access hospitals, inpatient rehabilitation facilities, and long-term care hospitals)
  • Inpatient care in a skilled nursing facility (not custodial or long term care)
  • Hospice care services
  • Home health care services

You usually don’t pay a monthly premium for Medicare Part A coverage if you or your spouse paid Medicare taxes while working.

Medicare doesn’t cover everything. If you need certain services that Medicare doesn’t cover, you’ll have to pay out-of-pocket unless you have other insurance to cover the costs. Even if Medicare covers a service or item, you generally have to pay deductibles, coinsurance and copayments.

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Medicare Part B Medical Insurance

Medicare Part B helps cover medically necessary services like doctors’ services, outpatient care, home health services and other medical services. Medicare Part B also covers some preventive services. You can find out if you have Medicare Part B by looking at your Medicare card.

You pay the Medicare Part B premium each month. Most people will pay the standard premium amount.

There are two kinds of Medicare Part B-covered services:

  1. Medically-necessary services are services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
  2. Preventive services include health care to prevent illness or detect it at an early stage, when treatment is most likely to work best (for example, Pap tests, flu shots, and colorectal cancer screenings).

Medicare doesn’t cover everything. If you need certain services that Medicare doesn’t cover, you must pay for them unless you have other insurance to cover the costs. Even if Medicare covers a service or item, you generally have to pay deductibles, coinsurance and copayments.

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Medicare Part C Medical Insurance

A Medicare Advantage Plan (like an HMO or PPO) is another health coverage choice you may have as part of Medicare. It’s important you know what choices are available when selecting your Medicare health benefit options. You can enroll in Original Medicare or select from a variety of Medicare Advantage plans that can include prescription drug coverage and other benefits that may better fit your health care or financial needs.

Medicare Advantage Plans, sometimes called Medicare Part C or MA Plans, are offered by private companies approved by Medicare. If you join a Medicare Advantage Plan, the plan will provide all of your Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) coverage. In all plan types, you’re always covered for emergency and urgent care.

Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care. Original Medicare covers hospice care even if you’re in a Medicare Advantage Plan. Medicare Advantage Plans aren’t considered supplemental coverage.

Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage. In addition to your Medicare Part B premium, you usually pay one monthly premium for the services provided.

Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services, for example, whether you need a referral to see a specialist or if you have to go to only doctors, facilities, or suppliers that belong to the plan.

Medicare Advantage Plans include the following:

  • Health Maintenance Organization (HMO) Plans
  • Preferred Provider Organization (PPO) Plans
  • Private Fee-for-Service (PFFS) Plans
  • Medical Savings Account (MSA) Plans
  • Special Needs Plans (SNP)

Make sure you understand how a plan works before you join. Not all Medicare Advantage Plans work the same way, so before you join, find out the plan’s rules, what your costs will be, and whether the plan will meet your needs.

More About Medicare Advantage Plans

As with Original Medicare, you have Medicare rights and protections, including the right to appeal.

  • Check with the plan before you get a service to find out whether they will cover the service and what your costs may be
  • You must follow plan rules, like getting a referral to see a specialist or getting prior approval for certain procedures to avoid higher costs; check with the plan
  • You can join a Medicare Advantage Plan even if you have a pre existing condition, except for End-Stage Renal Disease
  • You can only join a plan at certain times during the year
  • If you go to a doctor, facility, or supplier that doesn’t belong to the plan, your services may not be covered, or your costs could be higher, depending on the type of Medicare Advantage Plan
  • If the plan decides to stop participating in Medicare, you’ll have to join another Medicare health plan or return to Original Medicare

You can join, switch, or drop a Medicare Advantage Plan at these times:

  1. When you first become eligible for Medicare (the seven month period that begins three months before the month you turn age 65, includes the month you turn age 65, and ends three months after the month you turn age 65).
  2. If you receive Medicare due to a disability, you can join during the three months before to three months after your 25th month of disability. You’ll have another chance to join three months before the month you turn age 65 to three months after the month you turn age 65.
  3. The 45 day disenrollment period that takes place January 1-February 14th.

In most cases, you must stay enrolled for that calendar year starting the date your coverage begins. However, in certain situations, you may be able to join, switch, or drop a Medicare Advantage Plan at other times. Some of these situations include the following:

  • If you move out of your plan’s service area
  • If you have both Medicare and Medicaid
  • If you qualify for Extra Help to pay for your prescription drug costs
  • If you live in an institution (like a nursing home)

Call your State Health Insurance Assistance Program (SHIP) for more information.

Medicare Advantage Plans are private health plan options approved by Medicare. Plans are administered by various insurance companies.

Texas Medicare Advantage plans pay instead of Medicare, and you will pay co-pays for medical services.

Medicare Advantage plans are an option for Medicare beneficiaries who have Medicare Parts A & B and live in the plan's service area.

Here are some facts to consider about Medicare Advantage:

  • Texas Medicare Advantage plans usually have a low premium, sometimes even a $0 premium.
  • Though Medicare Advantage premiums may be low, you will have cost-sharing (copays or coinsurance) for most medical services, such as doctor visits, hospital stays, lab work, MRI scan, and even chemotherapy and radiation
  • Medicare Advantage plans sometimes offer extra benefits such as routine physicals and vision care.
  • Only one health question is asked, so for some Medicare beneficiaries, getting accepted into a Medicare Advantage plan is possible despite health conditions.

 

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Texas Medicare Part D Drug Plans

Medicare offers prescription drug coverage (Medicare Part D) to everyone with Medicare. To get Medicare drug coverage, you must join a Medicare Part D plan run by an insurance company or other private company approved by Medicare. Each plan can vary in cost and the covered drugs.

There are two ways to get Medicare prescription drug coverage:

  1. Medicare Prescription Drug Plans. These plans add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service Plans, and Medicare Medical Savings Account Plans.
  2. Medicare Advantage Plans (like an HMO or PPO) or other Medicare health plans that offer Medicare prescription drug coverage. You get all of your Medicare Parts A and B coverage, and prescription drug coverage (Part D), through these plans.

Texas Medicare Part D Drug Plans help Medicare recipients control their prescription drug costs. . For 2012, there are approximately 33 Texas Medicare Part D drug plans to choose from.

Medicare Part D covers most types of prescription drugs in the U.S., with just a few exceptions.

For example, the following types of drugs are among those not covered:

  • Drugs for cosmetic purposes or hair growth or fertility
  • Barbiturates & Benzodiazepines
  • Most prescription vitamins & mineral products
  • Drugs for anorexia, weight loss or weight gain
  • Drugs for symptomatic cold & cough relief
  • Erectile dysfunction drugs

However, Part D drug plans work differently than other types of prescription drug insurance.

It's important to understand the Coverage Gap and how it may affect you. To learn how Texas Medicare Part D drug plans work and help understanding Texas Medicare Part D, please contact us.

Texas Medicare Part D drug plans work and help understanding Texas Medicare Part D, please contact us.

 

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Texas Medicare Supplement or Medigap – What is It?

Medicare Supplemental insurance coverage helps pay some of your share of the health care costs not covered by the Medicare Plan; such as deductibles and coinsurance or copayment amounts. Some supplemental health insurance plans also cover certain hospital or medical services not covered by Medicare.

Sometimes called Medigap insurance, Medicare supplements give you freedom to choose your own doctor. Once insured, you can never be dropped due to health reasons.

Medicare Supplemental health insurance coverage is available to you if you are 65 or older and have enrolled in the Medicare Plan, Parts A and B. And in some states, coverage is available if you are under age 65 and are Medicare eligible due to disability or kidney disease.

Medicare Part A and Part B plans do not cover all of your health care costs. If you end up in the hospital or need a doctor’s care, you will end up with out-of-pocket expenses. And with the rising costs of health care, these expenses can end up being very costly.

Texas Medigap insurance policies are designed to fill in the gaps. These plans provide coverage for costs not picked up by Texas Medicare. Your supplemental insurance policy can cover numerous items including: deductibles, co-insurance and co-payments. And when you choose the right plan, your out-of-pocket expenses could cost you absolutely nothing. Contact us today to see how we can eliminate your out-of-pocket expenses.

There are a variety of Medigap plans available to Texans. However, all Texas Insurance companies that sell plans provide at least the same base coverage. That should make it simple to choose a plan that fits your specific needs. Unfortunately, it is still very easy to get confused on coverage and, even worse, to overpay for your coverage.

Currently, there are 10 standardized Medicare Supplement Plans (A, B, C, D, F, G, K, L, M, and N). All companies do not sell all plans. Many people suffer from information overload when it comes to these plans. However, the coverage in a plan F from one company to another will be the same. This helps cut down on the confusion when searching for the right policy.

We help you navigate the maze of choices. It is important to have a Texas Medigap Professional to help you choose correctly.

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