Medicare is a government-run health insurance program covering people 65 and over. It also covers people under 65, who have been receiving social security disability insurance for at least 24 months.
The Centers for Medicare and Medicaid Services (CMS) is the federal agency that runs Medicare. The program is funded in part by Social Security and Medicare taxes paid by people who are working.
Though they are all government programs, Medicare, Medicaid, and Social Security are different. Medicaid is a health insurance program for those with limited income. Social Security provides benefits and assistance to retired people and to people who are unemployed or disabled.
Medicare and Social Security are linked. Both serve people 65 and over as well as those receiving Social Security Disability Insurance due to a disability. To enroll in Medicare, you must sign up through the Social Security Administration.
If you choose a Medicare Advantage plan there are two options:
A Health Maintenance Organization (an HMO)
- You’ll use doctors in the network
- You might need a referral to see a specialist
- HMO’s generally have lower premiums than PPO’s
A Preferred Provider Organization (a PPO)
- You’re not assigned a Primary Care Physician (PCP)
- You can see a specialist without a referral if you already have health insurance (e.g., coverage through an employer or union), check to see how it works with Medicare.
Who is eligible for Medicare? Generally, people who are:
- Ages 65 or over
- Under 65 with a qualifying disability
- Ages 21 and over who qualify due to end-stage renal disease
There are premiums for Medicare insurance. If you have a limited income, you may qualify for a program called Extra Help to pay for your monthly plan premium and prescription drugs.
Medicare Has Four Parts
Covers hospital insurance
Covers medical insurance, like doctor visits
In addition to Part A and Part B (Original Medicare) you have the option to purchase:
- Part D (a separate prescription drug plan
- Supplemental insurance, sometimes called MediGap or MedSupp plans
MediGap and MedSupp plans usually cover items such as:
- health care you get outside the U.S.
They usually don’t help cover:
- vision care and eyeglasses
- hearing aids
- dental care
- long-term care
- private-duty nursing
Original Medicare does not cover expenses incurred by you if you are traveling outside of the United States, even if it is an emergency. Medicare Advantage plans typically have coverage for foreign travel outside the United States and Medicare Supplement plans may cover foreign travel as well. Another option is to replace Original Medicare with a Medicare Advantage plan.
Medicare Advantage Plans
Help pay for prescription drugs
Part C: Medicare Advantage
- Can be purchased from private insurance companies such as Virginia Premier
- Allows you to choose a private insurance company such as Virginia Premier to receive your Medicare coverage
- Combines Part A and Part B into one plan for full coordination of your care and usually includes a Part D prescription drug plan
- Medicare Advantage provides most of what Original Medicare covers and can also include additional benefits like dental, hearing, vision, wellness services and a nurse phone line
To be eligible for Medicare Parts C & D you must:
- Reside in the approved service area
- Have Parts A & B
- Not be diagnosed with end-stage renal disease
Frequently Asked Questions
I’m still working and on my employer’s health insurance plan. When I turn 65, do I need to sign up for Part B during my Initial Enrollment Period?
No. You can wait until you’re ready to retire and move off your employer plan or your spouse’s insurance plan if that is an option. When you do so, you’ll be eligible for a Special Enrollment Period and have an eight-month window to sign up for Part B. The eight-month period begins when your employer or union coverage ends or when your employment ends, whichever is first. Be sure to elect Part B at that time so you don’t have to pay a lat e enrollment penalty. That penalty is 10% a year for late enrollment.
If I’m covered for Medicare, is my spouse automatically covered as well?
No. Medicare is an individual enrollment. Both you and your spouse must sign up for coverage and the policies are not related. There is no family coverage under Medicare.
If I enroll for Medicare Parts A and B with Social Security, do I also enroll for Part D prescription drug coverage?
No. Part D is not related to your Original Medicare coverage. It is additional coverage for prescription drugs your doctor prescribes. You must enroll with a private insurance plan that contracts with Medicare. You have two choices: you can take Original Medicare and then sign up with a Part D plan or you could enroll in a Medicare Advantage Part C plan that has prescription drug and medical in an all-in-one plan.
When I decide to enroll in Medicare and choose a Medicare Advantage plan do I need to stay with the same insurance company I had with my employer?
No. When you leave your employer and no longer have health insurance coverage you can choose a Medicare Advantage plan from any company that offers service in your area. Or you may stay in Original Medicare and buy a Medicare Supplement plan and a Part D prescription drug plan.
Does all Medicare private coverage have annual open enrollment periods?
No. It’s important to know the difference before you enroll: For Medicare Advantage and Medicare Part D prescription drug plans, there’s an annual open enrollment period (October 15 to December 7, with enrollments effective January 1 of the coming year). During this time, you can switch to any other Medicare Advantage or Part D plan available in your area, regardless of your medical history.
There’s no annual open enrollment period for Medicare Supplement plans. You can apply for a Medicare Supplement plan anytime, but after your initial seven-month enrollment window has passed, the carrier can use your medical history to determine your eligibility and premium. However, states can impose their own regulations for Medigap plans. If you’re in good health, you’ll be able to switch to a different Medicare Supplement plan, but some Medicare Supplement plans are priced based on the enrollee’s age when the plan is issued, so they’ll be more expensive if you enroll later, even if you’re healthy
If you have questions, check with your State Health Insurance Program — the Virginia Counseling and Assistance Program (VICAP). VICAP offers free unbiased, confidential counseling on health insurance, education and assistance to seniors and adults with disabilities and their families. This program can help in understanding Medicare and making decisions about prescription drug plans, Medicare Advantage plans, Medicare Supplement plans or long-term care insurance.
How can I reach VICAP?
Write to: Virginia Division for the Aging (DARS),1610 Forest Avenue, Suite 100, Richmond, Virginia 23229
Toll-Free: 1-800-552-3402 (Nationwide Voice/TTY)