Navigating health insurance can be confusing at any stage of life, but Medicare enrollment presents its own unique challenges. Part A, Part B, Medicare Advantage, Medigap—what do they all mean, and which plan is right for you?
To help untangle this complex system, EastRise partnered with Age Well, a leading organization dedicated to helping Vermonters age with confidence through advocacy, personalized guidance, and access to vital services. This guest post by Abigail Stevenson of EastRise Credit Union breaks down the basics of Medicare enrollment and introduces key resources to support you along the way.
The article features expert insight from Sharon O’Neill, State Health Insurance Assistance Program (SHIP) Coordinator at Age Well, and Caitlyn Morrison-Gillis, Care and Service Coordination Supervisor. Together, they provide free, confidential health insurance counseling to Medicare beneficiaries and their families. SHIP counselors serve as trusted navigators, helping people bridge the gap between state and federal benefits and choose the coverage that best fits their needs.
We’re grateful to Abigail and the team at EastRise Credit Union for helping bring clarity to this important topic and for their commitment to community education and financial well-being.
Getting Started
The initial enrollment period for Medicare begins when someone turns 65 or receives Social Security Disability (SSDI) for 24 months, as well as a few other exceptions.
According to O’Neill, the best place to start is with the Social Security Administration (SSA) to gather the information you need three months before turning 65. You must have coverage within three months of turning 65, or there could be a penalty assessed.
The SSA will determine Medicare eligibility, assess whether you will incur an Income Related Monthly Adjustment Amount (IRMAA) to be added to the payment of your Medicare plans, and guide your qualification for the low-income subsidy program. By starting ahead of time, you will be ready to sign up when the time comes.
It is important to note that Medicare pertains only to you. Two people cannot have the same Medicare card. “Make sure that the information that they have for you is correct. Even if you have lived at the same place for a long time, it’s best to check,” O’Neill says.
The SSA will determine how much your Medicare premium is, and the Centers for Medicare and Medicaid Services (CMS) will assist with the Medicare coverage options that are available to you. The SSA will determine your IRMAA based on IRS tax returns from two years prior to the year when you begin to pay for Medicare.
Original Medicare Costs
There are various options available for plans. In general, these are the plans that are available, and the costs associated with each:
- Part A Hospital Insurance: Most people do not pay a premium for Part A.
- Part B Medical Insurance: Most people pay a premium for this, and IRMAA if applicable.
- Part D Prescription Drug Insurance: There is a plan premium, and IRMAA if applicable.
- Medicare Supplemental Coverage (also known as Medigap): There is an optional plan premium associated with this.
Now that you have an overview of what each plan is, let’s dive a little deeper into the details for each plan.
Medicare Part A: Hospital
Part A helps to pay for inpatient care pertaining to a hospital stay, skilled nursing facility, home health care, or hospice care.
If you contributed 40 work quarters to your job, Medicare part A should be free. However, there is a deductible associated with Part A. The benefit period begins the day you enter the hospital, or skilled nursing facility, and ends when you haven’t received any hospital or skilled care for 60 days in a row.
Part A also has 20% coinsurance, meaning it will only pay 80% of the cost. For this reason, some people opt for Medigap coverage to cover the 20% cost.
Medicare Part B: Medical
This insurance helps to pay for medically necessary and preventative services, such as doctors’ services, lab tests, x-rays, ambulance transportation, durable medical equipment, and outpatient services.
Part B does carry a monthly premium, which may be adjusted higher with IRMAA, a deductible, and 20% coinsurance.
Medicare Part D: Prescription drugs
Everyone on Medicare is required to have a drug plan for coverage that is provided through insurance companies. O’Neill recommends researching and selecting the plan that covers your medications, as the plans can vary what is covered.
The best place to find this information is at medicare.gov, or by referring to the “Medicare and You” handbook for the year and state that you are enrolling.
There is a seven-month initial enrollment period when you first sign up for Part D. It begins three months before you turn 65, the month of your birthday, and then you have three months after that date.
However, the annual enrollment period is October 15 – December 7, and some specific groups or life circumstances could also qualify for a special enrollment period.
It is important to note that there is a late enrollment penalty that will accrue for someone who goes more than 63 days without creditable drug coverage. If someone has Veteran’s RX benefits, or is receiving insurance through a qualified employer, proof of creditable coverage is required to be furnished.
What Medicare does not cover
While the list is certainly longer than this, here are some examples of what is not covered by Medicare: routine foot care, eyeglasses, hearing aids, dental care, dentures, non-emergency transportation, cosmetic surgery, acupuncture, health care outside of the U.S., routine eye care, and prescription drugs (if not enrolled in Part D).
Medicare Supplemental Insurance (Medigap)
Medigap is designed to fill the gaps of what Medicare Parts A and B do not cover, such as when the 20% coinsurance kicks in. There are federally standardized plans that are listed as A through G, or K through N in Vermont.
“One thing when you’re talking about Medigap insurance… is making sure that you have a good idea of everything that’s available to you and then making the choice that works for your situation,” O’Neill says.
Head to this website to view a chart of the supplemental plans available in your state.
Now, for the mysterious Medicare Part C: Advantage Plans (Medicare Advantage)
Medicare Part C is an alternative option to Medicare Parts A and B. These plans are offered by private insurance companies that have been approved by Medicare. They offer the same coverage as original Medicare, plus additional benefits. Those benefits could include things like dental, vision, and prescription drug coverage.
What makes Part C unique is that you pay as you use the services of your providers (who must be a part of the network in the plan that you have).
“They can cost less. So, they’re good for people who cannot afford a Medigap plan,” notes O’Neill.
Usually, Advantage plans do offer drug coverage, but they are not required to. If the plan does not offer drug coverage, you are not permitted to get coverage by joining a separate prescription drug plan.
There is a special trial right period for Advantage plans. You do have the right to try an Advantage plan for a year, and if you do not like it, you can go back to a Medigap plan.
Tips to protect yourself from fraud
Ultimately, there are a lot of moving parts with Medicare, and it can be confusing. It’s best to start early, do your research, and be aware that medical fraud can happen.
Here are a few tips to protect your personal information:
- Protect your Medicare card and information. Do not provide your Medicare number to a third part insurance agent if you are just in the fact-finding stage. It should only be required to enroll.
- Use Federal websites that have .gov at the end of the URL.
- Know that Medicare will not call you at home.
- Review your Medicare statements and plan letters.
- Shred your personal records before throwing them away.
- Be aware that plans cannot ask for payment over the internet or phone.
- Door-to-door salespeople are prohibited.
You can report any suspicious activity to Age Well at 1.800.642.5119, or Medicare directly at 1.800.633.4227. Refer to the video presentation for further resources and information on how to contact Age Well for assistance.
Taking the time to get started as soon as you can to get the right information could make a difference of a smooth transition into the world of Medicare.
By Abigail Stevenson, EastRise Credit Union
Need help navigating health insurance? Are you approaching medicare eligibility or have a loved one receiving Medicare benefits?Age Well’s State Health Insurance Assistance Program (SHIP) offers free and confidential health insurance counseling.
