How Does Medicare Work?
Medicare is a federal health insurance program that provides benefits to American citizens and permanent legal residents (of at least five continuous years) aged 65 and older, or who have a qualifying disability or illness. Most people are automatically enrolled into Original Medicare, Part A and Part B, when they become eligible; however, some people need to manually enroll in Medicare. Medicare Part A is hospital insurance; Medicare Part B is medical insurance.
You may want to take a look at these Medicare plan options.
Medicare Advantage (Medicare Part C) gives you a way to get your Original Medicare coverage through a private, Medicare-approved insurance company instead of directly through the government. Medicare Advantage plans provide all your Medicare Part A and Part B benefits other than hospice care, which Part A still covers. But many Medicare Advantage plans include extra benefits, such as routine dental and vision services. And most Medicare Advantage plans include prescription drug coverage, letting you get all your Medicare benefits through a single plan. You still need to continue paying your Medicare Part B monthly premium, besides any premium the Medicare Advantage plan might charge.
If you stay with Original Medicare, be aware that prescription drugs aren't covered in most situations. Medicare Part D offers prescription drug coverage through private, Medicare-approved insurance companies. You may want to consider adding a stand-alone Medicare Prescription Drug Plan.
If you decide to stay with Original Medicare, another option you may have is to sign up for a Medicare Supplement (Medigap) insurance plan to help pay for Original Medicare's out-of-pocket costs. Different Medigap plans pay for different amounts of those costs, such as copayments, coinsurance, and deductibles.
Availability and costs of Medicare plan options may vary from one insurance company to another, and from one geographic area to another.Back to TopDo I need Medicare Part A or Part B if I am still working?
This depends on your situation. If you've worked at least 10 years (40 quarters) under Medicare-covered employment and paid Medicare taxes during that time, you qualify for premium-free Medicare Part A and will be automatically enrolled at age 65 even if you're still working. If your spouse has enough employment quarters, you can also qualify for premium-free Medicare Part A based on his or her work history.
Another Medicare eligibility requirement is that you need to be an American citizen or permanent legal resident of at least five continuous years.
If you don't have enough work history to get Medicare Part A without paying a premium, you can decide to delay enrollment if you already have health coverage through an employer or union (or through your own work or your spouse's employer). Medicare Part B always comes with a monthly premium, so you may similarly choose to delay your Part B enrollment if you or your spouse are still working and have employer-based group coverage.
Remember, if you don't sign up for Medicare when you're first eligible and don't have other coverage based on current employment, you could have to pay a late-enrollment penalty later when you do enroll. The late-enrollment penalty applies to Medicare Part B (and Part A, if you have to pay a premium for it).
One factor to consider is that even if you have health coverage through your employer or union, Medicare may help pay for some of the costs not covered by your group health plan. For example, enrolling in Medicare may be useful if you work for a small company (less than 20 employees) because Medicare could be the primary payer before your group health insurance. You may want to consult with your employer or union benefits administrator for specifics on how your health coverage and costs may compare with Medicare.
If you do decide to wait until your group coverage ends to enroll in Medicare Part A and/or Part B, you'll have an 8-month Special Enrollment Period to sign up for Medicare that starts once you stop working or your group coverage ends (whichever happens first). You can also enroll in Medicare at any time that you are still working and have employer-based coverage.
If you choose COBRA after you stop working, do not wait until your COBRA coverage ends to sign up for Medicare. If you delay enrolling in Medicare Part A and/or Part B after your Special Enrollment Period ends, you'll have to wait until the next General Enrollment Period (January 1 to March 31 every year) to enroll, and you may have to pay a late-enrollment penalty.Back to TopWhich doctors accept Medicare assignments?
Not every doctor may accept Medicare assignment (a payment agreement). Doctors who have been approved to accept Medicare assignment can fall into any of the following categories:
Participating doctors accept Medicare assignment, meaning that they accept the Medicare-approved amount as payment for their services. These doctors charge the Medicare program 80% and the beneficiary 20% of the cost of the benefit.
Non-participating doctors can choose to either accept or not accept Medicare assignment. If the doctor does not accept Medicare assignment, you might have to pay a 15% additional charge above the cost of the service, known as a Medicare excess charge. You would then be responsible for up to 35% of the reduced Medicare-approved amount instead of 20%.
Doctors who have opted out of Medicare may charge you whatever they see fit for services and supplies, and you are responsible for the full cost of these benefits.
To find a participating doctor in your area, you may use the Medicare.gov Physician Compare tool. This tool will help you find an approved Medicare doctor based on medical specialty, geographical area, or doctor's name. In addition to finding Medicare-approved physicians, this tool provides information about each doctor, along with maps and directions to help you find the doctor's office.Back to TopWhat is the "Welcome to Medicare" physical exam?
The "Welcome to Medicare" physical exam is a one-time, preventive physical exam Medicare covers within the first 12 months that you have Medicare Part B. The visit will include a thorough review of your health, along with education and counseling about the preventive services you need, like certain screenings, shots, and referrals for other care.
This visit is a great way to get up-to-date on important screenings and shots and to talk with your doctor about your family history and how to stay healthy. During the “Welcome to Medicare” visit, your doctor will record your medical history and check your vision, blood pressure, and weight and height to measure your body mass index (BMI). Body mass index is a measure of body fat that applies to both adult men and women.
Your doctor will check that you are up-to-date with preventive screenings and services, such as cancer screenings and immunizations. Further tests may be ordered, if necessary, depending on your general health and medical history. Your doctor will also give you advice to help you prevent disease, improve your health, and stay well. You will get a written plan (such as a checklist) when you leave, letting you know which screenings and other preventive services you should get in the future.
Your doctor will also talk with you about creating advance directives. Advance directives are legal documents that explain in writing what kind of health care you would want if you were too ill to speak and/or make decisions for yourself. Talking to your family, friends, and health care providers about your wishes is important, but these legal documents help ensure your wishes are followed.
When do I get my "Welcome to Medicare" exam?
Once you enroll into Medicare Part B, schedule your “Welcome to Medicare” preventative visit right away. Medicare will only cover this physical exam if it occurs within the first 12 months from when you enroll into Medicare Part B.
If you've had Medicare Part B for over 12 months, you can get a yearly "Wellness" visit instead. This visit is also covered and can help you and your doctor develop a personalized health plan.
How much does the exam cost?
You pay nothing for your “Welcome to Medicare” preventative visit or the yearly “Wellness” visits if the doctor or health care provider accepts assignment. If you have additional tests or receive other services during this visit that aren’t covered under these preventative benefits, you may have to pay coinsurance and the Medicare Part B deductible may apply.
What should I bring with me to the exam?
You should bring the following things with you when you go to your “Welcome to Medicare” visit:
Medical records, including immunization records.
A list of prescription drugs, as well as over-the-counter drugs and supplements that you currently take, how often you take them, and why.
Family health history. Try to learn as much as you can about your family's health history before your appointment.
Any information you can give your doctor to help determine if you are at risk for certain diseases.Back to TopDo I need to renew Medicare coverage?
In general, once you're enrolled in Medicare, you don't need to take action to renew your coverage every year. This is true whether you are in Original Medicare, a Medicare Advantage plan, or a Medicare prescription drug plan. As long as you continue to pay any necessary premiums, your Medicare coverage should automatically renew every year with a few exceptions as described below.
There are some exceptions where you'll need to take action to continue your coverage. Some situations where your Medicare Advantage or stand-alone Medicare Part D prescription drug plan coverage won't be automatically renewed include, but aren't limited to:
- Your plan reduces its service area, and you now live outside of its coverage area.
- Your plan doesn't renew its Medicare contract for the upcoming year.
- Your plan leaves the Medicare program in the middle of the year.
- Medicare terminates its contract with your plan.
If your Medicare plan doesn't renew its contract with Medicare for the coming year, your Special Election Period will run from December 8 to the last day of February of the following year. If you have Medicare Advantage and don't enroll in a new plan by the date that your current plan ends its contract with Medicare, you'll be automatically returned to Original Medicare.
Keep in mind that your new coverage starts on the first day of the month after you submit your enrollment application, meaning if you apply on February 8, your new Medicare plan wouldn't begin until March 1.
You'll also get a three-month Special Election Period if your Medicare Advantage or Medicare Part D Prescription Drug Plan terminates its contract with Medicare. This period starts two months before the contract ends and runs an additional month after the contract ends. If Medicare terminates your plan's contract, you will have a Special Election Period that begins 1 month before the termination effective date and ends 2 months after the effective date of the termination.
While you may not need to renew your Medicare coverage, it's still a good idea to review your coverage annually. Benefits, provider and pharmacy networks, drug formularies, and cost sharing can all change from year to year and affect how much you pay out of pocket. Comparing plans annually is one way to make sure your coverage continues to meet your health needs and budget.
If you need help finding a plan that could work for you, you can type your zip code into the form on this page to see a list of Medicare plans in your vicinity.Back to Top