A Guide to Understanding Medicare Eligibility and Enrollment

There is a lot of information out there about Medicare and other health insurance options. eHealth’s Medicare content is compliant with CMS regulations and provides reliable information that can help you make the best decisions for your individual situation.

You can enroll in Medicare during a seven-month window that begins three months before your 65th birthday and continues for three months after. This is called your Initial Enrollment Period.

What is Medicare?

The Medicare program is the federal health insurance that covers the costs of hospitalizations, doctor’s visits, prescription drugs and some other medical services. It also pays the cost of some long-term care services, such as home health care and hospice care. It also pays for some of the costs of durable medical equipment, and it helps pay for some preventive care. There are several plans you can avail, such as the aetna medigap plan g.

The center that oversees Medicare is the Centers for Medicare & Medicaid Services, or CMS. It is responsible for determining eligibility and enrollment for Medicare Part A, Part B, Part C and Part D of the Medicare program. It is also responsible for making Extra Help payments, low income subsidies, and Medicare Advantage plan contracts, among other responsibilities.

Medicare was created in 1965 to provide people over age 65 with the health coverage they need as they enter retirement, and it is one of the most important social programs that the United States has ever built. Today, it is a vital source of health care for nearly 60 million beneficiaries.

Most traditional Medicare beneficiaries receive their benefits through Original Medicare, also known as Traditional Medicare or Fee-for-Service Medicare. Beneficiaries in this program are able to visit any doctor or hospital that accepts Medicare anywhere in the country, and they typically pay no monthly premium for Part A. In addition, most traditional Medicare beneficiaries choose to enroll in Medicare Advantage Plans, which are sponsored by private health care companies (including integrated health delivery systems or spin-outs, unions, religious organizations, and some insurers) that offer Medicare-covered Part A and Part B services but have different rules, costs and restrictions.

People may also choose to join Medicare Advantage Plans that offer supplemental coverage, like vision and hearing aids. However, these plans usually have network restrictions.

Who is Medicare for?

People ages 65 and over and people with certain disabilities under age 65 may enroll in Medicare. The program is financed by a combination of payroll taxes paid into Social Security by employees and employers and general revenues from the federal government. Beneficiaries share the cost of the program through deductibles and copayments for some services. In addition, Medicare beneficiaries often have private group health insurance or other supplemental insurance coverage that pays some of their medical costs.

Individuals who miss their SEP due to conditions beyond their control may be able to enroll during a Special Enrollment Period. To qualify, an individual must provide documentation or written attestation that shows the circumstances were extraordinary and outside their control. Individuals who do not qualify for a Special Enrollment Period will have to wait until the next GEP. If they do not sign up during the GEP, they will have to pay a late enrollment penalty.

Some individuals have the option to sign up for Part B and premium Part A without paying a late enrollment penalty, if they do so during an SEP. These SEPs occur when an individual’s employment or a spouse’s employment ends, the individual is disenrolled from their employer-sponsored group health plan, or their ESRD treatment is completed.

Individuals should complete form CMS-40B or a similar enrollment form for Part B to use during this SEP. If they need to enroll in premium Part A, they should complete form CMS-L564. Individuals who are applying for the SEP for Working Aged and Working Disabled should also include form CMS-10797. Enrollment forms can be found in the downloads section of this page. These enrollment forms are also available in Spanish.

How do I enroll in Medicare?

You generally sign up for Medicare during a seven-month window that begins three months before your 65th birthday and ends the month after. This is called your Initial Enrollment Period, or IEP. If you don’t enroll during this period, your coverage won’t start until July of the following year and you may have to pay a monthly penalty.

The good news is that you can still apply during the General Enrollment Period that runs from January 1 to March 31 each year. Your coverage will begin the month after you enroll, and you’ll usually pay a penalty for late enrollment. This penalty is tacked on to your monthly premium (what you pay each month for health care coverage).

There are some exceptions. People who receive Social Security disability benefits or Railroad Retirement Board disability benefits get Medicare automatically, as do those with End-Stage Renal Disease and Amyotrophic Lateral Sclerosis (ALS, or Lou Gehrig’s disease). People can also sign up for Medicare earlier than age 65 if they’ve been receiving SSDI or RRB disability benefits for at least 24 months, have ESRD or ALS, and meet other criteria.

Those who miss their IEP have to wait until they qualify for a Special Enrollment Period to make changes to their Medicare plans. These SEPs are based on certain events in your life, such as losing group health plan coverage from current employment. You can find more information on the SEPs and how to apply in this Medicare guide. People who are enrolled in Medicare Advantage plans — all-in-one Medicare options offered by private health insurance companies — can usually change their plans between open enrollment periods without paying penalties.

Are there programs that help lower Medicare costs?

Many Medicare beneficiaries face a mountain of confusing information about their health insurance options. eHealth helps you sort through it all by providing trusted information to help you make informed decisions about your coverage. You can rest assured that our content is compliant with CMS regulations and our team of experts is here to answer any questions you may have about your Medicare coverage.

Generally, you’re eligible for Medicare when you turn 65 or are receiving retirement or disability benefits from Social Security or the Railroad Retirement Board. You also might be able to get Medicare earlier if you or your spouse paid Social Security payroll taxes for a specified amount of time and have End-Stage Renal Disease (permanent kidney failure that requires dialysis or a transplant) or Lou Gehrig’s disease (ALS).

If you’re a new Medicare beneficiary, the SSA will send you an enrollment package about three months before your birthday. In most cases, the SSA will automatically enroll you in Parts A and B, and you’ll receive your Medicare card shortly thereafter. But if you don’t want this coverage, you can choose not to sign up or decline it at that time without paying a penalty later on.

There are several Special Enrollment Periods that you can use to change your Medicare coverage. These periods vary depending on your circumstances, but they all allow you to enroll in premium Parts B and C or Medicare Advantage, as well as change from one plan to another during certain time frames.

What are my options?

There are a few different ways to get Medicare coverage. You can enroll in Original Medicare (Parts A and B), or you can sign up for a Medicare Advantage Plan, which combines Parts A and B into a private insurance plan that also typically covers prescription drugs and other health care services.

You can enroll in Medicare during your Initial Enrollment Period, which is the 7-month window that starts 3 months before you turn 65, ends the month of your birthday, and continues 3 months afterward. It’s also possible to get Medicare benefits earlier if you have a disability, end-stage renal disease, or amyotrophic lateral sclerosis (ALS, Lou Gehrig’s Disease).

If you miss the Initial Enrollment Period or are still working and covered by an employer group health plan, you can still sign up for Medicare during the General Enrollment period between January 1 and March 31 each year. Your coverage will then begin July 1. You may be charged a 10% surcharge for each year you sign up for Part B after your Initial Enrollment Period.

If you’re already enrolled in a Medicare Advantage Plan and want to change your plan, you can do so during the Annual Enrollment Period from Oct. 15 – Dec. 7. You may be subject to a late enrollment penalty for changing plans, however, unless your current plan is no longer accepting new members or you lose your Medicaid eligibility. Learn more about Medicare and its special enrollment periods to understand when you can change your plan or add or drop coverage. A licensed Medicare agent can help you decide the best options for your unique situation. Find one in your area.

Rebecca Alderson
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