A Medicare guide – Learn about open enrollment, plan options and much more

Medicare is…complicated. You must be wondering whether to enroll in Original Medicare or a Medicare Advantage Plan, what sort of coverage you’re qualified for, whether to sign up for prescription medication coverage and more.

Medicare open enrollment

Your circumstances determine when you may enroll in Medicare or alter your plan.

If you’ve never had Medicare, the open enrollment period starts three months before you turn 65 and lasts for seven months. That’s also called the initial enrollment period. So, for example, if you’re turning 65 in November, you can enroll from August through March. If you miss this opportunity and sign up later, you’ll be penalized, so plan ahead.

These regulations determine Medicare eligibility:

If enrolled before 65, coverage starts the month you turn 65.

Coverage starts next month if enrolled in the fourth month of the initial enrollment period.

If enrolled in the fifth month of the initial enrollment period, coverage starts two months later.

If you enrolled in the sixth month, coverage begins three months later.

For those currently enrolled, open enrollment for next year, also called the annual election period, is Oct. 15-Dec. 7. You can change plans or enroll at this time. These changes are effective Jan. 1. Annual election changes include:

Original-to-Advantage Medicare switches and vice-versa

Switching between Medicare Advantage plans

Switching between Part D plans

Part D enrollment

Other conditions follow enrollment periods: There are special enrollment periods for those who’ve been through some life changes like losing insurance, moving, qualifying for financial aid, and more. See Medicare.gov for more.

General Medicare enrollment spans from Jan. 1 to Mar. 15. That’s for people who didn’t sign up for Medicare Part A or Part B when first eligible and don’t have a special enrollment period. Coverage for those who sign up during this time starts Jul. 1.

Medicare eligibility:

Medicare enrollment isn’t mandatory. Many still-working Medicare-eligible persons choose not to enroll or delay enrollment. So, which categories of people are eligible for Medicare?

U.S. residents 65 and older are U.S. citizens or have lived in the country for at least five years before applying.

Social Security, Railroad Retirement, and SSDI recipients

Certain patients with end-stage renal illness or Lou Gehrig’s disease

24-month Social Security Disability recipients

If you have more questions, check Medicare.gov for eligibility and the monthly premium calculator.

Medicare plans and coverage types

Original Medicare and Medicare Advantage are the main Medicare programs. Original Medicare is government-funded. Here are some facts about these plans:

They include Medicare Part A (hospital insurance for inpatient care, skilled nursing care, and specific home health and hospice care) and Medicare Part B (doctor and provider services, outpatient care, home health care, durable medical equipment, and some preventive services).

They allow specialist visits without pre-approval.

Premiums, deductibles, and coinsurances are required.

You can enroll in supplemental Medigap insurance to lower out-of-pocket payments.

Medicare Part D prescription medication coverage is not included; instead, it’s solely offered by commercial insurers.

People who have paid Medicare taxes long enough are entitled to free Medicare Part A, but Part B requires premiums.

Private insurance firms manage Medicare Part C, generally known as Medicare Advantage. HMOs, PPOs, and private fee-for-service plans are typical Medicare Advantage programs. General information concerning these plans:

They integrate Parts A and B with dental, eye, and hearing care.

They often cover prescriptions.

They usually involve a particular network of doctors from which you must choose.

They might require a referral for a specialist visit.

Some medication expenditures or services may need approval.

They often have lower out-of-pocket expenses than Original Medicare plans.

Private companies provide two more supplemental insurance plans. Medicare Part D covers prescription medicines. You can buy this supplement insurance with Original or Advantage Medicare plans that don’t cover prescription medication.

Medigap supplements Original Medicare but not Medicare Advantage. Medigap is optional and offered by private insurance companies. These plans cover deductibles, coinsurance, and copays after Original Medicare pays its half. In addition, Medigap insurance may cover expenditures Original Medicare doesn’t, such as care received when abroad.

Each Medigap plan has identical coverage, but rates vary by insurer. Depending on where you reside, you may be able to select from up to ten different Medigap insurance available in your state. Before you get Medigap insurance, do your homework.

What to ask when enrolling in Medicare

Now that you know your Medicare options, ask these questions before enrolling:

What are your health expenses now? First, estimate your yearly out-of-pocket expenses, like premiums, copays, coinsurance, and deductibles. That’ll help you make informed modifications or choices. Then compare the costs of the plans you’re considering and estimate costs for any service you wish to receive.

Which physicians accept Medicare and are in your plan’s network? That might affect your chosen plan since you’ll probably want to keep your trusted providers. This especially applies to Medicare Advantage plans.

Do you have retiree insurance that covers particular health care expenses? For instance, many retirees have medication coverage. In that case, you won’t need Part D and can select Original Medicare over Medicare Advantage.

Do you need any specific coverage? Consider your health and for what you’ll use your insurance. For example, a  Medicare Advantage plan may be beneficial if you need a lot of dental or vision treatments.

What trade-offs are you ready to accept? For example, a Medicare Advantage plan may have higher premiums but lower out-of-pocket expenses. In contrast, Original Medicare offers a more extensive network of physicians and lets you see specialists without a referral.

Can you get cost-reduction programs? If you qualify, use state and federal programs like Medicaid to help pay for Medicare costs.

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