Consumer Resources

Medicare is the federal health insurance program for:

• Most people age 65 and over
• Certain people younger than 65 with disabilities
• People with amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease
• People with end-stage renal disease (ESRD), also known as permanent kidney failure

If you are receiving Social Security or Railroad Retirement benefits, you may be automatically enrolled. If you are automatically enrolled, you don’t need to pay a premium for Part A. For more information about automatic enrollment call Social Security at 1-(800) 772-1213.

If you are not automatically enrolled, you can enroll by calling Social Security or enroll online at www.ssa.gov.

Medicare covers health care services and items that are medically necessary and reasonable as follows:

• Medicare Part A covers inpatient hospital stays, inpatient skilled nursing facility stays, home health care and hospice care.
• Medicare Part B covers outpatient medical services such as doctor visits, diagnostic lab tests and preventative care.
• Medicare Part D covers most prescription drugs.

Note: Medicare Part C refers to Medicare Advantage (MA) plans. An MA plan is an alternative to Original fee-for-service Medicare. MA plans are sponsored by Medicare, which pays private insurance companies to provide health services to beneficiaries who enroll in these plans. For more information, see Medicare Advantage.

Part A: (Hospital Insurance) Premium

• Most people do not pay a monthly Part A premium because they or a spouse has 40 or more quarters of Medicare-covered employment.
• The Part A premium is $248.00 per month for people having 30-39 quarters of Medicare-covered employment.
• The Part A premium is $450.00 per month for people who are not otherwise eligible for premium-free hospital insurance and have less than 30 quarters of Medicare-covered employment.

Part B: (Medical Insurance) Premium

If your income is above $85,000 (single) or $170,000 (married couple), then your Medicare Part B premium may be higher than $135.50 per month. To find more information about the income-related monthly adjustment amounts or to apply for Medicare Part A or B, please visit www.socialsecurity.gov/mediinfo.htm or call Social Security at 1-(800) 772-1213 (TTY 1-(800) 325-0778).

If you have creditable prescription drug coverage (meaning it is as good as or better than the standard Medicare Part D drug benefit), you may decide not to enroll in a Medicare Part D plan or to enroll later. For example, if you have the Veterans Affairs (VA) healthcare benefits or TRICARE for Life, you have creditable prescription drug coverage.

If you do not have credible prescription drug coverage, you may be required to pay a 1% per month penalty on your future premiums for each month you went without a prescription drug plan.

Most people supplement Medicare with some other form of coverage, such as a Medigap plan, retiree plan or Veterans Affairs (VA) benefits (if they qualify). Others receive Medicare through private health plans called Medicare Advantage (MA) plans.

Both are offered by private insurance companies.

Medigap refers to a group of supplemental insurance plans that work in conjunction with your regular Medicare benefit to fill in the gaps that Parts A and B leave you with (i.e. deductibles, copays and coinsurance).

In contrast, Medicare Advantage plans are separate from Medicare. These plans are offered by private insurance companies that contract with Medicare to provide you with all your Medicare Part A and Part B benefits. Medicare Advantage plans may also cover other services, including prescription drugs. Medicare Advantage plans have different structures and may be HMOs, PPOs or Private Fee-for-Service plans (PFFS). If you are enrolled in a Medicare Advantage plan, Medicare services are covered through the plan, and Original Medicare will not pay for any healthcare services received by the enrollee.