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Qualifying for Medicare

You qualify for Medicare if one of the following applies to you:

• You're age 65+ and eligible for Social Security or Railroad Retirement Board benefits. You may already be receiving these benefits.
• You're age 65+ and you or your spouse had Medicare-covered government employment.
• You're under age 65 and have received Social Security or Railroad Retirement Board disability benefits for 24 months.
• You may also qualify if you've been diagnosed with End Stage Renal Disease (ESRD) or Lou Gehrig's Disease (ALS).

Medicare Parts

Medicare as we know it today was passed in two different pieces of legislation. The first piece of legislation in 1965 established Medicare Part A and Part B. These parts are also referred to as Original Medicare and are managed by federal organizations.

The second piece of Medicare legislation was passed in 2003. It established Part C and Part D to provide a private Medicare option and better coverage for prescription drugs.

Here's the breakdown of each of Medicare's parts:

Part A — Hospital insurance that covers medically necessary hospital or skilled nursing facility stays, but not long-term or custodial care. It also covers hospice and some home health care — physical and occupational therapy.

Part B — Medical insurance that covers medically necessary treatment, preventive care, Durable Medical Equipment, and outpatient services.

Part C — Private insurance plan that offers the same coverage as Part A and Part B under one plan. Many also include qualifying prescription drug coverage. Often called Medicare Advantage plans, these plans usually include additional coverage and perks like fitness memberships, as well as dental, vision, and hearing coverage. Additional perks and coverage vary by company.

Part D — Separate prescription drug coverage offered by private insurance companies. These plans are usually for people with Part A and Part B. If your Medicare Advantage plan has qualifying drug coverage, then you cannot buy a Prescription Drug Plan (PDP).

Medicare Supplement Insurance — Not technically a part of Medicare, but offers additional coverage for out-of-pocket costs from Part A and Part B. These Medigap plans are offered by private insurers and are standardized by the government Plan A, B, C, D, F, G, K, L, M, and N. You may be able to buy a high deductible option for Plan F and Plan G depending on what's available in your state. Massachusetts, Minnesota, and Wisconsin have different Medigap plans than the rest. Medicare supplement plan availability varies by state. Certain states have not approved all Medigap plans for sale.

Medigap Plans

Medigap plans offer a combination of the following:

• Coinsurance and hospital expenses for an additional 365 days after Medicare benefits max-out (all Medigap plans)
• Coinsurance and copays for Part B (all Medigap plans offer varying levels of coverage)
• First three pints of blood (all Medigap plans offer varying levels of coverage)
• Hospice coinsurance or copay (all Medigap plans offer varying levels of coverage)
• Skilled nursing facility care coinsurance (Plans C, D, F, G, K, L M, N offer varying levels of coverage)
• Part A deductible (Plans B, C, D, F, G, K, L, M, N)
• Part B deductible (Plan C and Plan F)
• Part B excess charge (Plan F and Plan G)
• Foreign travel, coverage subject to plan limits (Plans C, D, F, G, M, N)
• Out-of-pocket limit (Plan K and Plan L)

Massachusetts Medigap Plans

Massachusetts offers three Medigap plans. All plans cover the following:

• Partial coverage for Part A coinsurance for days 61 through 150 and full coverage for an additional 365 days of inpatient hospital care
• Part B coinsurance, usually at 20 percent of the Medicare-approved amount
• First three pints of blood annually
• Hospice coinsurance or copay

The Core Plan also covers inpatient mental health hospital stays 60 days per calendar year.

The Supplement 1 Plan extends the mental health hospital stay coverage to 120 days and offers coverage for the Part A deductible for the first 60 days of hospital stays, skilled nursing facility coinsurance days 21 through 100, and coverage for the Part B deductible. It also offers coverage for Medicare-covered services needed while traveling out of the country. 

The Supplement 1A Plan offers the same coverage as the Supplement 1 Plan, but does not cover the Part B deductible.

Minnesota Medigap Plans

It's trickier to say what Medigap coverage is available in Minnesota. The state's site lists nine plan options with limited information on the coverage offered by each. The federal Medicare site only lists two plan options with more details on what they cover. We'll review that information here.

Both the Basic and Extended Basic plans cover Part A coinsurance for inpatient hospital care, Part B coinsurance, the first three pints of blood each year, and out-of-pocket costs for hospice, respite care, and home health services and supplies. These plans also cover state-mandated benefits like diabetic equipment and supplies, cancer screening, immunizations, and reconstructive surgery.

The Basic Plan also covers skilled nursing facility Part A coinsurance for 100 days, foreign travel emergency at 80 percent, outpatient mental health at 50 percent, Medicare-covered preventive care, and physical therapy at 20 percent.

The Extended Basic Plan offers the same coverage as the Basic Plan, but it also covers care in foreign countries and extends skilled nursing facility coinsurance to 120 days.

Wisconsin Medigap Plans

Wisconsin's basic Medigap benefits include coverage for Part A coinsurance for inpatient hospital care, Part B coinsurance, the first three pints of blood annually, and Part A hospice coinsurance or copay.

The Basic Plan covers these and skilled nursing facility coinsurance, an additional 175 days per lifetime of inpatient mental health coverage, and an additional 40 home health care visits. It also offers coverage for state mandated benefits, though these are unspecified on Medicare.gov.

You can also buy plans similar to Plan K and Plan L. These are called the 50% Cost-Sharing Plan and the 25% Cost-Sharing Plan. There is also a high-deductible plan option.

You can customize your Medigap plan with the following riders:

• Part A deductible (full or 50 percent)
• Part B deductible (not available to new Medicare enrollees after January 1, 2020)
• Part B copayment or coinsurance
• Part B excess charges
• Extra home health care visits
• Emergency coverage for foreign travel

Availability of these riders may vary by insurer.

Medicare Costs

Like health insurance plans, Medicare has monthly premiums, deductibles, coinsurance, and out-of-pocket costs. Monthly costs and cost-sharing rules vary by part.

Check out our Medicare Guide to learn more about the cost, enrollment, and coverage offered by each Medicare Part.

Part A

Premiums — $0 if you or spouse have been employed and paid Medicare taxes for at least 10 years. If not eligible for free monthly premiums, the monthly premiums are set annually. If you or your spouse have at least 30 quarters of Medicare-covered employment, you'll pay a reduced monthly premium.
Deductible — changes annually
Coinsurance after the deductible — changes annually, different amounts for inpatient hospital day 61 through 90, lifetime reserve days, and skilled nursing facility care
Annual out-of-pocket max — None

Part B

Premiums — based on income from two years ago and vary year to year. Payment is automatically taken from Social Security benefits. Be aware of late enrollment penalty assessed on the premium, which can increase costs by 10 percent per 12-month period.
Deductible — changes annually, typically lower than the Part A deductible
Coinsurance after the deductible — usually 20 percent of the Medicare-approved amount
Annual out-of-pocket max — None

Part C

Premiums — set by private insurers and vary
Deductible — set by private insurers and varies
Cost-sharing — set by private insurers and varies
Annual out-of-pocket max — set by private insurers and varies

Part D

Premiums — set by private insurers and vary. Watch out for late enrollment penalties assessed on monthly premiums if you do not have prescription drug coverage for a continuous 63 days or more after your initial enrollment period ends. If your income is above a certain amount, you'll pay an additional Income-Related Monthly Adjustment Amount (IRMAA) to Medicare, not your insurer.
Deductible — varies by plan, annual limits set by Medicare
Cost-sharing — varies by plan and how each medication is classified. Understand what the annual threshold for your insurer's and your spending on prescriptions that trigger the coverage gap, or doughnut hole.
Annual out-of-pocket max — set annually by Medicare. Once you reach this amount, you're out of the coverage gap and will only pay small amounts of coinsurance or copays — called catastrophic coverage.

Medigap

Premiums — vary by plan
Deductible — not applicable
Cost-sharing — varies by plan
Out-of-pocket max — applies to some Medigap plans. Annual limits vary by plan.

Medicare Advantage vs Medicare Supplement Insurance

Medicare Enrollment

Each part of Medicare has a different method for enrollment. 

Part A — Enrollment is automatic if you are receiving Social Security benefits and over age 65. If your enrollment is not automatic, you can enroll online, over the phone, or in person at your local Social Security office.

Part B — Must be enrolled in Part A and complete application to enroll for the Social Security Office.

Part C — Once you find a plan you like, you'll work with the insurance company to complete enrollment. These plans change year-to-year, so check your plan each year during Medicare Annual Election Period.

Part D — Work with the insurer offering the plan you want to enroll. You can also view options through Medicare's Plan Finder, use a comparison site, work with a licensed agent, or work directly with the carrier.

Medigap — Work with the insurer offering the plan to enroll. Use comparison websites to compare costs.

Medicare Enrollment Periods

Initial Enrollment Period (IEP) — The seven-month period when you first become eligible to be a Medicare beneficiary. It starts three months before your 65th birthday month and ends three months after your 65th birthday month. You can choose to enroll in Original Medicare or a Medicare Advantage plan. It's recommended to enroll in Part B during the first three months to avoid late enrollment penalties.

Medicare Supplement Open Enrollment — If you opt for Original Medicare during your IEP, your Medicare Supplement Open Enrollment period will start. During this period, you can enroll in a Medigap plan without answering health questions for underwriting. You can enroll in a Medigap plan later, but you will need to complete underwriting.

Read more about Medigap:

• 5 Questions to Ask About Medigap
• What You Should Know about the Medigap Underwriting Process

Special Enrollment Period (SEP) — Allows people covered by a group plan to enroll in Part A and Part B outside of their IEP. If you're a volunteer in a foreign country, you may also be eligible. Your SEP starts the month after your employment ends and lasts eight months.

COBRA is not eligible for an SEP. You'll avoid late enrollment penalties if you qualify for an SEP. It's recommended to stop contributions to a Health Savings Account (HSA) six months before you apply for Medicare.

General Enrollment Period — Allows you to enroll in Medicare if you missed your IEP and do not qualify for an SEP. You may have late enrollment penalties assessed on your premiums for Part A and Part B. It runs January 1-March 31 each year.

Annual Election Period (AEP) — Also called Annual Enrollment Period. Anyone enrolled in Medicare is eligible. You can switch between a Medicare Advantage plan and Original Medicare and vice versa. You can also enroll in a different Medicare Advantage plan from your current one or enroll in a different prescription drug plan from your current drug plan.

Prescription drug plan members can also cancel their plan. If you've never had a drug plan, you can buy one. All changes you make will happen January 1 of the following year. Work with a trusted advisor to understand whether late enrollment penalties will apply and other consequences changes may have.

Read more about Annual Election Period:

• 5 Answers That Clear Up Medicare Annual Election Period Confusion
• 3 Ways to Prepare for Medicare Annual Enrollment
• 5 Pitfalls to Avoid During Medicare Annual Enrollment

Medicare Advantage Open Enrollment — Allows people on Medicare Advantage plans to change to a different Medicare Advantage plan or enroll in Original Medicare. If you switch to Original Medicare, you can also enroll in a prescription drug plan. This enrollment period runs each year from January 1 to March 31.