Frequently Asked Medicare Questions

If you get benefits from Social Security or the Railroad Retirement Board, you are automatically eligible for Medicare starting the first day of the month you turn 65.

If you are under 65 you are eligible to receive Part A benefits under the following circumstances:

• You have been receiving Social Security Disability Insurance for more than two years.
• You have permanent kidney failure (end-stage renal disease requiring ongoing dialysis or a kidney transplant. You have been diagnosed with amyotrophic lateral sclerosis (Lou Gehrig’s disease). 

Resources:

• An Overview of Medicare Benefits
• Medicare & You 2018

Medicare Part A, also known as the Hospital Insurance program, helps cover the costs of care in the following facilities:

• Inpatient care in hospitals
• Inpatient care in a skilled nursing facility
• Inpatient rehabilitation facility
• Hospice care services
• Some home health care services
• Inpatient mental health and psychiatric care

If you are eligible for Medicare you will not have to pay a monthly premium for Part A if you or your spouse paid Medicare payroll taxes while working.

If you and your spouse did not work or did not pay enough Medicare payroll taxes you may not be eligible for premium-free Part A. However, you may be able to purchase Part A by paying a monthly premium, which is either $422/month or $232/month in 2018, depending on how many years you paid into Medicare payroll taxes.

You should contact your local Social Security office 3 months before your 65th birthday to sign up.

Medicare Part B is also known as the Medical Insurance program. In general, Part B covers two types of services:

• Medical services – healthcare that you may need to diagnose and treat a medical condition. Medicare will only pay for services that they define as being medically necessary.
• Preventive services – healthcare to prevent illness (such as a flu shot) or help detect an illness in an early stage so it can be managed before getting worse (such as screening for colon cancer).
• Under Part B, Medicare helps pay for durable medical equipment such as oxygen equipment, wheelchairs, walkers, and other medically necessary equipment that your doctor prescribes to use in your home.

Most Medicare drug plans have a coverage gap, also known as the “doughnut hole.” This means that after you and your drug plan have spent a certain amount of money for covered medications, you have to pay higher out-of-pocket costs for your drugs (up to a limit). Your yearly deductible, your co-insurance or copayments, and what you pay in the coverage gap all count toward this limit.

Before the Affordable Care Act (ACA) was implemented, Medicare beneficiaries had to pay the full cost of their medications while they were in the doughnut hole. But the ACA started closing the gap in 2011. In 2018, while in the doughnut hole, Part D enrollees pay just 35 percent of the cost of their brand-name drugs, and 44 percent of the cost of generic drugs. By 2020, the doughnut hole will be completely eliminated, with enrollees paying 25 percent of the cost of their drugs (the same as they currently pay on a standard plan design below the doughnut hole).

Original Medicare (Part A and Part B) pays for many, but not all, health-related services and medical supplies. You can purchase an insurance policy to cover the “gaps” that are not paid for by Medicare, such as copayments, coinsurance, and deductibles - which can add up to a lot of out-of-pocket expenses. 

Some Medigap policies also will pay for certain health services outside the United States and additional preventive services not covered by Medicare. Medigap insurance (also known as Medicare Supplement Insurance) is voluntary and you are responsible for the monthly or quarterly premium. Medicare will not pay any of your costs to purchase a Medigap policy.

Medicare Part C, also known as the Medicare Advantage program, allows you to choose a health plan offered by a private insurance company that is approved by Medicare. Medicare Advantage plans include:

• Managed Care Organizations (such as a PPO or HMO)
• Private Fee-for-Service Plans

Medicare Advantage plans receive payments from Medicare to provide you with the benefits covered by Medicare, including Part A and Part B. Most Medicare Advantage plans include Part D drug coverage and many offer extra coverage, such as vision and hearing care, dental services, and wellness programs.

The Affordable Care Act made several changes to Medicare that have improved benefits and access to preventive care for millions of enrollees. Some significant changes include:

• Coverage Gap Savings: If you reached the coverage gap (the doughnut hole) in 2010 you received a one-time rebate check of $250 from Medicare. Starting in 2011, enrollees who reached the coverage gap began receiving a discount on their medications while in the coverage gap. The discounts have increased each year, and the coverage gap will be completely eliminated by 2020.
• Preventive Care: Beginning in 2011, Medicare now pays for an annual checkup, including a physical examination and a total elimination of cost sharing for appropriate preventive services and screenings.

You have two main choices for how you get your Medicare—Original Medicare or a Medicare Advantage Plan. If you choose Original Medicare (which includes Part A Hospital Insurance and Part B Medical Insurance), you will also have the option to enroll in a Part D Prescription Plan. You will also need to decide if you want to purchase Medicare Supplement Insurance (Medigap) to pay for the out-of-pocket costs that go along with Parts A and B.

If you choose a Medicare Advantage Plan, you will have the option to select a plan that includes prescription drug coverage. If you have a Medicare Advantage Plan, you do not need Medigap coverage.

Medicare will only pay for services that are considered to be medically necessary. According to Medicare, services or supplies are considered medically necessary if they:

• Are proper and needed for diagnosis, or treatment of your medical condition.
• Are provided for the diagnosis, direct care, and treatment of your medical condition.
• Meet the standards of good medical practice in the medical community of your local area.
• Are not mainly for the convenience of you or your doctor.

Medicare pays for certain healthcare services to prevent illness (such as a flu shot) or help detect an illness in an early stage so it can be managed before getting worse (such as screening for colon cancer). Your doctor can tell you what tests you need and how often you need them.

As a result of the ACA, Medicare enrollees get a free annual wellness visit, along with a variety of free preventive care.

Medicare covers some diabetes supplies, including:

• blood glucose test strips
• blood glucose monitor
• lancet devices and lancets, and
• glucose control solutions for checking the accuracy of test strips and monitors.

Medicare may limit how much or how often you get these supplies. Regular Medicare (ie, Part B) does not cover insulin. You will have to pay 100% for insulin (unless used in an insulin pump), syringes, and needles, unless you have enrolled in a Medicare Part D prescription drug plan or have a Medicare Advantage plan with drug coverage.

Medicare does not cover routine dental care or most dental procedures such as cleanings, fillings, tooth extractions or dentures. Medicare Part A may pay for some dental services that you get while you're hospitalized, including emergency dental surgery performed in an inpatient setting. Some Medicare Advantage plans may include dental benefits as an added benefit. Check with your Medicare Advantage plan directly to see what dental services are covered, if any.

Medicare covers services for the diagnosis and treatment of eye disease both in your doctor’s office and the hospital. This includes the treatment of glaucoma and the removal of cataracts.

Medicare does not cover the cost of a routine eye refraction or the cost of eyeglasses or contact lenses. However, following cataract surgery with an intraocular lens, Medicare will help pay for cataract glasses, contact lenses, or intraocular lenses provided by an ophthalmologist.

If you have Original Medicare (Part A and Part B), call Social Security at 1-800-772-1213, or visit www.socialsecurity.gov/medicarecard. When you request a replacement Medicare card online or on the phone, you will need:

• Your name as it appears on your most recent Social Security card
• Your Social Security Number
• Your date of birth

You should receive your replacement Medicare card in the mail in about 30 days. You can also visit your local Social Security office. 

The government is mailing new Medicare cards to all beneficiaries, starting in April 2018. The new cards use a unique identification number instead of Social Security numbers.

If you are enrolled in a Medicare Advantage Plan and lost your card, call your plan’s customer service number for a replacement.

According to Medicare, if you need a drug that is not on your Part D formulary, or that is on the list but you think it should be covered for a lower copayment, you can do the following:

• Contact the plan and ask for an exception. You will probably have to provide information from your doctor about why you need the drug your plan won’t cover.
• If your plan denies the exception, you can appeal. Your Part D plan must give you information on how to appeal.

Drugs on a Part D formulary are usually grouped into tiers, and your copayment is determined by the tier that your medication is on. A typical Part D drug formulary includes three tiers.

Tier 1 has the lowest co-payment and usually includes generic medications.

Tier 2 has a higher co-payment than tier 1 and usually includes preferred brand name medications.

Tier 3 has the highest co-payment and usually includes non-preferred brand name medications. Your plan may place a medication in tier 3 because there is a similar drug on a lower tier of the formulary that may provide you with the same benefit at a lower cost.

With very limited exceptions, Original Medicare (Parts A and B) generally doesn’t cover health care while you are traveling outside the U.S. and its territories. Some Medigap policies Foreign Travel Emergency health care coverage when you travel outside the U.S.

Some Medicare Advantage plans may provide worldwide coverage benefits for health care needs when you travel outside the United States. Before traveling outside the country, check with your Medicare Advantage plan regarding travel benefits.

If you know that you will not have Medicare-related coverage when you travel, you may want to consider purchasing a temporary travel health insurance policy.

You have several options if you need help with medical and drug costs, such as premiums, deductibles, and other out-of-pocket expenses. These options include:

• Medicaid
• Medicare Savings Program
• Extra Help and Low-Income Subsidy
• State Pharmaceutical Assistance Program
• Pharmaceutical Assistance Program

Do you have questions about Medicare? Are you having a problem with Medicare coverage or a Medicare claim? Not sure where to turn?

You also can get some of your Medicare questions answered directly from the “horse’s mouth” at the Medicare Support Center, by calling 1-800-MEDICARE.

Medicare Questions and Problems: Where to Get Help will show you the six best resources for answering your Medicare questions and resolving your Medicare problems.