An Overview of Medicare

Medicare is health insurance for people 65 or older, and in some cases, people with disabilities. A disability is a mental or physical problem that will last for at least 12 months, or cause death. It must be severe enough to interfere with working.

You can earn money and be considered disabled, but there is a limit to how much you can earn. The limit on earning money is related to something called substantial gainful activity (SGA). SGA looks at someone’s ability to earn money from a job. The Social Security Administration (SSA) determines that amount each year. To learn more, visit Substantial Gainful Activity on the SSA website.

There are special rules for people who are railroad workers or are at least 55 years old and blind. To learn more about whether a disability qualifies you for Medicare, you can speak with someone at the Michigan Medicare/Medicaid Assistance Program (MMAP). MMAP is a free, state-wide counseling service designed to help people with questions about health care.

The Different Parts of Medicare

There are multiple parts of Medicare that offer insurance coverage for different things. The different parts of Medicare are:

• Part A (hospital insurance)
• Part B (medical insurance)
• Part C – Medicare Advantage Plans
• Part D (prescription drug coverage)
• Medigap (Medicare supplement policies)
• Medicare Savings Programs

To learn more, read The Different Parts of Medicare.

Choose Between Original Medicare and Medicare Advantage

There are two Medicare options you can choose from when you first enroll and during certain times of the year. They are Original Medicare and Medicare Advantage.

Original Medicare

Original Medicare covers doctor and hospital services and supplies. It does not cover vision, dental, hearing, or prescription drugs, but you can buy separate drug coverage. Original Medicare usually does not cover care outside of the U.S., but you may be able to buy separate coverage for this.

With Original Medicare, you can see any doctor that accepts Medicare. You also do not need a referral to see a specialist in most cases. In general you also do not need to get approval for medical services or supplies before they are covered.

You have to pay a premium (monthly cost for coverage) for Part B. If you choose to buy prescription coverage, there is a separate premium. There is also a deductible you will have to pay for Part B. A deductible is an amount of your health care costs you are responsible for before your benefits start. For example, if you have a $100 deductible, you are responsible for the first $100 of your health care costs before your benefits start.

After you meet your deductible for Part B coverage, you usually pay 20% of the Medicare-approved amount. If your income is less than 100% of the Federal Poverty Level, you can get both Medicaid and Medicare. The Michigan Department of Health and Human Services (MDHHS) will cover the 20% that Medicare does not cover.

There is no yearly limit on what you pay out-of-pocket. You can buy Medigap (Medicare Supplement policies) to help cover your out-of-pocket expenses.

To learn more, read How Original Medicare Works on the Medicare website.

Medicare Advantage

Medicare Advantage plans cover doctor and hospital services and supplies within the U.S. Some plans even cover vision, dental, and hearing. Prescription drug coverage is part of most Medicare Advantage plans.

With Medicare Advantage, you usually need to use doctors who are in the plan’s network for all non-urgent care. In most cases, these plans won’t cover non-urgent care you get outside of their network. To find out if a provider is in the network, you can contact the office before your visit. In some cases you can search your insurance plan’s website for providers in the network. You may need a referral to see a specialist. You also may need to get medical services and supplies approved ahead of time to have them covered.

Out-of-pocket costs vary. In some cases there may be no out-of-pocket costs, or they may be low. Your plan may help pay for your premium for prescription drugs and Part B services. In some cases, there may be no premium. These plans have a yearly limit on what you pay out-of-pocket for services. You cannot buy Medigap coverage to help with out-of-pocket expenses before you reach the yearly limit. Once you reach that limit, you won’t have to pay anything else out of pocket for the rest of the year. There are some plans that offer lower expenses. 

Get Help Choosing the Right Coverage for You

For practical tips on choosing the right coverage, read Consider These 7 Things When Choosing Coverage on the Medicare website. For help choosing the right coverage plan for you, you can visit the Medicare Plan Finder on the Medicare website. You can also call the Medicare helpline at 1-800-633-4227 (TTY users call 1-877-486-2048).

MMAP workers can also help answer your questions.

How Do I Apply?

You can apply for Medicare online through the Social Security Administration website, or call the toll-free number, 1-800-772-1213 (TTY 1-800-325-0778). You can also visit your local Social Security office to apply in person. If you decide to apply in person, it is best to call ahead to make an appointment to reduce your wait time.

Some people get Part A and Part B automatically. To learn more about this, read the section "Automatic Enrollment" below.

When Can I Apply?

People who are close to turning 65 and are not getting Social Security or Railroad Retirement Board (RRB) benefits should apply for Medicare during the three months before they turn 65. Not applying for Part B during this period could cause a delay in coverage. It could also cause you to pay a penalty every month for as long as you have Part B coverage.

If you are not automatically enrolled in Part A, you can sign up to buy it during one of the enrollment periods. To learn more about the enrollment periods, read Enrollment Periods below.

People younger than 65 who are getting Retirement, Survivors, and Disability Insurance (RSDI), can apply to get Medicare. Once someone starts getting RSDI, there is a two-year waiting period before their Medicare eligibility starts.

To learn more about RSDI, visit the Social Security Administration website.

Enrollment Periods

You can only sign up for Medicare during an enrollment period. The different periods are initial, special, and general.

Initial Enrollment Period

The initial enrollment period for Part A and Part B is seven months long. It includes the three months before you turn 65, the month you turn 65, and the three months after you turn 65. If you sign up for coverage during the three months before you turn 65, your coverage usually starts on the first day of your birth month. If your birthday is the first day of the month, your coverage will start on the first day of the month before your birth month.

If you sign up for coverage in the three months after your turn 65, there will be a delay in your coverage. There may also be a late enrollment penalty fee if you don’t sign up during the three months before you turn 65. To learn more about the delay and penalty, visit the Medicare website, or call 1-800--633-4227 (TTY 1-877-486-2048).

MMAP workers can also help answer your questions.

Special Enrollment Period

You might have a special enrollment period if you have health insurance from an employer. The employment could be your own or your spouse’s. It could also be another family member’s if you are disabled. If you didn’t sign up for coverage during the initial enrollment period, you may be able to sign up if you were covered in a group plan based on current employment (not retirement). If you are disabled and getting coverage based on a family member’s employment, the employer must have at least 100 employees for you to be eligible for the special enrollment period.

If any of the above situations apply to you, you can sign up for Part A and Part B coverage anytime you are still covered by the other plan. If you don’t, you may still be able sign up during the eight month period after the employment or coverage ends, whichever happens first. Having Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage does not count as employer based coverage.

Usually there is no late enrollment penalty if you sign up during the special enrollment period.

To learn more, visit Sign up/change plans on the Medicare website, or call 1-800--633-4227. TTY users can call 1-877-486-2048.

MMAP workers can also help answer your questions.

General Enrollment Period

If you didn’t sign up for coverage during the initial enrollment period, and you don’t qualify for a special enrollment period, you can sign up during the general enrollment period. General enrollment happens each year between January 1 and March 31. Your coverage will be delayed until July 1. You may also have to pay higher premiums and penalties because of the late enrollment.

To learn more, visit Sign up/change plans on the Medicare website, or call 1-800--633-4227. TTY users can call 1-877-486-2048.

MMAP workers can also help answer your questions.

Automatic Enrollment

If you get RRB or Social Security benefits, you will start getting Part A and Part B automatically the first day of the month you turn 65. If your birthday is the first of the month, then you will start getting benefits the first day of the month before your month of birth.

If you are younger than 65 and have a disability, you will automatically get Part A and Part B after 24 months of getting Social Security or RRB disability benefits.

You will also get automatic enrollment if you have Amyotrophic Lateral Sclerosis (ALS). Your Part A and Part B coverage will start the month your Social Security disability benefits do.

Getting Medicare

You will get letters explaining your coverage and different insurance cards from Medicare, depending on your policies. If you have questions about your policies, you can call the numbers on the back of the cards or contact MMAP for help.

Medicare recommends you do these five things during your first year with Medicare:

• Complete an authorization form if you want a friend or family member to be able to call Medicare on your behalf
• Make a preventative visit appointment
• Create an account on mymedicare.gov
• Review what your policies cover
• Decide if you want to go paperless (only receive information electronically)

Medicare and Other Insurance

If you have Medicare and other insurance, there are rules to decide which one pays first. The insurance that pays first covers costs up to the limits of its coverage. The insurance that pays second may cover some of the costs left over. The insurance that pays second might not cover all the remaining cost.

Medicare will pay first if you:

• Have retiree insurance from your or your spouse’s former job
• Are 65 or older and have insurance from your or your spouse’s current job, and the employer has fewer than 20 employees
• Are under 65, disabled, and have insurance through a family member’s current job, and the employer has fewer than 100 employees

The other insurance will pay first if you are:

• 65 or older and have insurance from your or your spouse’s current job, and the employer has at least 20 employees
• Under 65, disabled, and have insurance through a family member’s current job, and the employer has at least 100 employees

Sometimes employers join other employers or unions to sponsor a multi-employer plan. When this happens, Medicare will look at the largest employer or union in the plan to decide who will pay first.

If you have Medicare because of End-Stage Renal Disease (ESRD), your other insurance will pay for the first 30 months after you become eligible to enroll in Medicare. After that Medicare will pay the next 30 months.

Appealing a Decision

If you don’t agree with a decision that Medicare makes, you may be able to appeal it. You can appeal a Medicare denial of your request for a health care service, item, or prescription if:

• You think you should be able to get it
• You already got it and Medicare doesn’t want to cover it
• You want to change the amount you must pay for it, even if Medicare stops paying for it
• You believe it should count towards your deductible, if you have one

There are other decisions you may be able to appeal. To learn more about Medicare appeals and the appeals process, read “How do I file an appeal?” on the Medicare website.

Mistakes in Billing

Understanding what your policies cover is the easiest way to spot mistakes in billing and correct them. If you have questions or concerns about a bill, contact MMAP.

A lawyer may also be able to help you. Use the Guide to Legal Help to find lawyers in your area.