FREQUENTLY ASKED QUESTIONS ABOUT MEDICARE

 *** What and when is the Initial Medicare Enrollment Period?   

• Also known as the Initial Enrollment Period (IEP), this a 7-month window of time when you first become eligible for Medicare coverage, starting 3 months before the month your turn 65 and ending 3 months after the month you turn 65.
•  If you're not already collecting SS benefits before your initial enrollment period starts, you'll need to sign up for Medicare online or contact the Social Security Administration www.ssa.gov/benefits/medicare. To avoid a lifelong Part B enrollment penalty, be sure to sign up for Medicare during this period unless you are still working and have employer group coverage. 

*** What happens if I don't sign up for Medicare A and/or B when eligible at age 65 and               am not working or covered under an employer group health plan?

• Yikes, don't miss this deadline!  But IF you do, and occasionally this does happen, (especially if you are not collecting SS benefits and are not automatically enrolled by Social Security) you will need to wait until the General Enrollment period (January 1-March 31st) to sign up for Original Medicare.

*** What and when is Open/General Enrollment?   

• Window of time from January 1 - March 31st annually when a person can sign up for Medicare if they did not sign up for it during their Initial Eligibility Period. Coverage will become effective the first day of the following month.  
• During this period, Medicare Advantage (MA) plan participants may also switch to another MA plan, or to Original Medicare with or without a stand-alone prescription drug plan (Part D). Changes to coverage begins on the first day of the following month.  If you have a MA Plan and a separate Part D plan (unlikely), you can switch to a MA Plan that does not include Part D coverage, however, you can NOT change Part D plans until the fall Annual Election Period (AEP). 

*** What and when is the Annual Election Period (AEP)?     

• The AEP is a window of time from October 15 - December 7th annually when a Medicare recipient can add, drop, or change their Part D drug plan and/or their Medicare Advantage Plan. This period of time does not apply to Medigap (Supplemental) plans. Changes to coverage will take effect on January 1st.  The Annual Election Period is also referred to as "Fall Open Enrollment."  

*** What is a Special Enrollment Period (SEP)?    

• Under certain circumstances you may be eligible for a SEP which allows you to change your health and/or drug coverage outside of the normal enrollment period windows. Some special circumstances include:  relocating out of your plan's service area; changes in Medicaid eligibility status; desire to disenroll from your first Medicare Advantage Plan within the first 12 months (12-month trial right); and if the insurer no longer offers coverage for your plan.  

*** What's the difference between Medicare and Medicaid?  

•  Medicare is federal health insurance for anyone age 65 and older, and some people under 65 who certain disabilities or conditions.  Medicaid is a joint federal and state program that provides health coverage for some people with very limited income. Medicaid offers benefits like nursing home care, personal care services, and assistance paying for Medicare premiums and other costs. If you qualify, you can have both Medicare and Medicaid and may even be eligible for a Dual Special Needs Plan (D-SNP) which is a type of Medicare Advantage plan that offers even more benefits.  To find out if you qualify for Medicaid in Nevada, contact the Nevada Medicaid office at (877) 638-3472.

 *** If I prefer to not use the online Medicare services provided by the government, who can I contact? 

•  ​1-800-MEDICARE (800-633-4227)  

***How exactly do I sign up for Medicare?   

• If you already receive Social Security benefits, you will be automatically enrolled in Hospital Insurance (Part A) and Medical Insurance (Part B). The Social Security Administration (which administers the Medicare program) will mail you all the information you need a few months before you become eligible (age 65).  Note: Residents of Puerto Rico or foreign countries won’t automatically receive Part B. They must elect this benefit. 
• If you don’t receive Social Security benefits and are not ready to apply for them yet, you may sign up for Medicare starting three months before your 65th birthday month and up to the third month after your 65th birthday month (7-month window), though the sooner the better as it can take up to 60 days to receive your Medicare Insurance Card.  
• The easiest way to apply for Medicare is by using the online application at http://www.ssa.gov/medicare/.  If you'd rather not apply online, make an appointment by calling 1-800-772-1213 (TTY 1-800-325-0778), 8:00 am – 7:00 pm, Monday through Friday.  The good news is that applying for Medicare is a relatively quick and easy process!

*** Do I need to sign up for Original Medicare (Parts A and B) yearly, or just once?  

• Generally, you only need to sign up for Original Medicare one time. Each year, during certain enrollment periods you can make changes to your Medicare coverage, i.e., switching to or from an Advantage Plan, or adding, dropping or changing your prescription drug coverage. You may change Medigap (Supplemental) coverage anytime during the year, but if you have an MA/MAPD plan and want to switch to Medigap or return to Original Medicare, you will need to wait until either the fall Annual Election Period or winter Open Enrollment to drop your MA/MAPD plan first. 

*** Do I need to sign up for Original Medicare when I turn 65 if I'm covered for health benefits as a retiree under my (or my spouse's) employer's retiree group health plan?    

• Yes. In most cases, you will need to enroll in both Part A and Part B to get full benefits from your retiree coverage as retiree coverage may not pay your medical costs during any period in which you were eligible for Medicare but did not sign up for it.  Typically, Medicare will pay your health care bills first and your group plan pays second (secondary coverage). Your retiree coverage is likely to be similar to Supplement Insurance (Medigap) in that it usually offers benefits that fill in some of the gaps in Medicare coverage like coinsurance and deductibles. I highly recommend you review your employer's plan benefits package for additional information on applicable coverage, or contact your employer's benefits administrator for more information. 

*** If I am still employed when I turn 65 and have group health coverage, do I need to sign up for Medicare Part A and B?  What if my spouse is still working for an employer who provides my group health coverage when I turn 65?   

• If you or your spouse's employer has 20 or more employees, as long as you have group health insurance from an employer for which you or your spouse actively work after you turn 65, you can delay enrolling in Medicare until your employment ends or your health coverage stops (whichever happens first), without incurring any late penalties if you enroll later, as the employer is required to continue to offer the same coverage to those 65 years or older as it does to younger employees. 
• If you do choose to delay enrollment in Medicare in this situation, you will later be able to enroll in Medicare through a Special Enrollment Period.  It may be a wise idea to enroll in Part A when you turn 65 because it is premium free (with 10 years of work credits) and will be of no cost to you, yet offer additional Part A coverage.   If you require care at a hospital, your Part A benefits will keep your costs lower. For example, if your (or your spouse's) employer’s group insurance plan has a $4,000 deductible, it makes sense to enroll in Part A and take advantage of the lower Part A deductible.  
• If you or your spouse's employer has less than 20 employees, you may be required to enroll in Medicare at age 65 as some smaller employers may no longer offer health coverage to employees turning 65. In this case, Medicare will become your primary coverage, and the employer's health plan provides secondary coverage.  You may also opt to discontinue the employer's health coverage at which point Medicare would become your sole coverage.  
• It is best to contact your health insurance provider to assist you with making this important decision. If you have dependents covered by your group health plan, there are other considerations you will need to explore before dropping your employer coverage. Bear in mind that Medicare coverage will not be delayed or started automatically. You will need to contact your local Social Security office to complete the process.      

*** Should I sign up for Original Medicare at age 65 if I have Veterans Benefits?

• Unless you are still working and covered by your employer's group health plan at 65, signing up for Original Medicare will provide you with more coverage choices and options for medical and hospital care, therefore it is highly recommended. Not to mention, VA benefits and priority levels are always subject to future coverage changes by Congress, so having additional coverage provides you even greater security. You will also have access to providers outside of the VA hospital network. You will be able to sign up for a Medicare Advantage plan which provides even more benefits.  
• VA benefits are NOT considered creditable coverage for a Part B waiver of late enrollment penalty, therefore, if you don’t sign up for Part B when you are first eligible you may have to wait to sign up, which will delay your coverage and you will likely be required to pay a late enrollment penalty for as long as you have Medicare Part B. (*If eligible for Part B after 2010 but did not enroll in Part B you may qualify for a penalty waiver. Contact your local Social Security office to apply for a waiver)
• VA benefits are considered creditable coverage for Part D (Prescription Drug Coverage)

*** Can I benefit from a Medicare Advantage Plan and/or Part D prescription drug coverage if I have Veterans Benefits and /or Tricare for Life?   

• Yes, the more coverage you have, the richer your benefits will be.  If your coverage area has a MA plan with no monthly premium, there will be no additional cost to you to enroll in a MA/MAPD plan! Eligibility periods do apply, therefore, it is best to enroll in an MA/MAPD plan upon your Initial Enrollment Period at age 65, otherwise you will need to wait until the fall Annual Election Period (Oct. 15th-Dec. 7th) to enroll. 
• For veterans with VA-only benefits (not military retirees): A MA plan will not negatively affect your VA health coverage and in fact, will provide additional supplemental coverage as the MA plan will act as a secondary insurance to your primary VA coverage. You can greatly benefit from a MA plan "with" prescription drug coverage (MAPD) as you will have more provider options and other benefits (depending on the plan) such as vision, dental, hearing, gym membership, house calls, foreign travel, ER/Urgent care, etc. If you visit an in-network doctor, you will be able to fill your prescriptions at a non-VA pharmacy and may even choose to have your prescriptions delivered via mail order. If a medication is not covered under your VA benefit plan, it may be covered under your MAPD plan. Also, a medication you take regularly may be listed in a lower Tier in your MAPD drug formulary which may equate to less out-of-pocket costs for you. 
• For military retirees with TFL:  Beneficiaries can benefit from a MA only plan (not a MAPD) as Prescription Drug Coverage is typically unnecessary because TFL provides excellent prescription drug benefits. MA plans often include additional benefits not provided by TFL such as vision, dental, hearing and sometimes gym memberships, and sometimes at no additional cost to the beneficiary.  It's important to mention that when enrolled in an MA plan, the MA insurer becomes the primary insurer and TFL pays secondary, paying any necessary co-pays or coinsurance.  Providers must be reminded to bill TFL for co-pays/coinsurance, otherwise, a reimbursement claim may need to be submitted by the beneficiary. 
•  Veterans and military retirees are highly encouraged to contact your VA and/or TFL advisor to find out how your military benefits will work with an MA/MAPD plan. 

*** What is the late enrollment penalty for Part B?  

• 10% for each year you could have signed up for Part B but didn't.   The penalty is added to your monthly Part B premium and lasts for as long as you have Part B coverage.  

 *** What is the late enrollment penalty for Part D (Prescription Drug coverage)?  

• 1% for each month you could have signed up for Part D but didn't. The penalty amounts to roughly 35 cents per month for each month of elapsed coverage.  That's an extra $4.20 per year for a 1-year delay, $8.40 per year for a 2-year delay, and $12.60 per year for a 3-year delay, etc.   The penalty is added to your Part D premium and lasts for as long as you have Part D coverage (even if you change plans). *If you have creditable drug coverage or qualify for Extra Help through Medicare, you will not have to pay a penalty.   

*** Are my Medicare premiums based on my income?  

• Yes, Part B and Part D are income based. Individuals with a gross income of more than $103,000 and married couples with a gross income of more than $206,000  (2024 data) will pay a larger percentage of their monthly Medicare Part B and Part D costs based on their income. There is a monthly surcharge that will be added to monthly premiums in this case.  For more information, visit www.medicare.gov.  

*** Do Medicare Advantage Plans (Part C) and Supplemental Plans (Medigap) have a yearly limit on what the recipient pays out-of-pocket? 

• Only Medicare Advantage Plans have a yearly limit on out-of-pocket costs.  Once the plan's limit (cap) is met, the plan pays for 100% of covered health services for the remainder of the plan year.    Supplemental Plans typically do not have a yearly maximum threshold on out-of-pocket expenses however, these plans generally cover most Part A and Part B expenses, resulting in lower out-of-pocket costs when services are utilized. 
• Keep in mind that Medicare Parts A and B do NOT have a cap/maximum out-of-pocket on medical expenses. This is why additional coverage options should be considered. 

*** Does Original Medicare (Parts A & B) have a yearly limit on what the recipient pays out-of-pocket? 

• Don't we wish!  If it did, then there wouldn't be as much of a need for Supplements and Medicare Advantage Plans. There is no-out-of-pocket limit on how much a recipient can pay with Original Medicare, unfortunately. The insured will pay 20% of the Medicare-approved costs after the Part A and B deductibles are satisfied. If the Medicare approved costs for an overnight ER stay is $20,000, Medicare pays 80% and you will pay 20% (after paying the Part B deductible). 

*** If I have a Medicare Advantage or Supplemental Plan, do I still pay the Part B premium?  

• Yes. You must continue paying your Part B premium to stay enrolled in your Advantage or Supplement Plan.  *** Qualified Medicaid recipients may have their Part B premium paid for them by Medicaid. 

*** If I travel outside of the country frequently where Original Medicare is not accepted, will an Advantage plan or a Supplemental plan cover any medical expenses I incur while traveling?

• In only a few rare circumstances will Original Medicare cover a portion of your health-related expenses while in a foreign country (www.medicare.gov/coverage/travel).  Medicare generally does not cover health care while you’re traveling outside the U.S., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands. 
• Some Supplemental Plans (C, D, F, G, M, and N) cover emergency coverage in foreign countries, though they will typically carry a $250 deductible, co-insurance of 20%, have a lifetime cap, and only cover the first 60 days of travel. 
• Some Advantage plans provide coverage for emergency health services outside of the U.S. Often, plans may place restrictions on specific health services.
•  Be sure to let your agent know foreign travel medical coverage is important to you so that your Medicare plan includes the appropriate coverage to protect you and give you peace of mind while traveling abroad.  

*** How do I terminate my Medicare Part B insurance? 

• A person age 65+ who enrolls in Part B but later becomes covered under an employer's group insurance plan, may decide to drop coverage under Part B without future penalty. 
• Any person can voluntarily terminate their Medicare Part B health coverage at any time as Part B requires a premium, however, since this is a serious decision that could later result in stiff penalties if you later decide to re-enroll in Part B, you may need to have a "personal interview" with Social Security. A SS representative will assist you further and help you complete Form CMS 1763.

*** What is the difference between Original Medicare and Medicare Advantage? 

• After you become Medicare-eligible and enrolled in the program, you can choose to receive your benefits directly through the federal government as part of "Original Medicare", or from a private company that contracts with Medicare as part of Medicare Advantage. Medicare pays the insurance company to cover your Medicare benefits. 
•  An Advantage Plan must provide the same benefits of Original Medicare, except hospice care (Original Medicare will always cover hospice).   If you join an Advantage Plan, the plan will provide all of your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage. Typically, the plan also includes prescription drug coverage which Original Medicare does not provide. Many plans also offer additional benefits not provided by Original Medicare such as dental, vision and hearing coverage, and gym memberships.
• Unlike Original Medicare, MA plans provide a financial safety net due to an established annual out-of-pocket limit. If your medical costs reach this limit, your plan will cover 100% of your Medicare-covered healthcare costs for the rest of the year.
• Medicare Advantage may be a great choice for you if you are wanting more than the basics that Original Medicare provides with a low to no monthly premium, but most importantly, you need to pick a plan that fits your personal needs, such as a Supplemental Plan.

*** What do Medicare Supplement (Medigap) plans pay for?  

• Private insurance companies in each state underwrite a range of Medicare Supplement plans. Medicare Supplement plans typically cover your Medicare Part A deductible, coinsurance, plus an additional full year of Part A benefits after your Medicare benefits are exhausted. They also will cover some or all of your Medicare Part B co-insurance, Part B deductibles (some), all or a portion of coinsurance and copayments, and your first three pints of blood. Without a Supplement plan, you’d have to pay those expenses yourself out-of-pocket.  
• Many plans also cover a portion of emergency health care services accessed outside of the U.S.  
• For those who live in more than one state throughout the year, Supplement plans will continue to cover healthcare costs in the secondary state of residence.  These plans are sold based on your state of primary residency, with different health insurers offering plans in different states. Once you have the coverage, you can use it nationwide which provides one a lot of flexibility, thanks Medigap!
• It is critical to speak to an agent who can help you determine the right coverage for your needs. Some of the things you will need to think about are the types of healthcare services you typically access, your healthcare needs, needed prescriptions, whether you travel abroad, if you prefer to see specific providers, if you see specialists, and of course, your budget. 

*** How does Part D work with other Prescription Drug coverage I may have?  

• If you have Medicare Part D and another insurance policy with drug coverage, there will be a coordination of benefits between the separate policy companies to determine which policy is the primary payer and which is the secondary. The determination of payments for prescription drugs will be based on the enrollee's personal situation.   

*** If I have limited income but do not qualify for Medicaid  in my state,  is there assistance available for my prescription medications? 

• Yes,  The Extra Help program or Low Income Subsidy helps people with limited income and resources lower or cut Part D costs. Medicare Part D provides drug coverage. The Extra Help program helps with the cost of your prescription drugs, like deductibles and copays.  
•  For more information visit: https://prescriptionassistance.us/st/nevada. Also, some individuals may qualify for special assistance through the Part D "Extra Help" program offered through Social Security: https://www.ssa.gov. 
•  To determine eligibility, the Social Security Administration will need information about your income, savings, investments, and real estate (other than your primary residence).  
•  You can apply online at www.ssa.gov, by phone at 1-800-772-1213 (TTY 1-800-325-0778), or at your local Social Security Office. You can apply at any time, before or after you enroll in Part D. 

*** Additional helpful information can be found at http://www.Medicare.gov.