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Medicare signup deadlines and rules can be found here on Medicare.gov and here on Medicarerights.org
What is Medicare?
Medicare is a Federal program that provides health insurance to people who have been determined disabled by the Social Security Administration or who have turned age 65 and who have paid into Social Security and have earned 40 quarters (a minimum of 10 years of work). In addition, Medicare is only available to citizens or legal permanent residents of five or more years. For people who have been determined disabled by Social Security, there is a two year wait period before Medicare starts. The wait period for Medicare is part of the Social Security Act that was created decades ago and just applies to people who are under 65. During this wait period, disabled people have two options: They can either apply for Medicaid (eligibility depends on income and assets, and what programs are available in the state of residence) or they can apply for private insurance now available through the Affordable Care Act (ACA). Before the Affordable Care Act, many disabled people had little or no access to insurance. Please see the section on Medicaid eligibility and the Affordable Care Act for more information on these programs.
Are you starting Medicare soon? We offer in-depth personalized assistance and advice.
Contact me here.
Click here to preview and compare plans on your own. Your information is kept confidential and is never sold.
Medicare signup deadlines and rules can be found here on Medicare.gov and here on Medicarerights.org
What is Medicare?
Medicare is a Federal program that provides health insurance to people who have been determined disabled by the Social Security Administration or who have turned age 65 and who have paid into Social Security and have earned 40 quarters (a minimum of 10 years of work). In addition, Medicare is only available to citizens or legal permanent residents of five or more years. For people who have been determined disabled by Social Security, there is a two year wait period before Medicare starts. The wait period for Medicare is part of the Social Security Act that was created decades ago and just applies to people who are under 65. During this wait period, disabled people have two options: They can either apply for Medicaid (eligibility depends on income and assets, and what programs are available in the state of residence) or they can apply for private insurance now available through the Affordable Care Act (ACA). Before the Affordable Care Act, many disabled people had little or no access to insurance. Please see the section on Medicaid eligibility and the Affordable Care Act for more information on these programs.
Medicare is not Cadillac coverage. There are deductibles and coinsurance with “Original Medicare” (Part A and B only). There are separate deductibles for Medicare Part A and Part B. Many people choose to add additional coverage to help fill in the gaps, but below is an explanation of Original Medicare:
Medicare has several parts. Medicare Part A is sometimes referred to as “hospital insurance.” The easiest way to think about Medicare Part A coverage is to think of your physical inpatient presence in a hospital or rehabilitation/nursing facility: the bed you lay in, the food you eat, and sometimes the prescription drugs you are given (Part D drug coverage often covers medicines in the hospital or nursing home). Medicare Part A does not cover charges for the doctor who sees you in the hospital, the surgeon who performs your surgery, or any equipment you might need such as a wheelchair. Those are all Part B services. I often speak to people who believed that Medicare Part A would paid for their ambulance ride or all their care in the hospital. It does not. If you have outpatient surgery, Part B covers you rather than Part A.
Medicare has several parts. Medicare Part A is sometimes referred to as “hospital insurance.” The easiest way to think about Medicare Part A coverage is to think of your physical inpatient presence in a hospital or rehabilitation/nursing facility: the bed you lay in, the food you eat, and sometimes the prescription drugs you are given (Part D drug coverage often covers medicines in the hospital or nursing home). Medicare Part A does not cover charges for the doctor who sees you in the hospital, the surgeon who performs your surgery, or any equipment you might need such as a wheelchair. Those are all Part B services. I often speak to people who believed that Medicare Part A would paid for their ambulance ride or all their care in the hospital. It does not. If you have outpatient surgery, Part B covers you rather than Part A.
What is Part A?
For most people, Medicare Part A has no premium. Individuals who have fewer than 30 quarters of coverage can buy Part A for $506 per month. Medicare Part A is often called "hospital" insurance--referring to your stay as an inpatient in a hospital or nursing home/rehab center. Part A covers inpatient hospital care, skilled nursing, home healthcare, and hospice care, but does not typically cover the doctor services you receive while in the hospital.
Part A has a $1,600 deductible that runs in 60 day periods. Let’s say you go into the hospital on January 1—your 60 day deductible starts January 1 and runs for 60 days, until March 1st. If you leave the hospital and don’t return until after the 60 days is up, a whole new deductible starts next time you go into the hospital. For example, if you come back on February 15th, you have already met your deductible. However, if you return on March 3rd, a new deductible period begins.
After you’ve met your $1,600 deductible, Medicare pays 100% for your costs during your first 60 days. However, if you are still in inpatient in either a hospital or a nursing home on day 61, you pay $400 per day of your stay. If you are still an inpatient on day 91, you pay $800 per day until day 150—after which you can use your 60 lifetime reserve days at that same price. Once you’ve used up your 60 lifetime reserve days, Medicare pays 0% and you pay 100% of the charges.
What is Part B?
Medicare Part B is essential to Medicare coverage. I far too often saw people who rejected Part B because there is a monthly premium. In 2023, the Medicare Part B premium is $164 for people new to Medicare, and people with income over $170,000 pay more for their premium due to income-related adjustments. That’s right, Medicare isn’t free. Some people with very low income can apply for a state program that will help them pay the premium. Please see the section on Medicare Premium Assistance for more information. Part B covers most of the outpatient services you will need, after you meet a $226 deductible, you pay 20% of the Medicare approved charges if your doctor accepts “Medicare Assignment.” Doctor’s visits and services, durable medical equipment, diabetic supplies, ambulance rides, and more.
Medicare Part B is essential to Medicare coverage. I far too often saw people who rejected Part B because there is a monthly premium. In 2023, the Medicare Part B premium is $164 for people new to Medicare, and people with income over $170,000 pay more for their premium due to income-related adjustments. That’s right, Medicare isn’t free. Some people with very low income can apply for a state program that will help them pay the premium. Please see the section on Medicare Premium Assistance for more information. Part B covers most of the outpatient services you will need, after you meet a $226 deductible, you pay 20% of the Medicare approved charges if your doctor accepts “Medicare Assignment.” Doctor’s visits and services, durable medical equipment, diabetic supplies, ambulance rides, and more.
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Does every doctor accept Medicare?
Not every doctor accepts Medicare. For people on Medicare, there are 3 types of doctors in the world: 1. Doctors who accept Medicare Assignment—you pay 20% of Medicare approved charges. 2. Doctors who do not participate in Medicare but agree to bill Medicare (sometimes these doctors will say they “accept Medicare” but not “accept Medicare Assignment”)—you pay 20% of Medicare approved charges PLUS up to 15% extra in “excess charges”, meaning the difference between what Medicare allows and what the doctor charges for the service. 3. Doctors who have opted out of Medicare (usually stated as “do not accept Medicare”)--you pay 100% of whatever the doctor charges and the doctor's office will not send a bill to Medicare. |
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What about prescription drug coverage?
Medicare beneficiaries can add on prescription drug coverage through a Part D plan, offered through private insurance companies. Wisconsin also has a prescription drug program for people 65 and older called SeniorCare that can either take the place of Part D or work with Part D. People with limited income and assets may qualify for the Low Income Subsidy to help pay some of the costs of prescription drug coverage.
Do I have other options?
In addition to Original Medicare (Parts A and B), Medicare beneficiaries can add on a Medicare Supplement plan or replace Part A and B with a Medicare Advantage plan.
What is a Medicare Advantage plan?
Medicare Advantage plans (previously known as Part C plans) are offered through private insurance companies and take the place of Original Medicare for most services. Advantage plans must be at least actuarially equivalent to Original Medicare, and can offer additional coverage Original Medicare does not. Most Advantage plans also offer prescription drug coverage. Oftentimes, Advantage plans have networks of doctors/hospitals and may or may not offer out-of-network coverage for non-emergency care. Plans vary in availability and price. All Medicare Advantage plans offer an out of pocket maximum for medical services, meaning a cap on what a beneficiary can pay in a given year. Original Medicare does not cap the amount you could potentially pay in a year for medical services.
In addition to Original Medicare (Parts A and B), Medicare beneficiaries can add on a Medicare Supplement plan or replace Part A and B with a Medicare Advantage plan.
What is a Medicare Advantage plan?
Medicare Advantage plans (previously known as Part C plans) are offered through private insurance companies and take the place of Original Medicare for most services. Advantage plans must be at least actuarially equivalent to Original Medicare, and can offer additional coverage Original Medicare does not. Most Advantage plans also offer prescription drug coverage. Oftentimes, Advantage plans have networks of doctors/hospitals and may or may not offer out-of-network coverage for non-emergency care. Plans vary in availability and price. All Medicare Advantage plans offer an out of pocket maximum for medical services, meaning a cap on what a beneficiary can pay in a given year. Original Medicare does not cap the amount you could potentially pay in a year for medical services.
When can a person enroll in a Medicare Advantage or Prescription Drug plan?
1. When you first become eligible for Medicare, you can enroll in a Medicare Advantage plan and/or a Part D plan three (3) months before the month Medicare begins, during your first month, or during the three (3) month period following the month your Medicare begins. For example, if you start Medicare in June, you could enroll in a Medicare Advantage and/or Part D plan in March, April, May, June, July, August, or September.
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2. During Medicare’s Open Enrollment Period held October 15th-December 7th each year for coverage starting January 1st of the following year. Some other special circumstances, such as a Special Enrollment Period (click here for more information on Special Enrollment Periods).
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3. If you have Medicaid coverage, you have an ongoing Special Enrollment Period and can enroll year-round in a Medicare Advantage and/or Part D plan.
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4. If you have moved outside your current plan's service area
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5. You want to enroll in a 5 star plan (you can use once per year)
There are some additional Special Enrollment periods, too, such as for people enrolled in SeniorCare. Contact us for a screening.
1. When you first become eligible for Medicare, you can enroll in a Medicare Advantage plan and/or a Part D plan three (3) months before the month Medicare begins, during your first month, or during the three (3) month period following the month your Medicare begins. For example, if you start Medicare in June, you could enroll in a Medicare Advantage and/or Part D plan in March, April, May, June, July, August, or September.
Or
2. During Medicare’s Open Enrollment Period held October 15th-December 7th each year for coverage starting January 1st of the following year. Some other special circumstances, such as a Special Enrollment Period (click here for more information on Special Enrollment Periods).
Or
3. If you have Medicaid coverage, you have an ongoing Special Enrollment Period and can enroll year-round in a Medicare Advantage and/or Part D plan.
Or
4. If you have moved outside your current plan's service area
Or
5. You want to enroll in a 5 star plan (you can use once per year)
There are some additional Special Enrollment periods, too, such as for people enrolled in SeniorCare. Contact us for a screening.
What is a Supplement Plan?
Medicare Supplement plans may help fill in the gaps of Medicare Part A and B. As discussed above, Original Medicare has deductibles, copays for hospital/nursing home stays, and 20% coinsurance for outpatient services.
Supplement plans complement, not replace, your Original Medicare coverage. There are no networks, you bring your Supplement coverage with you to a doctor/hospital that accepts Medicare. This means that if you go to a doctor who does not accept Medicare, your supplement plan will not pay the difference.
Supplement plans are required to have certain benefits in Wisconsin, such as an additional 40 days of home health care or the first 3 pints of blood (Medicare has a “blood deductible”). Consumers may choose how much coverage they would like in the form of riders. There are many different kinds of Supplement plans, from basic coverage to add-ons like foreign travel.
The first opportunity to enroll in a Supplement plan is during the first 6 months of your Medicare eligibility (or up to two months before your Medicare starts). During this period, you are in “open enrollment” which means the Supplement company won’t consider any of your medical conditions and cannot deny your application based on medical factors. For most, this period begins at age 65. However, for those who became eligible for Medicare before age 65 due to disability, they will have another open enrollment period at age 65. For those who delay Medicare enrollment due to current employment (over 20 employees for people over 65, but over 100 employees for individuals under 65 on Medicare due to disability) based coverage, they will have an open enrollment period with guaranteed issue when they end their employment and take Medicare Part B.
You can quote supplement plans here if you would like to do it yourself or preview pricing.
Prescription drug coverage is not included in new Medicare Supplement plans, and you may buy both a Supplement plan and a Part D plan.
Medicare Supplement plans may help fill in the gaps of Medicare Part A and B. As discussed above, Original Medicare has deductibles, copays for hospital/nursing home stays, and 20% coinsurance for outpatient services.
Supplement plans complement, not replace, your Original Medicare coverage. There are no networks, you bring your Supplement coverage with you to a doctor/hospital that accepts Medicare. This means that if you go to a doctor who does not accept Medicare, your supplement plan will not pay the difference.
Supplement plans are required to have certain benefits in Wisconsin, such as an additional 40 days of home health care or the first 3 pints of blood (Medicare has a “blood deductible”). Consumers may choose how much coverage they would like in the form of riders. There are many different kinds of Supplement plans, from basic coverage to add-ons like foreign travel.
The first opportunity to enroll in a Supplement plan is during the first 6 months of your Medicare eligibility (or up to two months before your Medicare starts). During this period, you are in “open enrollment” which means the Supplement company won’t consider any of your medical conditions and cannot deny your application based on medical factors. For most, this period begins at age 65. However, for those who became eligible for Medicare before age 65 due to disability, they will have another open enrollment period at age 65. For those who delay Medicare enrollment due to current employment (over 20 employees for people over 65, but over 100 employees for individuals under 65 on Medicare due to disability) based coverage, they will have an open enrollment period with guaranteed issue when they end their employment and take Medicare Part B.
You can quote supplement plans here if you would like to do it yourself or preview pricing.
Prescription drug coverage is not included in new Medicare Supplement plans, and you may buy both a Supplement plan and a Part D plan.
What about COBRA?
Before electing or rejecting COBRA, we strongly urge you to consider all of your options. When you leave a job where you had employer-provided health insurance, your employer may offer you continuing coverage through COBRA. With COBRA, you would have to pay the full premium including the portion that your employer was previously covering. This premium can be high, ranging from a few hundred dollars to a few thousand per month. As we will explain below, once you take COBRA you may eliminate other options until the next Medicare Open Enrollment Period (OEP).
Are you eligible for Medicare? If you’re 65 or older and delayed Medicare Part B enrollment because either you or your spouse worked for an employer with 20 or more employees, call the Social Security Administration toll-free at 1-800-772-1213 (TTY 1-800-325-0778) right away to sign up. If you’re curious about the 20+ employees rule, here’s a Medicare guide on the topic. You have 8 months from the end of current employment coverage or when employment ended (whichever is first) to pick up Part B. After those 8 months have elapsed, you’ll have to wait until the General Enrollment Period which is January 1st to March 31st to enroll for a July 1st start date. That means if you leave your job in January, but wait September to ask for Part B, you can’t get coverage until July 1st of the following year! Therefore, we highly recommend you speak to a professional as soon as you can when you leave employment.
Before electing or rejecting COBRA, we strongly urge you to consider all of your options. When you leave a job where you had employer-provided health insurance, your employer may offer you continuing coverage through COBRA. With COBRA, you would have to pay the full premium including the portion that your employer was previously covering. This premium can be high, ranging from a few hundred dollars to a few thousand per month. As we will explain below, once you take COBRA you may eliminate other options until the next Medicare Open Enrollment Period (OEP).
Are you eligible for Medicare? If you’re 65 or older and delayed Medicare Part B enrollment because either you or your spouse worked for an employer with 20 or more employees, call the Social Security Administration toll-free at 1-800-772-1213 (TTY 1-800-325-0778) right away to sign up. If you’re curious about the 20+ employees rule, here’s a Medicare guide on the topic. You have 8 months from the end of current employment coverage or when employment ended (whichever is first) to pick up Part B. After those 8 months have elapsed, you’ll have to wait until the General Enrollment Period which is January 1st to March 31st to enroll for a July 1st start date. That means if you leave your job in January, but wait September to ask for Part B, you can’t get coverage until July 1st of the following year! Therefore, we highly recommend you speak to a professional as soon as you can when you leave employment.