Kaiser Permanente Guide to Medicare Basics The National Medicare program, which was created in 1965, has given people peace of mind and the security of knowing they ll have access to health coverage. Medicare is administered by the Centers for Medicare and Medicaid Services, or CMS, and provides health care coverage to people who are 65 and over and people under 65 who have certain disabilities, including end-stage renal disease, after diagnosis. Medicare is made up of parts A, B, C, and D. We ll explore each one, so you have the information you need. Let s look at Part A first. Part A is hospital insurance and provides coverage for: Inpatient hospital Skilled nursing Hospice Home health care Services not covered under Part A include custodial care and long-term care. If you ve worked at least 10 years of Social Security covered employment and are over 65, you generally will pay no monthly premium for Part A. Once you re eligible, you can sign up at your Social Security Office. Then you ll receive a red, white, and blue Medicare card that you ll use to get care. Next, Part B is medical insurance. It covers services like: Doctor visits Preventive services Inpatient and outpatient physician services Outpatient surgery
Lab Radiology Durable medical equipment Dialysis and other medical services and supplies not covered under Part A. If you qualify for Part A, you re eligible for Part B. And you ll keep your Part B benefits for as long as you continue to pay for them. And here s something important to remember. You must sign up for Part B once you are eligible, because if you don t, you may have to pay a Late Enrollment Penalty. This penalty increases the Part B monthly premium by 10 percent for each 12- month period you decline coverage. And that amount is not a one-time penalty. It lasts for as long as you remain enrolled in Part B. There are exceptions to this penalty, such as a person who continues to work after age 65. We ve now covered Part A and Part B, which together make up Original Medicare. Let s move on to Part C. Often referred to as Medicare Advantage, Part C is the part of Medicare that allows you to choose a private insurance company to provide your Medicare benefits. Medicare Advantage plans must cover all of the services that Original Medicare covers. However, hospice care and certain care for clinical research studies are exceptions. They re covered under Original Medicare and not Medicare Advantage plans. If you have a Medicare Advantage plan and need these services, you can still have them covered under Original Medicare.
Medicare Advantage plans feature a network of providers that you must use for care. If you choose to see an out-of-network provider, you ll be financially responsible, except in the case of an emergency or urgent care. When you sign up with a Medicare Advantage plan, you still have Medicare. You ll just receive your health care coverage through a private insurance company. Once you re enrolled, you will only need to show the Medicare Advantage plan s member I.D. card to get care. But you should still keep your red, white, and blue Medicare card. And then there is Part D. Part D provides outpatient prescription drug coverage and can only be purchased from a private company. A Part D plan must have a list of covered drugs called a formulary. And you may only have one Part D plan at a time. You re eligible for Part D if you are entitled to benefits under Part A and/or enrolled in Part B. The only way you can enroll in Part D is through one of these options: A Medicare Advantage plan that includes Part D prescription drug coverage A stand-alone Prescription Drug Plan, which offers prescription drug coverage only, and Some employers and unions Like Part B, Part D also has a Late Enrollment Penalty. This penalty for Part D is 1 percent of the monthly premium for every month that you defer your enrollment. The penalty does not apply to: those who are eligible for Low-Income Subsidy, also called Extra Help.
To apply for this program and get assistance in paying for your prescription drug premiums and costs, contact Social Security or your state Medicaid office or call 1-800-MEDICARE for more information. Now that we ve gone over the four parts of Medicare and the benefits they offer, let s go over how and when you can enroll in Original Medicare. The Initial Enrollment Period for Original Medicare begins 3 months before your 65th birthday and ends 3 months after the month you turn 65a total of 7 months. If you miss your Initial Enrollment Period, you can sign up during the General Enrollment Period between January 1 and March 31 each year and your coverage will begin on July 1 of that same year. If you decide to continue working after 65, but lose your employer or union coverage, you can take advantage of a Special Enrollment Period, which is anytime outside of the General Enrollment or Initial Enrollment Periods. In the next part, we ll discuss enrollment in parts C and D. To be eligible you must: Reside in the approved service area and Have parts A and B and Some exceptions apply, such as Medicare has specific rules around enrolling individuals with end-stage renal disease also known as ESRD, unless you qualify for an exception, you may not be eligible for a Part C plan. For more information please call 1-800-Medicare. Additionally, if you have an employer or union health plan or other health coverage through a company that offers Medicare Advantage plans, you may be able to join one of their Medicare Advantage plans. Most Medicare Advantage plans have limited enrollment periods. The Initial Enrollment Period for a Medicare Advantage Plan with Part D is the same as Original Medicare. You have a total of 7 months to enrollthe 3 months before you turn 65, your birthday month, and the 3 months after you turn 65.
If you miss your Initial Enrollment Period, you can still enroll in a Medicare Advantage plan with Part D during the Annual Election Period between October 15 and December 7. During this period, all Medicare beneficiaries may enroll, drop, or change their Medicare Advantage and/or Part D plan. Your plan will then become effective January 1 of the following year. This is also referred to as the Fall Open Enrollment season in some Medicare publications. You may qualify for a continuous enrollment period if you are eligible for Low Income Subsidy (also referred to as Extra Help). To see if you qualify for Extra Help, call 1-800-MEDICARE. There are also Special Election Periods based on individual beneficiary qualifications that allow you to change plans or enroll in a new Medicare Advantage Plan outside of the regular enrollment periods. Examples of these Special Election Periods are: Loss of employer or union group coverage Qualification for low-income status Relocationyou have moved/are moving If you enroll in a Medicare health plan that has received a 5-Star Quality Rating, you ll also have the freedom to sign up outside of the regular enrollment periods during the special enrollment period that s designated for 5-Star rated plans. Each year, the Centers for Medicare and Medicaid Services evaluate all Medicare health and prescription drug plans through their Medicare Star Quality Rating system. Plans are given an overall rating from 1 to 5 stars5 stars meaning excellent. These ratings are based on categories which include: Preventive care Chronic care Prescription drug services Customer service, and Member satisfaction
These ratings are a valuable, independent source of information when comparing Medicare health plans and can help you make a more informed choice. The 5-Star special enrollment period runs from December 8 to November 30 of the following year for Medicare health plans and prescription drug plans that get a 5-Star rating from CMS. All eligible Medicare beneficiaries can take advantage of this special enrollment period. If you live in an area that offers a 5-Star rated plan, your coverage will begin the first of the month following the verification of your Medicare eligibility. Finally, we d like to direct your attention to the Medicare Advantage Disenrollment Period. Each year during the period from January 1 to February 14 you can choose to disenroll from your Medicare Advantage plan and return to Original Medicare. You may also purchase a stand-alone Part D prescription drug plan at this time. So now you have the confidence of knowing the Basics of Medicare; understanding what the four parts, A, B, C, and D represent; the important enrollment and disenrollment periods; and the significance of the Medicare Star Quality rating system. If you need more information about Social Security, state assistance and Medicare (including Medicare Star Quality Ratings), please use these important websites and phone numbers displayed here. These references can also be found in our enrollment materials. We invite you to visit our website, kp.org/medicare, where you can learn more about the benefits and services we offer, and even enroll online. Thank you for watching and stay well.