New To Medicare

 

Medicare eligibility is your reward for years of hard work. But understanding your Medicare options can be confusing. That's where we can help!

Getting Started

Medicare eligibility is your reward for years of hard work. However, understanding your Medicare options can be confusing. Get detailed information by reading the information below, or registering to receive our Medicare Guidebook and emails. As always, Contact Us if you have any questions.

Register to receive a Medicare Guidebook and plan information.

The ABCs of Medicare

The ABCs of Medicare image

Introduction

Before you think about signing up, it's important to learn about the different parts of Medicare. You have choices to make, so first things first, let's break down how the various parts are categorized. Watch Our Medicare Tutorial.


Do I Have to Enroll in Medicare?

After years of paying into Medicare, it's a big milestone when you finally qualify to sign up. For some, it's a huge relief, and for others who aren't quite ready for Medicare, it's important to know your options.

While you are not required to enroll in Medicare, there are late enrollment penalties-Part B can have a 10% penalty and Part D can have a 1% of the national base premium penalty. These penalties may apply if you choose not to enroll when initially eligible and may also apply if you choose to enroll at a later date.

There are times when enrollment is not required (e.g., full-time employee and covered by a group plan that doesn't require Medicare enrollment). You might also qualify to delay your insurance if you work for a company or organization that employs 20 or more people.


When Can I Enroll?

You might not be ready yet, but you should plan to apply for Medicare Parts A and B (if eligible) if you aren't getting Social Security, Railroad Retirement Board benefits, or benefits through another retirement fund.

Sign up early to avoid a delay in coverage. To get Part A and/or Part B the month you turn 65, you must sign up during the first three months before the month you turn 65.

You can apply during any of the seven months that make up what's called the Initial Enrollment Period. This includes the three months before your birth month, the month of your birthday, and the three months after your birth month.

If you apply at any time during the three months before your birth month, you'll be covered by Original Medicare on the day you turn 65. Otherwise, you'll have to wait another month—or more.

If you wait until the last three months of your Initial Enrollment Period to sign up for Part A and/or Part B, your coverage will be delayed.

Learn more about ways to enroll in a Blue Cross plan.

Initial Enrolment Period

Your Medicare Coverage Choices

Medicare Coverage Choices

Types of Plans

There are several types of Medicare plans. It's up to you to decide which services you choose and who administers your benefits (a private health insurance company or the government).


Medicare Enrollment Frequently Asked Questions

Unless you or your spouse are still working, if you don't sign up for Part B during your Initial Enrollment Period, you may only be able to sign up during the General Enrollment Period or a Special Enrollment Period (if you qualify).

The General Enrollment Period runs from January 1 to March 31 of each year. You may also have to pay a penalty for your Part B premium if you don't sign up during your Initial Enrollment Period, so that's why signing up at 65 can be a smart move for your health—and your wallet.

Your monthly premium will permanently increase 10% for each 12-month period you could have enrolled but did not. This would mean you decided not to sign up during your Initial Enrollment Period or a Special Enrollment Period (if you qualify). However, if you get insurance through your job or your spouse's, then you don't have to pay the penalty.

10% increase for each 12-month period.

If you are covered by a group health plan under your own or through your spouse's current employer, you may be able to delay signing up for Part B during your Initial Enrollment Period and enroll later during a Special Enrollment Period. To find out the best time for you to enroll in Part B, call Social Security or your benefits administrator.

You may sign up for Part B any time while you are covered by a group health plan:

  • Based on your own or your spouse's current employment

  • During the eight-month period following the last month of employment

  • Or coverage by the health plan, whichever occurs first

People who sign up for Part B during the Special Enrollment Period usually don't pay a penalty.

You may want to enroll in premium-free Part A when you turn age 65, but wait to sign up for Part B (since you will have to start paying premiums). To find out the best time for you to enroll in Part B, call Social Security or your benefits administrator.

If you are getting Social Security benefits, the Part B premium is taken out of your monthly Social Security payment. If you don't get full Social Security benefits yet, Medicare will send you a bill for your Part B premium every three months. If you don't get your bill by the 10th of the month, call Social Security anytime, 24 hours a day at 1-800-772-1213 (TTY: 1-800-325-0778).


How Does Medicare Work With Other Insurance?

If you have Medicare and other health insurance (or coverage), each type of coverage is called a "payer." When there's more than one payer, the "coordination of benefits" rule decides which one pays first. The "primary payer" pays what it owes first and then sends the remainder of what is owed to the "second payer" to pay. In some cases, there may also be a third payer.

Whether Medicare pays first depends on a number of situations.


For example, if you are 65 or older, entitled to Medicare, and you are covered by a group health plan because you or your spouse is still working, the chart below demonstrates when Medicare would pay first.

If you have questions about who pays first, or if your coverage changes, call the Benefits Coordination & Recovery Center (BCRC) toll-free at 1-855-798-2627. (TTY: 1-855 797 2627)

If the employer has 20 or more employees

Group Health Plan

Medicare

If the employer has less than 20 employees

Medicare

Group Health Plan

* If your employer participates in a plan that's sponsored by two or more employers, the rules are slightly different.

 

How do primary and secondary coverage work together?


The insurance that pays first (primary payer) pays up to the limits of its coverage. Then the secondary payer only pays if there are costs that were not covered by the primary insurer. Keep in mind, the secondary payer (which may be Medicare) may not pay all of the uncovered costs.

If your employer insurance is the secondary payer, you may need to enroll in Medicare Part B before your insurance will pay.

What does "paying first" mean?


When an insurer pays first, it means they have paid the bill up to the limits of the coverage. It doesn't mean the primary payer necessarily paid before the secondary payer. In fact, if the primary payer doesn't pay the claim promptly (usually within 120 days), your doctor or other insurance provider may bill Medicare.

Medicare may make a conditional payment to pay the bill, and then later recover any payments the primary payer should have made. A conditional payment is a payment Medicare makes for services another payer may be responsible for.


Two Options to Getting Your Medicare Coverage

When it comes to health care coverage, you have options. The key is to explore them thoroughly and make the choice that best fits your lifestyle and health needs.

 

Medicare Chart

Option 1: Original Medicare + Supplemental Coverage.

Part A (Hospital Insurance): No premium for most people


Part B (Medical Insurance): Optional at a standard monthly premium

You can also add to Original Medicare with:

 

Medigap Policy (Medicare Supplement Insurance)


An optional policy, purchased from private insurance companies to fill in gaps in Original Medicare coverage.

 

Part D Prescription Drug Coverage


An optional policy, purchased from private insurance companies, which covers costs for prescription drugs. Part D plans are often paired with a Medigap plan for comprehensive coverage across all aspects of your health care.

Medicare Advantage chart

Option 2: Medicare Advantage Plans

  • Provide Medicare Parts A and Benefits (you must enroll in Parts A and B); possible additional benefits like vision, hearing, and dental.

  • Available for purchase from private insurance companies

  • Out-of-pocket costs vary by plan types and insurance companies

  • Medicare Advantage plans include

    • HMO

    • PPO

    • PFFS

  • Some plans include Part D prescription drug coverage

  • Your monthly premium equals your Part B premium and Medicare Advantage plan premium

 

For more information, visit www.medicare.gov and download the Medicare & You brochure, or call 1-800-MEDICARE (1-800-663-4227) (TTY: 1-877-486-2048), 24 hours a day/7 days a week, for details.


What Does Original Medicare Offer?

Original Medicare includes Part A (Hospital Insurance) and Part B (Medical Insurance). These complement each other. Part B helps pay for some services that Part A doesn't cover.

Medicare Part A (Hospital Insurance) helps pay for:

Your inpatient care in hospitals, including the cost of a shared hospital room, meals and nursing. It can also assist with costs associated with hospice, home health, and skilled nursing facility care if you meet certain requirements.

Medicare Part B (Medical Insurance) helps pay for:


Services that are considered important for the diagnosis or treatment of a medical condition. These include doctor visits, procedures that didn't require an overnight hospital stay and some preventive care services, such as flu shots.

Medicare Part A: If you and your spouse paid Medicare taxes while working, you many not have to pay a monthly premium for Part A services. If you don't qualify for premium-free Part A, you can purchase it.

To learn more, visit "Part A costs" at medicare.gov, or call 1-800-MEDICARE (1-800-663-4227) (TTY: 1-877-486-2048), 24 hours a day/7 days a week, for details.

Medicare Part B: Like most people, you may pay a monthly premium for Part B. (In 2017, the Part B Premium is $183 per month.)

You may pay more or less for your premium based on your income. For Original Medicare, you may also pay:

  • A deductible, a set amount you pay every year before Medicare coverage begins

  • The entire cost of services not covered by Medicare

  • Co-insurance, or a portion of what the Medicare-approved service costs. In most cases, you will pay 20%


How Do Medicare Advantage Plans Differ From Medicare Supplement Plans? (And…which is right for you?)

Medicare Advantage plans may be your best choice if you prefer a low monthly premium and the simplicity of a single plan to cover your medical, hospital, and prescription costs.

  • Provides your Part A and Part B coverage from the Medicare Advantage plan and not Original Medicare

  • May offer additional benefits that are not part of Original Medicare such as vision, hearing, dental, wellness programs, and more

  • May include prescription drug coverage

  • Typically require the use network providers

Medicare Supplement insurance plans may be your best choice if you want the most freedom to travel and see any doctor or hospital that accepts Medicare.

  • Designed to pay for certain health care expenses not covered by Medicare Part A and Part B

  • Does NOT provide prescription drug coverage (but can be added as a standalone Part D prescription drug plan)

  • Provides free choice of your doctor and hospital (who must accept Original Medicare)

Coverage provided by:

Must cover the same Part A and Part B benefits as Original Medicare. Can also cover benefits like vision and dental care.

Helps cover many of the costs that Original Medicare leaves you to pay out of pocket, such as deductibles and co-insurance.

Prescription Drug coverage

Some plan options include prescription drug benefits.

Medicare supplement plans DO NOT cover prescription drugs.

Plan options

The most common types are HMOs (Health Maintenance Organizations), PPOs (Preferred Provider Organizations) and PFFS (Private-Fee-for-Service) plans.

Two standard Medigap policies are offered to Massachusetts residents: Medicare Supplement Core and Medicare Supplement 1. However, some insurers may offer additional plan options.

Doctor and hospital choice

Medicare Advantage plans may require you to only see providers within the plan's network. Some plans allow you to go out of network but higher costs may apply.

You can see any provider that accepts Original Medicare.


All About Medicare Prescription Drug Coverage

Medicare Part D plans help cover your costs for prescription drugs. Part D plans are available through private companies, and you must actively enroll. Even if you currently don't spend a lot of money on medications, choosing to enroll in a Medicare Part D plan now can help protect you from high drug costs in the future. And, if you don't enroll when you are first eligible, you may pay a penalty fee if you enroll later.

  • You can enroll in a Medicare Advantage plan that includes Part D coverage.

  • Or, you can enroll in a standalone Medicare prescription drug plan (PDP), if you want drug coverage along with Original Medicare.

If you aren't already enrolled in a Part D plan and suddenly need drug coverage, you can't start coverage until next enrollment period (usually next October)-which could mean you have no coverage for a lengthy period of time!

  • commonly used brand name and generic drugs

  • drugs that are covered can vary from plan to plan

  • some plans offer more drugs than others

Typically, Part D plans don't cover over-the-counter medications.

  • depends on the way you receive the benefit

  • may include an annual deductible and co-insurance or copayments

  • most PDPs also have a monthly premium you pay for the coverage, in addition to your Part B premium

  • Medicare Advantage plans also require a premium that may include the cost of Medicare Part D

If you are getting Social Security benefits, the Part B premium is taken out of your monthly Social Security payment. If you don't get full Social Security benefits yet, Medicare will send you a bill for your Part B premium every three months. If you don't get your bill by the 10th of the month, call Social Security anytime, 24 hours a day at 1-800-772-1213 (TTY: 1-800-325-0778).

Most Medicare drug plans have a coverage gap, also called the “donut hole.” After you and the plan spend a certain amount on covered drugs, you pay:

  • no more than 35% of the plan's costs for brand drugs, and...

  • 44% of the plan's costs for generic drugs, until...

  • your yearly out-of-pocket drug costs reach $3,750

  • Medicare Advantage plans also require a premium that may include the cost of Medicare Part D

These savings in the coverage gap increase each year through 2020.

Once you reach your plan's out-of-pocket limit, you automatically get "catastrophic coverage", which ensures that once you have spent up to your plan's out-of-pocket limit for covered drugs, you only pay a small co-insurance amount or copayment for covered drugs the rest of the year.

For more information, download the free publication "Closing the Coverage Gap" from medicare.gov.


Build the Medicare Plan That's Right for You

What to consider

As you consider how to assemble the right coverage for your situation, remember to consider these important factors:

  • Cost

  • Benefits

  • Doctor and hospital choice

  • Convenience

  • Pharmacy choice

  • Quality of care

Two ways to build your plan

  1. If you're the type of person who prefers to tailor a plan to best meet your specific needs, you can pull together different types of Medicare coverage into one package…
Tailored Plans Chart

 

Part A
 - Hospital Insurance

Part B
 - 
Medical Insurance

Part D
 - 
Prescription Drug Coverage

Medicare Supplemental Insurance Policy 
(Medigap Policy)

2. If you think that an available Medicare Advantage plan best meets your needs, you can opt for one plan that combines the Parts you need…

One Plan Chart

 

Part C

(Includes Medicare Part A and Part B and some additional benefits like dental vision or hearing care. Medicare Advantage plans may also include prescription drug benefits.)


Researching Medicare: Resources For Deeper Understanding

The Social Security Administration

For information about signing up for both Social Security and Medicare, call your local Social Security office toll-free at 1-800-772-1213 (TTY: 1-800-325-0778). Recorded information is available 24 hours a day.

Medicare.gov

Helpful publications about Medicare are available online. These will help you compare the Medicare Supplement and Medicare Advantage Plans, and the Medicare Part D Prescription Drug Plans that are available in your area.

SHINE

SHINE stands for Serving the Health Information Needs of Everyone. They work closely with the Massachusetts Councils on Aging, who support the independence of adults 60 and older by advocating for programs and services to meet their needs. You can contact Massachusetts' state health insurance program for free, one-on-one insurance information, counseling and assistance.

Glossary


Still Working?

Talk to your current benefits coordinators. They can explain the Medicare process and other retirement issues, plus discuss whether you should continue with your group coverage.

Talk to Your Doctor

They may be a good source of information. The insurance coordinator in your doctor's office may also be able to discuss health care coverage choices.