Medicare FAQs

Understanding the Basics

1. Who administers Medicare?

The Centers for Medicare and Medicaid Services (CMS) , a part of the Department of Health and Human Services (HHS) administers the Federal Medicare Program. The Social Security Administration is responsible for determining Medicare eligibility and processing premium payments for the Medicare program. You enroll in Medicare at the Social Security office.

2. What is Medicare Part A?

Medicare Part A helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities. Part A also covers hospice care and home health care. This is not blanket coverage; you must meet certain requirements to get these benefits.

3. What is Medicare Part B?

Medicare Part B helps cover medical services like outpatient care, doctors’ services, and other medical services that Part A does not cover. Part B covers these services when they are medically necessary. Part B also covers some preventive services.

4. What is Medicare Part C?

Medicare Part C, formerly known as “Medicare+Choice,” is now known as “Medicare Advantage.” If you are entitled to Medicare Part A and enrolled in Part B, you are eligible to switch to a Medicare Advantage plan, provided you reside in the plan’s service area. Medicare Advantage Plans include: Preferred Provider Organization (PPO) Plans; Health Maintenance Organization (HMO) Plans; Private Fee-for-Service (PFFS) Plans; Special Needs Plans (SNPs); and Medicare Medical Savings Account (MSA) Plans.

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5. What is Medicare Part D?

Medicare Part D is prescription drug coverage. If you have Medicare Part A or Medicare Part B, or a Medicare Advantage Plan (Part C), you are eligible for Part D. Although this prescription insurance is optional, if you decide not to enroll when you are first eligible, you may pay a penalty if you choose to join later. Part D plans are offered by private insurance companies and other private companies approved by Medicare. Most times, you pay an additional monthly premium for Part D coverage.

6. How do I enroll in Medicare?

If you are receiving Social Security benefits when you turn 65, you will automatically get both Medicare Part A and Part B on the first day of the month in which you turn 65. You may decline Part B in some situations. If you are not receiving Social Security when you turn 65, you should go to your local Social Security office to enroll in Medicare three months before your 65th birthday

If you are disabled and have been receiving Social Security Disability Insurance (SSDI), you are eligible for Medicare after you have been receiving SSDI for 24 months. This 24 month period is lessened for certain disabilities. To enroll in Part D plan, you have to join a Medicare private drug plan that is offered in your area. Whether or not you should sign up for a Part D plan depends on your circumstances.

7. What is the difference between Original Medicare and a Medicare Advantage Plan?

The original Medicare program is available nationwide and is a pay-per visit health plan. You can go to any health care provider who accepts Medicare and is accepting new Medicare patients. There are costs that you must pay, such as deductibles, co-payments and coinsurance. Some people buy a Medigap policy to cover these gaps in coverage (see Question # 15: “What is a Medigap policy?” below).

Original Medicare has two parts. Part A provides hospital insurance and Part B, which is optional, provides medical insurance. If someone chooses Part B, a monthly premium is deducted from his or her Social Security benefits. Insurance companies and other private companies work with Medicare to offer prescription drug coverage. Costs vary depending on which plan is selected by the individual.

Medicare Advantage Plans, also known as Part C, are managed care Medicare plans. Medicare pays a set amount of money for a beneficiary’s care every month to these private health plans whether or not services are used. In most of these plans, generally there are extra benefits and lower copayments than in the Original Medicare Plan. However, you may have to see doctors that belong to the plan or go to certain hospitals to get services.

If you enroll in a Medicare Advantage Plan, you probably won’t need a Medigap policy because Medicare Advantage Plans usually provide a wider range of services. Remember: Medicare—whether Original Medicare or Medicare Advantage Plan—does not cover all health care services, nor does it pay the entire cost of all the services that it does cover.

8. Where do I request a replacement Medicare card?

If your red, white, and blue Medicare card is lost or damaged, you can order a new one through Social Security by calling 1-800-772-1213, by visiting on line, or by arranging an appointment at your local Social Security office.

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9. What does the term Extra Help mean in regard to Part D prescription drug coverage?

If your monthly income and your assets fall within certain limits, you may be eligible for Extra Help, a federal program that helps you pay for some or most of the costs of Medicare prescription drug coverage. If you qualify, you will get help paying, not only for your prescription drug plan’s monthly premium, but also for the plan’s yearly deductible and prescription co-payments.

10. Where do I apply for Extra Help?

You automatically qualify for Extra Help (and so do not need to apply for it) if you have Medicare and have or become eligible for Medicaid benefits, a Medicare Savings Program, or receive Supplemental Security Income (SSI) benefits without Medicaid. If you do not automatically qualify for Extra Help, apply for it by calling Social security at 1-800-772-1213, visiting on the web, or submitting an application at the Department of Social Services Medicaid office.

11. What is a Medicare Savings Program?

Medicare Savings Programs offer assistance to people with limited income and resources. These programs pay Medicare premiums and, in some cases, Medicare Part A and Part B deductibles and co-insurances.

12. Where do I apply for a Medicare Savings Programs?

Apply for Medicare Savings Programs at the Department of Social Services/Medicaid office. It is worth it to apply even if you think your income and resources are above the limits because certain income and resources are not counted.

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13. What is EPIC?

EPIC (Elderly Pharmaceutical Insurance Coverage) is the New York State sponsored prescription plan for senior citizens who need help paying for their prescriptions. New York State residents can join EPIC if they are 65 or older, and have an annual income of $35,000 or less if single, or $50,000 or less if married.

Seniors who receive full Medicaid benefits are not eligible for EPIC. Seniors with other prescription coverage through Medicare or most other plans can join EPIC to cover drug costs not covered by that other coverage. New EPIC eligibility requirements require enrollment in a Federal Prescription drug plan.

14. What is the difference between Medicare and Medicaid?

Medicare is a federally funded and administered program that provides health insurance for older Americans and those who are disabled. Individuals contribute to Medicare during their working years, just as they do to Social Security. Since Medicare is a federal program, eligibility guidelines and services are much the same all over the country.

Medicaid is a state-administered health insurance program financed and run jointly by the federal and state governments for low-income people of all ages who do not have the money or insurance to pay for health care.

15. What is a Medigap policy?

A Medigap policy (also known as Medicare Supplement Insurance) is health insurance designed to supplement the Original Medicare Plan. Medigap policies help pay some of the health care costs that Original Medicare does not cover, such as deductibles, co-pays or co-insurance. Medigap policies are sold by private insurance companies. In New York State, Medigap policies may be purchased at any time.

16. Who can help me with Medicare questions in Tompkins County?

Your best source of unbiased information will come from an independent, professional insurance agent. As an independent agency, we represent many fine insurance carriers and can help you decide which plan makes the most sense for your individual situation. With 18 years of experience working with people just like you, we are uniquely positioned to help answer your questions.

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