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How do I qualify for Medicare?

In order to qualify, you must meet one of the three following requirements

Turning 65

Turning 65

If you’re already getting benefits from Social Security or the Railroad Retirement Board (RRB), you’ll automatically get Part A and Part B starting the first day of the month you turn 65. (For those who have birthdays on the first day of the month, Part A and Part B will start the first day of the month before.)

If you automatically get Medicare, you’ll get your red, white, and blue Medicare card in the mail 3 months before your 65th birthday. If you’re close to 65, but NOT getting Social Security or RRB benefits, you’ll need to sign up for Medicare. You can do this by either going to your local Social Security Office, calling Social Security at 1-800-772-1213, or by going online to their website. If you worked for a railroad, contact the RRB.

By Having A Qualifying Disability Before Turning 65

Qualifying Disability

If you have a qualifying disability, you may start receiving coverage early. You’ll automatically get Part A and Part B after getting 24 months of disability benefits, either from Social Security or certain disability benefits from the RRB. You’ll get your red, white, and blue Medicare card in the mail three months before your 25th month of disability benefits.

Diagnosed With ESRD Or ALS

Diagnosed With ESRD Or ALS

If you have End-Stage Renal Disease (ESRD) and want Medicare, you’ll need to sign up for it. Contact Social Security to find out when and how to sign up for Part A and Part B. For more information, visit to review the booklet, “Medicare Coverage of Kidney Dialysis & Kidney Transplant Services.” If you have ALS (amyotrophic lateral sclerosis, also called Lou Gehrig’s disease), you’ll get Part A and Part B automatically the month your Social Security disability benefits begin.

When Do I Sign Up?

Initial Enrollment Period (SEP)

Your Initial Enrollment Period starts three months before your 65th birthday. You can sign up during that time, during your birthday month, or during the three months after your birthday month. If you sign up for Part A and/or Part B during the first 3 months, your coverage begins the first day of your birthday month, but if your birthday is on the first, it’ll start the month before. If you don’t sign up before the month you turn 65, your coverage starts the first day of the month after you sign up. There may be a penalty if you miss your IEP – unless you qualify for a Special Enrollment Period.

Special Enrollment Period (SEP)

After your Initial Enrollment Period is over, you may be able to sign up during a Special Enrollment Period. For example, if you didn’t sign up for Part B (or Part A if you have to buy it) when you were first eligible because you have group health plan coverage based on current employment, you can sign up for Part A and/or Part B any time you’re still covered by the group health plan or during the 8-month period that begins the month after the coverage ends.

Your coverage starts the first day of the month after you sign up. Usually, you won’t have to pay a late enrollment penalty if you sign up during a Special Enrollment Period. This period doesn’t apply if you’re eligible for Medicare based on End-Stage Renal Disease (ESRD), or you’re still in your Initial Enrollment Period

Medicare Part C and Part D Only

Annual Enrollment Period (AEP) – October 15th to December 7th

This is the time each year to enroll in or change your Medicare Advantage or Part D plan. You may also switch to only Original Medicare (Parts A and B). New coverage begins January 1 of each year.

Open Enrollment Period (OEP) – January 1st to March 31st

This is an extra time each year when you can make one enrollment change to your Existing Medicare Advantage plan. You can do one of the following:

  • Move to a different Medicare Advantage Plan
  • Drop your Medicare Advantage plan to stay with Original Medicare. If you do this and need drug coverage, you have until March 31st to add a Medicare Part D (prescription drug) plan.

What are the different Parts of Medicare?

Original Medicare – A Federal Program

Hospital Insurance

Part A covers Hospital Expenses, including Inpatient care, nursing facilities, hospice care, and home health.

What’s the cost?

If you’ve worked for 10 or more years (40 quarters or more) or are married to someone who did, your Part A is of no cost to you. Working for seven and a half years (or thirty quarters) means your monthly premium is $278. If you worked less than that, you must pay the full cost of the monthly premium which is $505 in 2024.

If you aren’t eligible for premium-free Part A, and you don’t buy it when you’re first eligible, your monthly premium may go up 10%. You’ll have to pay the higher premium for twice the number of years you could have had Part A but didn’t sign up. For example, if you were eligible for Part A for 2 years but didn’t sign up, you’ll have to pay a 10% higher premium for 4 years.

The Part A deductible is currently $1,632 and must be met by you every time you are admitted to a hospital.

Medical Insurance

Part B covers Medical Expenses, including doctor visits, outpatient care, home health, medical equipment, and preventative services.

What’s the cost?

The monthly premium for Part B in 2024 is $174.70. The premium changes every year, so you should expect increases as time goes on.

If your modified adjusted gross income is above a certain amount, you may pay an Income Related Monthly Adjustment Amount (IRMAA). IRMAA is an extra charge added to your premium.

The annual Part B deductible is currently $240. Often, people will choose to wait to enroll in Part B later if they’re still working and have creditable coverage so they don’t have to pay that premium on top of the insurance they already have. If you have other coverage and need help deciding if you should keep Part B, click here.

Additional Coverage – Private Plans

However, Medicare doesn’t cover everything. There are private companies that offer additional coverage following the program’s guidelines created by the Government. If you don’t have both Part A and Part B, you cannot get additional Medicare coverage.

Medicare Supplements

Medicare Supplements (also called Medigap) pay some or all of the costs not covered by Parts A and B. This can include copays, coinsurance, and/or deductibles. Supplements do not include drug coverage, but can work hand-in-hand with a Part D Drug plan. You can choose between Plan A, B, C, D, F, G, K, L, M, N, or Select. Each of the plans has various benefits, some considered better than others. Plans C and F are no longer available to people new to Medicare on or after January 1, 2020. Not all types of Medigap policies may be available in your state.

Medigap Plans Chart
BenefitsPlan APlan BPlan CPlan DPlan F*Plan G*Plan K**Plan L**Plan MPlan N
Medicare Part A coinsurance and hospital
costs (up to an additional 365 days after
Medicare benefits are used)
Medicare Part B
coinsurance or copayment
100%100%100%100%100%100%50%75%100%100% ***
Blood (first three pints)100%100%100%100%100%100%50%75%100%100%
Part A hospice care
coinsurance or copayment
Skilled nursing facility care coinsurance100%100%100%100%50%75%100%100%
Part A deductible100%100%100%100%100%50%75%50%100%
Part B deductible100%100%
Part B excess charge100%100%
Foreign Travel emergency
(up to plan limits)
This chart shows basic information about the different benefits that Medigap plans cover. If a percentage appears, the Medigap plan covers that percentage of the benefit, and you must pay the rest. If a box is blank, the plan doesn’t cover that benefit.

* Plans F and G also offer a high-deductible plan in some states. If you get the high-deductible option, you must pay for Medicare-covered costs (coinsurance, copayments, and deductibles) up to the deductible amount of $2,700 in 2023 before your policy pays anything, and you must also pay a separate deductible ($250 per year) for foreign travel emergency services.

** Plans K and L show how much they’ll pay for approved services before you meet your out-of-pocket yearly limit and your part B deductible ($226 in 2023). Plan K pays $6,940 and Plan L pays $3,470 in 2023. After you meet these amounts, the plan will pay for 100% of your costs for approved services for the rest of the calendar year.

*** Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that don’t result in an inpatient admission.

If you’re thinking about buying Medigap, be sure to contact us so we can help you compare plans. The costs can vary between plans offered by different companies for the same coverage, and may go up as you get older.

Medicare Advantage Plans

Medicare Advantage Plans (also called Medicare Part C and MA Plans) provide another way to get your Medicare Part A and Part B coverage. They are Medicare-approved plans offered by private companies that must follow rules set by Medicare. Most Medicare Advantage Plans include drug coverage (Part D). In many cases, you’ll need to use health care providers who participate in the plan’s network. These plans set a limit on what you’ll have to pay out-of-pocket each year for covered services. Some plans offer non-emergency coverage out of network, but typically at a higher cost. In many cases, you may need to get approval (prior authorization) from your plan before it covers certain drugs or services.

With a Medicare Advantage Plan, you may have coverage for things Original Medicare doesn’t cover, like fitness programs (gym memberships or discounts) and some vision, hearing, and dental services. Plans can also choose to cover even more benefits. For example, some plans may offer coverage for transportation to doctor visits, over-the-counter drugs that Part D doesn’t cover, and other health care services. Check with the plan before you join to find out what benefits it offers, and if there are any limitations. Plans can also tailor their benefit packages to offer additional benefits to certain chronically-ill enrollees. These packages will provide benefits customized to treat specific conditions.

Medicare Advantage Plan Types

Types of Medicare Advantage Plans

Health Maintenance Organization (HMO) PlanMedical Savings Account (MSA) PlanPreferred Provider Organization (PPO) PlanPrivate Fee-for-Service (PFFS) PlanSpecial Needs Plan (SNP)
Can I get my health care from any doctor, other health care provider, or hospital?No (except for emergency care, which is covered regardless).Yes. MSA plans usually don’t have a network.Yes. PPO plans have a network you can use. You can also use out-of-network providers for a higher cost.Yes. You can go to any health care provider or hospital that accepts the plan’s payment terms and hasn’t opted out of Medicare.Some SNPs cover services out of network and some don’t. Check with the plan to find out how it affects your costs.
Do these plans cover prescription drugs?In most cases, yes. If you want an HMO and Medicare Part D, you must join an HMO plan that offers drug coverage because you can’t join a separate drug plan.No. You’ll have to join a separate Medicare drug plan.In most cases, yes. If want a PPO and Medicare Part D, you must join a PPO plan that offers drug coverage because you can’t join a separate drug plan.Sometimes. If your PFFS Plan doesn’t offer Medicare Part D, you can join a separate Medicare drug plan.Yes. All SNPs must provide Medicare Part D
Do I need to choose a primary care doctor?In most cases, yes.No.No.No.Some SNPs require primary care doctors and some don’t.
Do I have to get a referral to use a specialist?In most cases, yes. No.In most cases, no.No.Some SNPs require referrals and some don’t.
What else do I need to know about this type of plan?If you get non-emergency health care outside the plan’s network without authorization, you may have to pay the full cost.
It’s important that you follow the plan’s rules, like getting prior approval for a certain service when needed.
The plan deposits money into a savings account to pay your Medicare-covered costs before you meet the deductible. Money left in your account at the end of the year stays there.
The plan will only begin to cover your Medicare costs once you meet a high yearly deductible, which varies by plan.
Because certain providers are “preferred,” you can save money by using them.The plan decides how much you pay for services. Some PFFS Plans contract with a network of providers who agree to always treat you, even if you’ve never used them before. Out-of-network doctors, hospitals, and other providers may decide not to treat you, even if you’ve used them before.A SNP is for: those living in institutions or who require nursing care at home (“Institutional SNP” or I-SNP); those eligible for both Medicare and Medicaid (“Dual Eligible SNP” or D-SNP); those with specific severe or disabling chronic conditions (like diabetes, ESRD, HIV/AIDS, chronic heart failure, or dementia) (“Chronic condition SNP” or C-SNP).

Prescription Drug Plans

Medicare drug coverage (Part D) helps pay for prescription drugs you need. It’s optional and offered to everyone with Medicare. Your actual drug coverage costs will vary depending on which prescriptions you take, what tier those prescriptions are in, and what benefit phase you’re in.

Part D Benefit Phases
Up To $545Deductible Phase
During this phase, you’ll pay the plan’s negotiated drug cost up to the deductible limit for your plan.
People Will Start Each Year In This Phase
Up To $5,030Initial Coverage Phase
During this phase, the plan will pay its share of the cost and you’ll pay a copayment or coinsurance (your share of the cost) for each prescription you fill until your total drug costs reach $5,030.
Most People Will Remain In This Phase
Up To $8,000Coverage Gap Phase
This phase is also known as the Donut Hole. During this phase, you’ll pay 25% of the cost for generics and brands. Some plans offer additional coverage in the gap for Tier 1 and Tier 2 drugs.
Some People Will Move Into This Phase
Through The End Of The YearCatastrophic Coverage Phase
You pay $0 for all Part D covered drugs during this phase. The cost of excluded drugs will vary depending on the plan.
Few People Will Reach This Phase

Even if you don’t take prescription drugs now, you should consider getting Medicare drug coverage once you’re eligible because you’ll likely pay a late enrollment penalty if you join a plan later. Generally, you’ll pay this penalty for as long as you have Medicare drug coverage.

If you have a higher income, you might pay more for your Medicare Part D. This is sometimes called “Part D IRMAA”. You’ll also have to pay this extra amount if you’re in a Medicare Advantage Plan that includes drug coverage.

Since I didn’t enroll in Part B when I first turned 65, can I enroll now?

Yes, you can. Lots of people hold off on Medicare Part B until later, usually because they’re still working and have creditable coverage. If you had creditable coverage, there is a Special Enrollment Period you may use to apply. You can apply any time you still have group coverage or up to eight months after your employment ends with no additional charge or penalty.

After you apply, you trigger the seven month period in which you can purchase additional coverage through private companies. You will have to provide proof of creditable coverage to the private company so they are aware, and you will have to do so again if you switch your plan to a different company. If you choose not to get additional coverage at this time, you must wait until the Annual Enrollment Period to do so unless you qualify for a different special enrollment. Please call us or fill out our contact form for further information.

If you did not have creditable coverage, you will be subjected to a Late Enrollment Penalty, also called a Part B Surcharge. This penalty is calculated by the Social Security Office. The longer you do not have a Part B, the more the late enrollment penalty will cost.

What is the Part D Penalty?

The late enrollment penalty is an amount that’s permanently added to your Medicare drug coverage (Part D) premium. You may have to pay a late enrollment penalty if you enroll after your Initial Enrollment Period if there’s a period of 63 or more days in a row when you don’t have drug coverage. You’ll generally have to pay the penalty for as long as you have Medicare drug coverage. If you get Extra Help, you don’t pay a late enrollment penalty.

The cost of the late enrollment penalty depends on how long you didn’t have creditable prescription drug coverage. Currently, the late enrollment penalty is calculated by multiplying 1% of the “national base beneficiary premium” ($34.70 in 2024) by the number of full, uncovered months that you were eligible but didn’t have Part D or other creditable prescription drug coverage. The final amount is rounded to the nearest $.10 and added to your monthly premium. The “national base beneficiary premium” may increase or decrease each year. If that occurs, the penalty amount may also increase or decrease.

There are 3 ways to avoid paying a penalty:

  1. Get Medicare drug coverage (Part D) when you’re first eligible for it. Even if you don’t take drugs now, you should consider joining a plan with drug coverage to avoid a penalty. You may be able to find a plan that meets your needs with little to no monthly premiums.
  2. Add Medicare drug coverage if you lose other creditable coverage. Your plan must tell you each year if your non Medicare drug coverage is creditable coverage. If you go 63 days or more in a row without Medicare drug coverage or other creditable prescription drug coverage, you may have to pay a penalty if you sign up for Medicare drug coverage later.
  3. Keep records showing when you had other creditable prescription drug coverage, and tell your plan when they ask about it. If you don’t, you may have to pay a penalty for as long as you have Medicare drug coverage.

After you get Medicare drug coverage, the plan will tell you if you owe a penalty and what your premium will be by sending you a letter. If you disagree with your penalty, you can request a review (generally within 60 days from the date on the letter). Fill out the “reconsideration request form” you get with your letter by the date listed in the letter. You can provide proof that supports your case, like information about previous creditable prescription drug coverage.

Can i have Medigap and medicare advantage?

While you can be enrolled in both, the two plan types can not be used together, only separately. If you have enrolled in a Medigap Plan and then enroll in a Medicare Advantage Plan, you need to drop your Medigap. If you’re in a Medicare Advantage Plan, it’s illegal for anyone to sell you a Medigap policy unless you’re switching back to Original Medicare. If you aren’t planning to drop your Medicare Advantage Plan, and someone tries to sell you a Supplement knowing that you have an Advantage Plan already, report it to your State Insurance Department.

The first time you enroll in a Medicare Advantage Plan, you are in a 12 month trial period. If you’re dissatisfied before the year is over, you can switch back to Original Medicare without medical underwriting. You also might be able to a buy a Medicare Part D plan during this period. If you don’t drop your Medicare Advantage Plan and return to Original Medicare within the trial period, you must keep your Medicare Advantage Plan for the rest of the year.

Talk to an Agent about Medicare plans, benefits, and premiums today!

Your agent will find the plan that’s right for you by taking into consideration your location, income, prescriptions, and medical needs. We represent the following companies that offer Part C, Part D, and Medigap Plans. Not all carriers sell all three types, and the plans offered will vary based on your location. Whether you’re ready to try out an Advantage Plan, move to a Supplement, or want Drug Coverage, Eversure Benefit Group has a variety of plans and options for you to choose from. Insurance doesn’t have to be hard; we’re here to help!

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