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Turning 65 and Have Questions About Medicare?

If you’re about to turn 65, you have some important decisions to make about your health care. Most adults become eligible for Original Medicare when they turn 65 – but will that cover all your needs?

Below are some common questions and answers people have about Medicare when they turn 65.

What is the difference between Original Medicare and Medicare Advantage?

People with Medicare can get their health coverage through either Original Medicare or a Medicare Advantage plan like Elderplan. Here’s a look at the differences between these two options.

Original Medicare is the traditional program offered directly through the federal government. You receive a red, white and blue card to show to your providers when receiving care, and it includes Part A (inpatient/hospital coverage) and Part B (outpatient/medical coverage). But it doesn’t provide certain benefits that you may need, like prescription drug coverage, long-term care, dental and eye exams, and more. Medicare usually pays only 80% of the costs, and the beneficiary is responsible for 20%.

Medicare Advantage plans usually have lower out-of-pocket costs and offer additional benefits that aren’t covered by Original Medicare, such as prescription drug coverage, hearing, dental, vision, wellness benefits, OTC coverage, transportation and much more! Medicare Advantage plans limit how much you will pay every year for medical costs. In most cases, you’ll need to use doctors in the plan’s network.

Should I choose Original Medicare or Medicare Advantage?

Medicare Advantage plans usually have lower out-of-pocket costs. They typically offer additional benefits that aren’t covered by Original Medicare, such as prescription drugs, hearing, dental, vision, wellness benefits like a gym membership, Over-the-Counter (OTC) coverage, and transportation. These benefits will vary depending on the plan you choose.

Compared to Original Medicare, Medicare Advantage plans are somewhat more restrictive since you will only be able to see the specific doctors covered by your plan. Some plans will also require a referral to see specialists. In addition, the coverage is often restricted to a particular geographical area, except in the case of an emergency.

You might consider Medicare Advantage if you:

– Confirm current physicians are covered by the plan you are considering or you are flexible about your choice of doctor

– Want to avoid deductibles and the 20% cost-sharing you are responsible for under traditional Original Medicare

– Live in one location most of the year

– Take several prescription drugs

– Have an interest in extra benefits (e.g., routine vision/dental/hearing services, membership in fitness programs, etc.)

When comparing Medicare Advantage plans, be sure to explore Elderplan, a member of MJHS Health System. Elderplan is a not-for-profit health plan that has cared for New Yorkers with compassion, dignity and respect for more than 35 years. Elderplan reinvests its earnings to provide improved benefits and services to Original Medicare- and dual-eligible (Original Medicare + Medicaid) beneficiaries.

When can I enroll in Medicare Advantage?

You must be enrolled in Original Medicare (Medicare Part A and Part B) to sign up for a Medicare Advantage.

The timeframe for enrolling in a Medicare Advantage plan is called an enrollment period. You have three enrollment periods during which you can choose or switch plans in each calendar year, the Initial Enrollment Period, Medicare Annual Enrollment Period (AEP), and the Medicare Advantage Open Enrollment Period (OEP). Learn More About When You Can Enroll in a Medicare Advantage Plan.

What is Original Medicare?

Original Medicare is the federal health insurance program for:

– People 65 years of age and older.

– Some people under age 65 who have disabilities.

– People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

What does Original Medicare cover?

Original Medicare has several Parts, and each Part covers a different aspect of your care:

  • Part A (Hospital Insurance)
  • Part B (Medical Insurance)
  • Part D (Prescription Drug Coverage)

Original Medicare often does not cover:

– Prescriptions

– Long-term care

– Dental

– Eye exams related to prescribing glasses

– Dentures

– Acupuncture

– Hearing aids and exams

You need to opt-in for a Medicare Advantage plan, like Elderplan, for these additional benefits.

What does Medicare Part A (Hospital Insurance) cover?

Medicare Part A helps pay for:

– Inpatient care in hospitals

– Skilled nursing facilities

– Hospice care

– Some home health care

For more information about Medicare Part A coverage, visit Your Medicare Coverage: English | Español.

What does Medicare Part B (Medical Insurance) cover?

Medicare Part B helps pay for:

  • Doctors’ services
  • Outpatient hospital care
  • Durable medical equipment (like wheelchairs, walkers, hospital beds, and other equipment)
  • Many preventive services (like screenings, shots or vaccines, and yearly “Wellness” visits)
  • Certain medically necessary services, such as physical and occupational therapy and some home health care

For more information about Medicare Part B coverage, visit Your Medicare Coverage: English | Español.

What is Medicare prescription drug coverage?

Medicare Prescription Drug Coverage (also known as Medicare Part D) helps cover your prescription drug costs (including many recommended shots or vaccines). You can join a Medicare drug plan in addition to Original Medicare, or you get it by joining a Medicare Advantage Plan, like Elderplan. The value of joining Elderplan is that you get your hospital, medical and prescription drug coverage under one plan.

Who accepts Original Medicare?

Most doctors and hospitals across the US accept Original Medicare, but you should always ask first.

Am I eligible for Original Medicare?

To be eligible for Medicare Part A and Part B, you must be a US citizen or a permanent legal resident for at least five continuous years and have worked and paid Medicare taxes for ten years. You must also meet at least one of the following criteria for Medicare eligibility:

– Be age 65 or older and eligible for Social Security

– Be permanently disabled and receive disability benefits for at least two years

– Have Lou Gehrig’s disease (Amyotrophic Lateral Sclerosis, or ALS)

For more information on Original Medicare eligibility, visit the Medicare website: English | Español.

When can I enroll for Original Medicare?

There are specific times you can enroll in Original Medicare.

– You can enroll in Original Medicare when you age into Medicare at 65 years old, beginning three months before your 65th birthday and extending to three months later.

– You can also enroll during the Annual Enrollment Period (AEP), which begins every year on October 15 and ends on December 7.

– Additionally, you can enroll during the Open Enrollment Period, January 1 – March 31. During this time, you can disenroll from your current plan and switch to a different Medicare Advantage plan or return to Original Medicare and purchase a Medicare supplement plan.

Outside of those times, there are special circumstances when certain life events occur that make you eligible to enroll. These chances to enroll are called ‘Special Enrollment Periods’ and may include the following:

– You move to a new address

– You change jobs

– You lose your current coverage

– You qualify for extra help from the government

– Your current plan changes its contract with Medicare

– And others

Learn more about when to enroll in Original Medicare

How do I sign up for Original Medicare?

If you decide to enroll in Original Medicare during the Annual Enrollment Period, you can sign up for Parts A and/or B by:

– Visiting your local Social Security office

– Calling Social Security at 1-800-772-1213 [TTY 1-800-325-0778] – make sure to ask for a written receipt

– Mailing a signed and dated letter to Social Security that includes your name, Social Security number, and the date you would like to be enrolled in Medicare – make sure to use certified mail and request receipt.

– Or, by applying online at ssa.gov – make sure to save your confirmation page.

– If you are eligible for Railroad Retirement benefits, enroll in Medicare by calling the Railroad Retirement Board (RRB) or contacting your local RRB field office.

Do I need a Primary Care Doctor with Original Medicare?

With Original Medicare, while you do not need to choose a primary doctor, you need to ensure that the doctor you wish to see accepts Original Medicare. However, if you enroll in a Medicare Advantage plan like Elderplan, you must choose a primary doctor within their provider network.

What are my additional options for health coverage beyond what Original Medicare covers?

If you have both Medicare Part A and Part B, you can sign up for a Medicare Advantage Plan from a private provider like Elderplan or for Medicare Supplemental Insurance (Medigap)

While there are several options to consider, one place to begin a search would be with the Medicare Options Compare on the Medicare website: English | Español. Or, call 1-800-MEDICARE (1-800-633-4227). TTY users can call 711 24 hours a day, seven days a week.

Do I automatically get Original Medicare when I turn 65?

If you are currently receiving Social Security benefits, you don’t need to do anything. You will be automatically enrolled in Medicare Parts A and B effective the month you turn 65. If you are not already receiving Social Security benefits, you will need to sign up for Original Medicare.

What happens if I don’t sign up for Original Medicare when I turn 65?

If you wait until the month you turn 65 (or the three months after you turn 65) to enroll, your Part B coverage will be delayed. This could cause a gap in your coverage. In most cases, if you don’t sign up for Medicare Part B when you’re first eligible, you’ll have to pay a late enrollment penalty.

What if I am still working and have employer insurance?

If you are working past age 65 and have insurance from your job (or your spouse is working and you get health coverage that way), you should contact your plan and review how your coverage will change before deciding whether you need to enroll in Original Medicare.

What is the difference between Medicare and Medicaid?

Medicare is federal health insurance for anyone age 65 and older and some people under 65 with certain disabilities or conditions. Medicaid is a joint federal and state program that provides health coverage for people with limited income and resources. Medicaid offers benefits like nursing home care, personal care services, and assistance paying for Medicare premiums and other costs.

Questions? Call Elderplan today.


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