The ABC’s of Medicare | California Benefits Team

Trying to figure out Medicare can be one of the most frustrating aspects of retirement.  Even the savviest of retirees struggle with figuring out when to enroll and which parts to enroll in – there’s Part A, Part B, Part C, Part D, Medigap plans and so on. And, what in the world is a donut hole, anyway?

What is Medicare?

Medicare is the government health care program for people 65 and over as well as some younger people with disabilities.  Medicare’s coverage plays an important role in containing medical costs as you age. Medicare is a different program than Medicaid, which offers health and other services to eligible low-income people of all ages.

Types of Medicare

  • Part A covers inpatient hospital stays, skilled nursing facility stays, some home health visits, and hospice care. Generally, you don’t have to pay premiums if you or your spouse paid Medicare taxes for at least 10 years.
  • Part B covers doctor visits and other medically necessary services and supplies. That includes preventive services or health care to prevent illness, as well as ambulance services, durable medical equipment and mental health coverage. Part B comes with a monthly price tag – the standard premium was $148.50 in 2021.
  • Part C or Medicare Advantage is a type of health plan offered by private insurance companies that provides the benefits of Part A and Part B and often Part D as well. These bundles plans may have additional coverage such as vision, hearing, dental care and may even include perks such as gym memberships or transportation to doctor’s appointments. Medicare Advantage plans have an annual limit on out-of-pocket costs.  Medicare Advantage plans are typically HMOs or PPOs.
  • Part D is the prescription drug benefit that covers most outpatient prescription drugs. It is a separate plan provided by private Medicare approved companies, and you must pay a monthly premium.  Unless you have creditable drug coverage and will have a Special Enrollment Period, you should enroll in Part D when you first get Medicare. If you delay enrollment, you may face gaps in coverage and enrollment penalties.  Most plans with Medicare prescription drug coverage (Part D) have a coverage gap (called a “donut hole”).  That means that after you and your drug plan have spent a certain  amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit.  Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again.
  • Medigap or Medicare Supplement Insurance is an additional health insurance policy you can buy from a private insurer to help pay some of the costs not covered by Medicare Part A and Part B, including deductibles, coinsurance and health care if you travel outside the U.S. Medigap policies do not cover prescription drugs, dental, vision, hearing aids, private nursing care or long-term care. There are 10 types of Medigap plans available in most states.

When to Sign Up for Medicare

For most people, signing up for Medicare occurs during a 7 month initial enrollment period(IEP).   The IEP starts 3 months before you turn age 65 and continues for 3 months after your birthday. You may be eligible sooner if you have a disability, End-Stage Renal Disease (ESRD), or ALS (also called Lou Gehrig’s disease).

During the IEP, you can sign up for Medicare Part A.  Even if you are still working after you turn 65, you should consider signing up for Part A now.  If you’ve worked and paid Medicare taxes, it comes at no cost to you and covers hospital services.

You can join, switch, or drop a Medicare Health Plan or a Medicare Advantage Plan (Part C) with or without drug coverage during these times:

  • Initial Enrollment Period – When you first become eligible for Medicare, you can join a plan.
  • Open Enrollment Period – From October 15 – December 7 each year, you can join, switch, or drop a plan.
  • Medicare Advantage Open Enrollment Period – From January 1 – March 31 each year, if you’re enrolled in a Medicare Advantage Plan, you can switch to a different Medicare Advantage Plan or switch to Original Medicare (and join a separate Medicare drug plan) once during this time.

Let’s be honest, no one gets too excited about enrolling in Medicare, but the more you know, the easier it is.  Being prepared for life’s unexpected twist and turns and keeping up with your health care is more important than ever.  By understanding the ABC’s of Medicare, you are empowering yourself for your future!

Other Helpful Resources Include:

Understanding Medicare’s Options: Parts A, B, C and D

What is Medicare?

An Overview of Medicare