If you're 65 or over (or turning 65 in the next 3 months) and not already getting benefits from Social Security, you need to sign up to get Medicare Part A (hospital insurance) and Part B (medical insurance). Part B is optional for Original Medicare; however, it is required when you apply for a Medicare Advantage plan. You can sign up for Medicare online or contact Social Security. Social Security will then review your records to see if you qualify for Medicare.
You are eligible to apply for Medicare 3 months prior to the month you turn 65 and the month you turn 65. If you don't apply for Medicare within 3 months of turning 65, you'll have to wait for the next enrollment period to apply.
HMO stands for health maintenance organization. HMO insurance has a narrower network than PPO insurance and is usually referral-based. Members typically are required to go to a primary care physician (PCP) first and then be referred to specialists, most likely in their network. Because of the limitations of the network covered, HMO insurance is typically a lower cost plan.
The Annual Election Period, October 15th to December 7th, is your yearly opportunity to compare your options and choose a Medicare Advantage plan that best meets your needs and budget. To help get you started, here are some things to consider:
— Does the plan offer a $0 monthly premium?
— Are the doctors and specialists that you see included in the plan’s network?
— Does the plan formulary include your prescription drug?
As explained on the Health and Human Services website, generally Medicare is available for people age 65 or older, younger people with disabilities, and people with end-stage renal disease, or ESRD (permanent kidney failure requiring dialysis or transplant). Medicare includes Part A (hospital insurance) and Part B (medical insurance). You are eligible for premium-free Part A if you are 65 or older and you or your spouse worked and paid Medicare taxes for at least 10 years. You can get Part A at age 65 without having to pay premiums if:
— You are receiving retirement benefits from Social Security or the Railroad Retirement Board.
— You are eligible to receive Social Security or Railroad benefits but you have not yet filed for them.
— You or your spouse had Medicare-covered government employment.
Medicare Part D is the prescription drug coverage of Medicare. The benefit is administered by commercial insurance plans, either as a stand-alone prescription drug plan or as a part of a Medicare Advantage plan that includes Part D, like Clover Health. Most of your prescriptions will be covered by your Part D benefit, but some are covered as part of your medical benefits. To learn more about how a drug you take is covered, contact Member Services.
Depending on your circumstances, you may be eligible for state and federal programs to reduce your Part D costs. Check with Medicare to see if you qualify for the Low-Income Subsidy (LIS).
Extra help is available to Medicare beneficiaries who need assistance paying for care. We're happy to help you learn more about what's available. Depending on your circumstances, the Medicare Low-Income Subsidy (LIS), State Pharmaceutical Assistance Programs (SPAP), discount programs, Medicaid, and state premium assistance programs like SLMB can all help lower your costs. To learn what's available in your area and how to apply, contact Member Services at 1-888-778-1478 (TTY 711) 8 am–8 pm local time, 7 days a week.*
Medicare places some restrictions on how beneficiaries can join and leave Medicare Advantage plans. These rules are common across all Medicare Advantage (MA) plans.
- Annual Enrollment Period (AEP) from October 15th to December 7th – when all beneficiaries may join an MA plan. You can also change from:
- One Medicare Advantage plan to another Medicare Advantage plan
- Original Medicare or Medicare Supplement Insurance (Medigap) to a Medicare Advantage plan
- A Medicare Advantage plan to Original Medicare
- Open Enrollment Period (OEP) from January 1st to March 31st – when all beneficiaries can:
- Switch to another Medicare Advantage plan
- Leave their Medicare Advantage plan and return to Original Medicare (Parts A & B)
Note: If you have Original Medicare only, you cannot use the Open Enrollment Period to select a Medicare Advantage plan.
- Initial Enrollment Period (IEP), the 7-month window when you can first sign up for Medicare Part A and/or Part B. For most, it’s when you turn 65/entitlement. The 7-month period includes:
- 3 months before you turn 65/entitlement
- The month you turn 65/entitlement
- 3 months after you turn 65/entitlement
Outside of these periods, beneficiaries can only change plans under certain circumstances. Under these circumstances, members are qualified for a Special Enrollment Period (SEP), during which they may change plans or enroll in a new plan.
The coverage gap is a period of reduced coverage common across most Medicare Advantage Part D drug plans. There are 4 phases of Part D coverage, including the gap phase. After you pay your plan's deductible, you pay the copays or coinsurance described in your plan benefits until the total cost of your prescriptions reaches a certain amount.
The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,130 (2021 level). Not everyone will enter the coverage gap. If you do reach the gap phase of your coverage, you'll pay more for your prescriptions until you reach the end of that phase. At the end of the gap phase, you'll pay a low, fixed amount through the end of the plan year for all your Part D prescriptions. If you have questions about your own Part D costs or extra help you might be eligible for in paying those costs, please contact Member Services at 1-888-778-1478 (TTY 711) 8 am–8 pm local time, 7 days a week.*