New to Medicare?
It is very important for everyone becoming eligible for Medicare to get accurate information about coverage and delivery options, including supplemental health insurance, Medicare health plans, and prescription drug coverage. Attention to these issues will help you avoid serious and costly problems later.
Several months before turning 65 you should begin to learn more about Medicare and how it relates to your circumstances. For example:
- If you or your spouse have paid into the Social Security System for 10 or more years, you are eligible for premium-free Medicare Part A (Hospital Insurance) at age 65. If you have paid in fewer than 10 years, you can buy Medicare Part A coverage. Everyone pays a premium for Medicare Part B (Medical Insurance).
- If you have been on Medicare due to disability, you have a brand new six month Open Enrollment Period for purchasing Medicare supplemental insurance when you turn 65.
- Talk to your employer's benefit officer and ask for any information about company health insurance after age 65. If you have an Employer Group Health Plan (EGHP) that will continue to pay secondary after you become eligible for Medicare, study the benefits booklet to find out the cost and benefits of the plan. You will then need to decide if you should keep your EGHP as secondary to Medicare or if you need to drop your EGHP and purchase a Medicare supplement or join a Medicare Advantage Plan. If your EGHP has drug benefits, make sure they are as good as or better than Medicare Part D.
- If you will not be covered by an EGHP plan that will pay secondary to Medicare, begin to investigate other health insurance options - either an individual Medicare Supplement Policy or a Medicare Advantage Plan. SHIIP can provide information about the Medicare Supplement Plans, Medicare Advantage Plans (Part C), and Medicare Prescription Drug Plan (Medicare Part D) options available in North Carolina.
When and How to Enroll in Medicare
Automatic Enrollment
If you are already receiving Social Security benefits, Railroad Retirement benefits, or Federal Retiree benefits, your enrollment in Medicare is automatic. Your Medicare card should arrive in the mail shortly before your 65th birthday. Check the card when you receive it to verify that you are entitled to both Medicare Parts A and B.
Initial Enrollment Period
If you are not eligible for Automatic Enrollment, contact the Social Security Administration at 800-772-1213 or enroll online at www.socialsecurity.gov, or visit the nearest Social Security office to enroll in Medicare Part A and Medicare Part B. You have a seven-month window in which to enroll in Medicare without incurring a penalty. If you’re not automatically enrolled in premium-free Part A, you can sign up for it once your Initial Enrollment Period starts. Your Part A coverage will start six months back from the date you apply for Medicare, but no earlier than the first month you were eligible for Medicare. However, you can only sign up for Part B (or Part A if you have to buy it) during the seven-month time window listed below:
- Three months before 65th birthday
- Enroll during this time and your Medicare is effective the first day of your birth month.
- Birthday month
- Enroll during this time and your Medicare effective date will be delayed until the first day of the month following the month you actually enrolled.
- First month after 65th birthday
- Enroll during this time and your Medicare effective date will be delayed until the first day of the second month following the month you actually enrolled.
- Two to three months after 65th birthday
- Enroll during this time and your Medicare effective date will be delayed until the first day of the third month following the month you acutally enrolled.
During this Initial Enrollment Period, you will also have the option to enroll in a Medicare Prescription Drug Plan (PDP) available under Medicare Part D. Enrollment in a Medicare PDP is strictly voluntary. These plans are offered by private insurance companies approved by Medicare. Information about PDPs can be found on the SHIIP website. If you fail to enroll in a Medicare PDP during your Initial Enrollment Period and you do not have equal or better coverage through an EGHP, you will incur a one percent penalty for each month that you are late enrolling, and you will only be allowed to enroll during the annual Open Enrollment Period of October 15 through December 7 for Medicare Advantage and Medicare Part D.
General Enrollment Period
If you do not enroll in Medicare Parts A and B during your seven-month window of eligibility, you cannot enroll until the General Enrollment Period, which is January 1 through March 31 each year (unless you are entitled to Special Enrollment). Your Medicare eligibility will not begin until the following July 1. Your monthly Medicare Part B premium will increase to include a permanent ten percent penalty for each year of delayed enrollment (unless you are eligible for Special Enrollment):
- January 1 through March 31
- Enroll during this time
- April 1 through June 30
- No Medicare coverage during this time
- July 1
- Medicare coverage begins with a penalty
Working Past Age 65 (Special Enrollment)
If you or your spouse are actively working at age 65, are covered by an Employer’s Group Health Plan (EGHP) and the company has 20 or more employees, you may be able to delay Medicare Part B coverage without penalty. You will still be eligible for Part A without paying a premium (as long as you or your spouse has 40 credits of work).
- Talk to your employer's benefits officer and ask for information about company health insurance options for people who continue working past their 65th birthday. Ask specifically how many hours you must work to keep your health insurance plan and whether the EGHP will be "primary" or "secondary" coverage to Medicare. Carefully study the company's current benefit booklet to determine cost and benefits of the plan.
- If your EGHP is primary to Medicare, you do not have to enroll in Medicare Part B at this time. You will need to enroll in Medicare Part B within eight months of the EGHP's termination of coverage or when it stops being primary. If your EGHP will be secondary to Medicare despite active employment, you must enroll in Medicare Part B during the seven-month Initial Enrollment Period to avoid future penalties. If you voluntarily disenroll from your EGHP before terminating your employment, you could lose any EGHP benefits when you retire.
- Contact the Social Security Administration at 800-772-1213 or www.socialsecurity.gov or the nearest Social Security Administration office to contirm that you have enrolled in Medicare Part A (Hospital Insurance).
- Give written notice to your company of your intention to continue working past age 65. When you decide to stop working, notify the Social Security Administration immediately. It is also advisable to notify the Social Security Administration that you or your spouse, if covered under your EGHP, will continue to work beyond age 65.
Supplemental Coverage
Medicare is a major federally-funded medical plan that provides a basic foundation of benefits. However, it does not pay 100 percent of all medical bills. Medicare beneficiaries are responsible for premiums, deductibles, and coinsurance. These amounts can be significant. Because of these costs, most beneficiaries need some kind of plan, policy or program to fill in the “gaps.”
Medicare Supplement Insurance
Medicare supplement plans are one health insurance option for people with Original Medicare. There are standardized Medicare supplement insurance plans available that are designed to fill the gaps left by Original Medicare (Parts A and B). These are sold by private insurance companies as individual insurance policies and are regulated by the Department of Insurance. After age 65 and for the first six months of eligibility for Medicare Part B, beneficiaries have an Open Enrollment Period and are guaranteed the ability to buy any of these plans from any company that sells them. Companies cannot deny coverage or charge more for current or past health problems. If you fail to apply for a Medicare supplement within your Open Enrollment Period, you may lose the right to purchase a Medicare supplement policy without regard to your health.
Medicare Prescription Drug Coverage (Medicare Part D)
Medicare Prescription Drug Plans (PDPs) are sold by private insurance companies approved by Medicare. All people new to Medicare have a seven-month window to enroll in a PDP – three months before, the month of and three months after their Medicare becomes effective. The month you enroll affects the PDP’s effective date. All people with Medicare are eligible to enroll in a PDP; however, unless you are new to Medicare or are entitled to a Special Enrollment Period, you must enroll or change plans during the Open Enrollment Period for Medicare Advantage and Medicare Part D, Oct. 15 through Dec. 7. There is a monthly premium for these plans. If you have limited income and assets/resources, assistance is available to help pay premiums, deductibles and co-payments. You may be entitled to “Extra Help” through the Social Security Administration. To apply for this benefit contact SHIIP at 1-855-408-1212 or the Social Security Administration at 800-772-1213 or www.socialsecurity.gov.
Employer or Military Retiree Coverage
If you or your spouse has an Employer Group Health Plan (EGHP) as retiree health coverage from an employer or the military (TRICARE for Life), you may not need additional insurance. Review the EGHP’s costs and benefits and contact your employer benefits representative or SHIIP to learn how your coverage works with Medicare.
Medicaid or Medicare Savings Programs
Medicare beneficiaries with limited income or very high medical costs may be eligible to receive assistance from the Medicaid program. There are also Medicare Savings Programs for other limited-income beneficiaries that may help pay for Medicare premiums, deductibles, and coinsurance. There are specified income and resources limits for both programs. Contact your local county Department of Social Services or SHIIP to apply for one of these programs.
Other Medicare Insurance Options
Medicare Advantage Plans (Medicare Part C)
Medicare Advantage plans are another health insurance option for Medicare beneficiaries. Medicare Advantage plans (HMOs, PPOs, SNPs and/or PFFS) are available in our state and provide all Medicare Part A and Part B benefits and possibly some extra benefits. Members may be required to utilize a network or group of preferred providers. Check with your health care providers to see if they accept the insurance plan you are considering. All plan options may not be available in the county in which you reside. If you join a Medicare Advantage Plan, you are still in the Medicare Program but you receive your Medicare benefits from the private carrier and are no longer enrolled in Original Medicare. Information about Medicare Advantage plans in North Carolina is available from SHIIP by calling 1-855-408-1212. You may enroll in a Medicare Advantage plan during your Initial Enrollment Period or during the Open Enrollment Period for Medicare Advantage and Medicare Part D from October 15 through December 7.
Call SHIIP for more information
Toll-free 1-855-408-1212
Monday through Friday from 8am to 5pm
The Seniors' Health Insurance Information Program (SHIIP) offers free, objective information about Medicare, Medicare Advantage Plans, Medicare claims, Medicare supplement insurance, Medicare Prescription Drug Plans, fraud and abuse prevention, and long-term care insurance. Trained SHIIP volunteer counselors are also available for one-on-one counseling in every county in the state.
Additional Resources
Medicare - Call 800-633-4227 or visit www.medicare.gov
Medicare provides information 24 hours a day, seven days a week about eligibility, enrollment, and coverage
Social Security Administration - Call 800-772-1213 or visit www.socialsecurity.gov
Contact the Social Security Administration to enroll in Medicare or to request a replacement Medicare card.
Your local Department of Social Services (DSS)
County DSS offices have information about Medicaid, Extra Help, and Medicare Savings Program eligibility and applications.
Medicare FAQs and Information to Consider
Files
Coordination-of-Benefits9.14.20 (002)_0.pdf
Coordination of Benefits
SHIIP Medicare Basics Form 2022_Web.pdf
SHIIP Medicare Basics Form
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