How to Circumvent the Medicare Maze
Updated: Mar 9
Article originally featured on Echo-Pilot
Choosing a Medicare plan can be a confusing process. Here are a few tips to help.
Consider these benefits of growing older. You can drive at age 16, vote at 18, drink adult beverages at 21 and at 65, you’re eligible for Medicare! Plus of course, you’re still here.
No matter how old you are or how intelligent you are, the Medicare maze is difficult to understand and navigate. It has a lot of moving parts. For example, Medicare Parts A, B, C, D, and more letters are among the supplements you can choose in Pennsylvania.
Medicare seminars can give you a broad overview; however, each person’s income, health, physician and hospital preferences, and other circumstances, should be factored into Medicare decisions. That’s why it’s nice to have a person you can sit down with to explain all the choices to you.
Get free advice for your specific situation from Medicare-certified, independent advisers
The very first step you should take is to meet with a Medicare adviser, according to Matthew Petruso, president of Benefit Advisors Insurance Group, in Millcreek. He is also the author of the book “Medicare Made-to-Order,” which is available free through his office or online at TheMedicareMentors.com.
“Everyone’s needs are different,” Petruso explained. “In fact, the biggest mistake anyone can make regarding Medicare is to take advice from friends, family members and even doctors about coverage. You should only take advice from a Medicare-certified, independent adviser who represents multiple insurance companies.”
Advisers are not allowed to charge a fee for services, he added. “We are paid directly by the insurance company only if we find a plan that best fits your needs.”
For information on other Medicare-certified advisers who can help you, ask your insurance company for recommendations.
Unlike other milestone benefits, however, Medicare is not automatic when you reach the age of eligibility – unless you are already receiving Social Security. And while Medicare can cover most of your health care needs, going through the maze of enrolling, then reviewing and choosing benefits and plans can be overwhelming.
If you do want some details now, however, or just some reading material to help you sleep, consider the following summary of how to enroll and get started with Medicare.
Here’s how it works:
1. You must apply for Medicare. It is not an automatic benefit unless you’re already receiving Social Security. You can first apply three months before or after you turn 65.
You may apply later if you’re covered under an employer health plan. You can apply online at MyMedicare.gov or by calling or visiting your local Social Security office.
2. You must pay for Medicare, which many people are surprised to learn. There is no premium charge for Part A if Medicare funds were deducted from your or your spouse’s pay for at least 10 years. Part A covers inpatient hospital care, though there are deductibles and co-pays. Most recipients pay a monthly premium charge of $144.60 for Part B, which covers about 80% of outpatient care such as doctors’ visits, preventive care, physical therapy and durable medical equipment. This premium is deducted from your Social Security payment. There is also a $198 deductible.
3. You may appeal if you are charged more than $144.60 per month for Part B, based on previous higher income which has ended. Retiring and losing a paycheck is considered a “life-changing event” so your new retirement income may qualify you for the standard $144.60 premium.
4. You must add supplemental plans if you want to cover the 20% gap not covered under Part B. “I strongly advise against maintaining only Parts A and B coverage,” says Petruso. “There is no cap on what you may be charged with only Part A and B. Simply put, if you were billed $100,000 for a Medicare-approved surgery and Part B covered 80%, you would be responsible for $20,000.”
5. You must add coverage for prescriptions, dental, vision or other services such as wellness programs. Options include:
Medicare Part C, also called Medicare Advantage. Plans generally cover 100% of in-hospital and outpatient care, after deductibles or co-pays. Covered benefits and costs vary.
Medicare Part D adds prescription drug coverage to Medicare Parts A and B. Premiums and benefits vary on Part D plans as well. You may also opt for plans from private insurers. Each carrier has a formulary list to review to see if your prescriptions are included.
Medicare Supplemental Plans generally cover 100% of in-hospital and outpatient care, except for deductibles and co-pays. In this region, there are dozens of insurance carriers and benefit plans to choose from.
6. You may stay on your employer’s health plan if you turn 65 and are still working, or if you’re covered under your spouse’s plan. You may also get Medicare while still employed. If your employer has more than 20 employees, the employer plan will pay health care costs first. If a firm has 20 or less employees, Medicare pays first. If you have a Health Savings Account, you should not get Medicare while employed as you are not able to contribute to it once you enroll in Medicare.
7. You must follow time frames and know deadlines. As mentioned, your first eligibility for Medicare enrollment is three months before your 65th birthday. General enrollment for Medicare Part B is Jan. 1 – March 31 each year. You may also enroll within eight months of leaving your employer’s health plan. If you go more than 63 days without Part D or another prescription drug plan, you will pay a lifetime penalty to add it later.
8. You can check on the status of your personal deductibles, claims and billing at MyMedicare.gov.
9. You can change your Medicare plans. Each fall, you will receive an Annual Notice of Change (ANOC). The ANOC will explain changes in coverages or costs that will occur the following year. From Oct. 15 through Dec. 7, you may change Parts C and D or supplemental plans. So you’re not locked in forever if you are uncomfortable with your choices.
If all of this sounds confusing, remember, you can meet with a Medicare adviser who can help you.
In summary, it’s great to be alive at 65 and eligible for Medicare. But ask professionals for advice preferably four to six months before you turn 65.