Medicare is the federal health insurance program for people who are 65 or older, younger people with disabilities and people with End-Stage Renal Disease (ESRD). Although Medicare has a lot of moving parts, Medicare Parts A and B are the formation of Original Medicare.

Part A of Medicare includes the basic functions of insurance. These include inpatient hospital stays, care in a skilled nursing facility, hospital care and some home health care. Part A may require a monthly premium for those who haven’t paid into social security for at least 10 years.

Part B of Medicare helps to cover medically necessary doctor’s expenses, outpatient care and preventative services like seasonal flu shots and other vaccines. Part B does come with a monthly premium that can be deducted from a social security check every month.

Am I Eligible?

Before you enroll into a Medicare plan, you must first make sure you’re eligible. Most people are automatically eligible if they are 65 years or older and either themselves or a spouse have worked for the past 10 years while paying into social security.

You may also be eligible if you’re already getting benefits from social security or the Railroad Retirement Board. People are also eligible under age 65 if they have End-Stage Renal Disease (ESRD) or other certain disabilities.

When Can I Enroll?

If you are turning 65 and have received your Medicare Card you have seven months to choose a Medicare Advantage Plan. Your initial enrollment period will begin three months before the month of your 65th birthday, the month of your birthday and three months after your 65th birthday.

Open enrollment begins every year from October 15th – December 7th you can renew, review and enroll into a plan of your choosing.

Medicare Advantage Plans are health plans offered by private insurance companies that contract with the government to provide Medicare Parts A and B, as well as extra benefits.

Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans and Medicare Medical Savings Account Plans. If you’re enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans also offer prescription drug coverage.

In most HMOs, you choose a Primary Care Physician (PCP) and use in-network providers. In this type of plan you are traditionally required to obtain an authorization prior to receiving specialty services.

In a PPO you have the option of accessing services both in-network and out-of-network. However, the cost shared by the beneficiary and the provider will be higher for out-of-network providers.

These types of plans are designed to service groups and limit enrollment for people with Medicare that meet specific qualifications:

  • Chronic Special Need Plans (C-SNP)
  • Dual Special Need Plans (D-SNP)
  • Institutional Special Need Plans (I-SNP)

Am I eligible for Medicare Advantage Plan?

In order to qualify for a Medicare Advantage Plan you must meet the following criteria:

  • Have Medicare Part A (Hospital) & Medicare Part B (Medical)
  • Live in a zip code covered by the Medicare Advantage Plan
  • Not have End Stage Renal Disease (ESRD)

For more information on Medicare from the experts at Prime Insurance Service, please contact us here or call us directly at 616.940.8118.




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