About Medicare + Medicaid

We break down the ABCs of Medicare and Medicaid show you what choices you have and when you should apply.

Medicare & Eligibility

Medicare is health insurance for people 65 or older. You’re first eligible to sign up for Medicare 3 months before you turn 65. You may be eligible to get Medicare earlier than age 65, if you have a disability, End-Stage Renal Disease (ESRD), or ALS (also called Lou Gehrig’s disease). If you are awarded Social Security benefits due to a disability, you may have to wait 24 months. Let's chat and see when you are eligible.

Medicare Part A
(Hospital Insurance)

Part A helps cover inpatient care in hospitals, skilled nursing facility care, hospice care, and home health care. It costs $0 for most people (because they paid Medicare taxes long enough while working - generally at least 10 years). This is sometimes called “premium-free Part A.” If you don’t qualify for a premium-free Part A, you might be able to buy it. In 2022, the premium is either $274 or $499 each month, depending on how long you or your spouse worked and paid Medicare taxes.

You also have to sign up for Part B to buy Part A. If you don’t buy Part A when you’re first eligible for Medicare (usually when you turn 65), you might pay a penalty.

Medicare Part B 
(Medical Insurance)

  • Services from doctors and other health care providers

  • Outpatient care

  • Home health care

  • Durable medical equipment (like wheelchairs, walkers, hospital beds, and other equipment)

  • Many preventive services (like screenings, shots or vaccines, and yearly “Wellness” visits)

  • Paid through your Social Security or checking account. IF you have extra help from the state you reside in, you may be eligible for the state to cover that cost. Ask me to see if you are eligible for Extra Help.

Example of Part B
Late Enrollment Penalty

If you waited 2 full years (24 months) to sign up for Part B and didn’t qualify for a Special Enrollment Period, you’ll have to pay a 20% late enrollment penalty (10% for each full 12-month period that you could have signed up), plus the standard Part B monthly premium ($170.10 in 2022).  

Medicare Part D
(Drug Coverage)

Helps cover the cost of prescription drugs (including many recommended shots or vaccines). You can join a Medicare drug plan in addition to original Medicare, or you get it by joining a Medicare Advantage Plan with drug coverage. Plans that offer Medicare drug coverage are run by private insurance companies that follow rules set by Medicare.

Extra Help with
Drug Costs

If you have limited income and resources, you may be able to get Extra Help to pay your plan premiums and other drug costs (like deductibles, coinsurance, and copays). If you qualify, you won’t have to pay the Part D late enrollment penalty. If you qualify for Extra Help, you won't pay a late enrollment penalty when you join a Medicare drug plan. If you currently get Extra Help, but aren't sure if you're paying the right amount, give me a call and we can discuss it.

Medicare Part D
Late Enrollment Penalty

The late enrollment penalty is an amount that's permanently added to your Medicare drug coverage (Part D) premium. You may owe a late enrollment penalty if at any time after your Initial Enrollment Period is over, or there's a period of 63 or more days in a row when you don't have Medicare drug coverage or other creditable prescription drug coverage, You’ll generally have to pay the penalty for as long as you have Medicare drug coverage.

Cost of the Part D
Late Enrollment Penalty

The cost of the late enrollment penalty depends on how long you went without Part D or creditable prescription drug coverage. Medicare calculates the penalty by multiplying 1% of the "national base beneficiary premium" ($33.37 in 2022) times the number of full, uncovered months you didn't have Part D or creditable coverage. The monthly premium is rounded to the nearest $0.10 and added to your monthly Part D premium. The national base beneficiary premium may change each year, so your penalty amount may also change each year.

Rules of Original Medicare

  • Original Medicare includes Part A and Part B.

  • You can join a separate Medicare drug plan to get Medicare drug coverage (Part D).

  • You can use any doctor or hospital that takes Medicare, anywhere in the US.

  • In most cases, you don’t have to get a service or supply approved in advance for Original Medicare to cover it.

  • To help pay your out-of-pocket costs in Original Medicare (like your 20% coinsurance), you can also buy supplemental coverage, like Medicare Supplement Insurance (Medigap), or have coverage from a former employer or union, or Medicaid.

Medicare Supplement Insurance (Medigap)

  • Monthly premiums vary based on which policy you buy, where you live, and other factors. The amount can change each year.

  • You must keep paying your Part B premium to keep your supplement insurance.

  • Helps lower your share of costs for Part A and Part B services in Original Medicare.

  • Some Medigap policies include extra benefits to lower your costs, like coverage when you travel out of the country.

  • You should choose to buy a Part D plan to help with drug costs at the time of your initial Medicare enrollment to avoid a Late Enrollment Penalty (LEP).

Medicare Part C
(Medicare Advantage Plan)

  • Monthly premiums vary based on which plan you join. The amount can change each year.

  • You must keep paying your Part B premium to stay in your plan.

  • Medicare Advantage is a Medicare-approved plan from a private company that offers an alternative to Original Medicare for your health and drug coverage. These “bundled” plans include Part A, Part B, and usually Part D. In most types of Medicare Advantage Plans, you can't join a separate Medicare drug plan

  • Plans have a yearly limit on what you pay out of pocket for services Medicare Part A and Part B covers. Once you reach your plan’s limit, you’ll pay nothing for services Part A and Part B covers for the rest of the year.

  • In most cases, you’ll need to use doctors who are in the plan’s Network. Plans may have lower out-of-pocket costs than Original Medicare.

  • Plans may offer some extra benefits that Original Medicare doesn’t cover — like vision, hearing, and dental services.

  • Plans must cover all of the medically necessary services that Original Medicare covers. 

  • You can’t buy and don’t need Medigap.

Medicaid & Eligibility

Medicaid is a joint federal and state program that helps with medical costs for some people with limited income and resources. It offers benefits that are not normally covered under Medicare, like nursing home care and personal care services. Another name for Medicaid is the Medicare Savings Plan.

Medicaid Spenddown

Even if you have too much income to qualify, some states let you "spend down" to become eligible for Medicaid. The "spend down" process lets you subtract your medical expenses from your income to become eligible for Medicaid. In this case, you're eligible for Medicaid because you're considered "medically needy."To be eligible as "medically needy," your measurable resources must also be under the resource amount allowed in your state. Call your State Medical Assistance (Medicaid) office to see if you qualify and learn how to apply.

Dual Eligibility

If you have Medicare and full Medicaid coverage, most of your health care costs are likely covered. You can get your Medicare coverage through Original Medicare or a Medicare Advantage Plan (Part C). If you have Medicare and full Medicaid, you'll get your Part D prescription drugs through Medicare. And, you'll automatically qualify for Extra Help paying for your  Medicare Drug Coverage (Part D). Medicaid may still cover some drugs and other care that Medicare doesn’t cover.

Who Pays First - Medicaid or Medicare?

Medicare pays first, and Medicaid pays second. Medicaid never pays first for services covered by Medicare. It only pays after Medicare, employer group health plans, and/or Medicare Supplement (Medigap) Insurance have paid.

Medicare-Medicaid Plans

Medicare is working with some states and health plans to offer demonstration plans for certain people who have both Medicare and Medicaid and make it easier for them to get the services they need. They’re called Medicare-Medicaid Plans. These plans include drug coverage and are only in certain states. Find out if a Medicare-Medicaid Plan is available in your area.