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SSA Publication No. 05-10043, September 2004, ICN 460000 [View .pdf Get Accessible Adobe Acrobat Reader]
 

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Contents

Part 1—Medicare

Part 2—What is Medicare?     

Medicare has two parts 

A word about Medicaid  

Part 3—Who can get Medicare?

Hospital insurance (Part A)  

If you have kidney disease

Medical insurance (Part B)

Part 4—Help for some low-income people

Part 5—Signing up for Medicare     

When should I apply?

Special enrollment situations    

Initial enrollment period for Part B   

When does my enrollment in Part B become effective?     

General enrollment period for Part B

Special enrollment period for people covered under an employer group health plan  

Part 6—Options for receiving health services  

Part 7—Savings on prescription drugs

Part 8— If You Have Other Health Insurance 

If you have a private insurance plan

If you have insurance from an
employer-provided group health plan     

If you have health care protection from other plans

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Part 1—Medicare

This booklet provides basic information about what Medicare is, who is covered and some of the options you have for choosing Medicare coverage.

In December 2003, the Medicare Prescription Drug, Improvement, and Modernization Act was signed into law. This new law preserves and strengthens the current Medicare program as described in this booklet. Over the next few years, it will add new prescription drug and preventive benefits, and provide extra help to people with lower income. For the latest information about Medicare, visit the website or call the toll-free number listed below.

 

Medicare

 Website: www.medicare.gov

Toll-free number: 1-800-MEDICARE
  (1-800-633-4227)
TTY number: 1-877-486-2048

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Part 2— What is Medicare?

Medicare is our country’s health insurance program for people age 65 or older. Certain people younger than age 65 can qualify for Medicare, too, including those who have disabilities and those who have permanent kidney failure. The program helps with the cost of health care, but it does not cover all medical expenses or the cost of most long-term care.

Medicare is financed by a portion of the payroll taxes paid by workers and their employers. It also is financed in part by monthly premiums deducted from Social Security checks.

The Centers for Medicare & Medicaid Services is the agency in charge of the Medicare program. But you apply for Medicare at Social Security, and we can give you general information about the Medicare program.

Medicare has two parts

The two parts of Medicare help pay for different kinds of health care costs.

  • Hospital insurance (also called Medicare Part A) helps pay for inpatient care in a hospital or skilled nursing facility (following a hospital stay), some home health care and hospice care.
  • Medical insurance (also called Medicare Part B) helps pay for doctors’ services and many other medical services and supplies that are not covered by hospital insurance.

You can get more information about these programs from the publication, Medicare &You (Publication No. CMS-10050). To get a copy, call the toll-free number, 1-800-MEDICARE (1-800-633-4227), or go to www.medicare.gov on the Internet and click on “Publications.”

A word about Medicaid

You may think that Medicaid and Medicare are the same. Actually, they are two different programs. Medicaid is a state-run program that provides hospital and medical coverage for people with low income and little or no resources. Each state has its own rules about who is eligible and what is covered under Medicaid. Some people qualify for both Medicare and Medicaid. For more information about the Medicaid program, contact your local medical assistance agency, social services or welfare office.

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Part 3—Who can get Medicare?

Hospital insurance (Part A)


Most people age 65 or older who are citizens or permanent residents of the United States are eligible for free Medicare hospital insurance (Part A). You are eligible at age 65 if:

  • You receive or are eligible to receive Social Security benefits; or
  • You receive or are eligible to receive railroad retirement benefits; or
  • You or your spouse (living or deceased, including divorced spouses) worked long enough in a government job where Medicare taxes were paid.

If you do not meet these requirements, you may be able to get Medicare hospital insurance by paying a monthly premium. Usually, you can sign up for this hospital insurance only during designated enrollment periods.

NOTE: Even though the full retirement age is no longer 65, you should sign up for Medicare three months before your 65th birthday.

Before age 65, you are eligible for free Medicare hospital insurance if:

  • You have been entitled to Social Security disability benefits for 24 months; or
  • You receive a disability pension from the railroad retirement board and meet certain conditions; or
  • You have Lou Gehrig’s disease (amyotrophic lateral sclerosis); or
  • You, your parent or your spouse (living or deceased, including a divorced spouse) worked long enough in a Medicare-covered government job and you or they meet the requirements of the Social Security disability program.

If you have kidney disease

If you have permanent kidney failure, you are eligible for free Medicare hospital insurance at any age. This is true if you receive maintenance dialysis or a kidney transplant and:

  • You are eligible for or receive monthly benefits under Social Security or the railroad retirement system; or
  • You have worked long enough in a Medicare-covered government job; or
  • You are the child or spouse (including a divorced spouse) of a worker (living or deceased) who has worked long enough under Social Security or in a Medicare-covered government job.

Medical insurance (Part B)

Anyone who is eligible for free Medicare hospital insurance (Part A) can enroll in Medicare medical insurance (Part B) by paying a monthly premium.

If you are not eligible for free hospital insurance, you can buy medical insurance, without having to buy hospital insurance, if you are age 65 or older and you are—

  • A U.S. citizen; or
  • A lawfully admitted noncitizen who has lived in the U.S. for at least five years.

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Part 4—Help for some low- income people
 If you cannot afford to pay your Medicare premiums and other medical costs, you may be able to get help from your state. States offer programs for people who are entitled to Medicare and have low income. The programs may pay some or all of Medicare’s premiums and also may pay Medicare deductibles and coinsurance. To qualify, you must have Part A (hospital insurance), a limited income, and, in most states, your resources, such as bank accounts, stocks and bonds, must not be more than $4,000 for a single person or $6,000 for a couple.

If you are not sure if you have Part A, look on your red, white and blue Medicare card. It will show “Hospital (Part A)” on the lower left corner of the card. If you are still not sure, you can call Social Security toll-free.

You can get more information about these programs from the publication, Don’t Miss Out On Your Turn For Medicare Savings (Publication No. CMS-10126-A). To get a copy, call the toll-free number, 1-800-MEDICARE (1-800-633-4227), or visit www.medicare.gov on the Internet and click on “Publications.”

Only your state can decide if you qualify for help under these programs. To find out, contact your state or local medical assistance (Medicaid) agency, social services or welfare office.

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Part 5—Signing up for Medicare

When should I apply?

If you are already getting Social Security retirement or disability benefits or railroad retirement checks, you will be contacted a few months before you become eligible for Medicare and given the information you need. You will be enrolled in Medicare Parts A and B automatically. However, because you must pay a premium for Part B coverage, you have the option of turning it down.

If you are not already getting retirement benefits, you should contact us about three months before your 65th birthday to sign up for Medicare. You can sign up for Medicare even if you do not plan to retire at age 65.

Once you are enrolled in Medicare, you will receive a red, white and blue Medicare card showing whether you have Part A, Part B or both. Keep your card in a safe place so you will have it when you need it. If your card is ever lost or stolen, you can apply for a replacement card on the Internet at www.socialsecurity.gov or call Social Security’s toll-free number. You will also receive a Medicare & You (Publication No. CMS-10050) handbook hat describes your Medicare benefits and Medicare plan choices.

Special enrollment situations

You also should contact Social Security about applying for Medicare if

  • You are a disabled widow or widower between age 50 and age 65, but have not applied for disability benefits because you are already getting another kind of Social Security benefit;
  • You are a government employee and became disabled before age 65;
  • You, your spouse or your dependent child has permanent kidney failure;
  • You had Medicare medical insurance in the past but dropped the coverage; or
  • You turned down Medicare medical insurance when you became entitled to hospital insurance (Part A).

Initial enrollment period for Part B

When you first become eligible for hospital insurance (Part A), you have a seven-month period (your initial enrollment period) in which to sign up for medical insurance (Part B). A delay on your part will cause a delay in coverage and result in higher premiums. If you are eligible at age 65, your initial enrollment period begins three months before your 65th birthday, includes the month you turn age 65 and ends three months after that birthday. If you are eligible for Medicare based on disability or permanent kidney failure, your initial enrollment period depends on the date your disability or treatment began.

When does my enrollment in Part B become effective?

If you accept the automatic enrollment in Medicare Part B, or if you enroll in Medicare Part B during the first three months of your initial enrollment period, your medical insurance protection will start with the month you are first eligible. If you enroll during the last four months, your protection will start from one to three months after you enroll.

The following chart shows when your Medicare Part B becomes effective:

If you enroll in this month of your Initial enrollment period: Then your Part B Medicare coverage starts:
1
The month you become eligible for Medicare
2
The month you become eligible for Medicare
3
The month you become eligible for Medicare
4
One month after enrollment
5
Two months after enrollment
6
Three months after enrollment
7
Three months after enrollment

General enrollment period for Part B

If you do not enroll in Medicare Part B during your initial enrollment period, you have another chance each year to sign up during a “general enrollment period” from January 1 through March 31. Your coverage begins the following July. However, your monthly premium increases 10 percent for each 12-month period you were eligible but did not enroll.

Special enrollment period for people covered under an employer group health plan

If you are 65 or older and are covered under a group health plan, either from your own or your spouse’s current employment, you have a “special enrollment period” in which to sign up for Medicare Part B. This means that you may delay enrolling in Medicare Part B without having to wait for a general enrollment period and paying the 10 percent premium surcharge for late enrollment. The rules allow you to:

  • Enroll in Medicare Part B any time while you are covered under the group health plan based on current employment; or
  • Enroll in Medicare Part B during the eight-month period that begins with the month your group health coverage ends, or the month employment ends—whichever comes first.

Special enrollment period rules do not apply if employment or employer-provided group health plan coverage ends during your initial enrollment period.

If you do not enroll by the end of the eight-month period, you will have to wait until the next general enrollment period, which begins January 1 of the next year.

People who receive Social Security disability benefits and are covered under a group health plan from either their own or a family member’s current employment also have a special enrollment period and premium rights that are similar to those for workers age 65 or older.

 
Part—6 Options for receiving health services

Medicare beneficiaries may have choices for receiving health care services.

You can get more information about your health care options from the following publications:

  • Medicare & You (Publication No. CMS-10050)—This general guide is mailed to people after they enroll in Medicare and an updated version is mailed each year after that.
  • Guide To Health Insurance For People With Medicare (Publication No. CMS-02110)—This guide describes how other health insurance plans supplement Medicare and offers some shopping hints for people looking at those plans.

To get a copy of any of these publications, call the Medicare toll-free number, 1-800-MEDICARE (1-800-633-4227), or go to www.medicare.gov on the Internet and click on “Publications.”

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Part—7 Savings on prescription drugs

You have a new choice to help you save money on your prescriptions. Medicare is contracting with private companies to offer voluntary, Medicare-approved drug discount cards. If you have Medicare and do not have outpatient prescription drug coverage through Medicaid, you can get a Medicare-approved drug discount card. Enrollment will continue until Medicare offers comprehensive prescription drug coverage on January 1, 2006. For a small annual enrollment fee of no more than $30, these cards may save you 10-15 percent on your total prescription costs and as much as 25 percent on certain drugs.

If you choose to get a Medicare-approved drug discount card, you might also qualify for up to a $600 credit each calendar year (2004 and 2005) to help pay for prescriptions. To get the $600 credit, you have to get a Medicare-approved drug discount card and all of the following conditions must apply:

  • You must have Medicare Part A and/or Part B.
  • You do not have other health insurance with any prescription drug coverage (except a Medicare + Choice plan or a Medigap policy).
  • Your income is no more than $12,569 if you are single, or no more than $16,862 if you are married (this includes your income and your spouse’s income).

To find out more about the $600 credit and drug discount cards in your area, call 1-800-MEDICARE (1-800-633-4227) and ask for information about Medicare-approved drug discount cards. You can also find information at www.medicare.gov on the Internet.

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Part 8—If you have other health insurance

Medicare hospital insurance is free for almost everyone, but you do pay a monthly premium for medical insurance. If you already have other health insurance when you become eligible for Medicare, is it worth the monthly premium cost to sign up for Medicare medical insurance?

The answer varies with each person and the kind of other health insurance you may have. Although we cannot give you “yes” or “no” answers, we can offer a few tips that may be helpful when you make your decision.

If you have a private insurance plan

Get in touch with your insurance agent to see how your private plan fits with Medicare medical insurance. This is especially important if you have family members who are covered under the same policy. And remember, just as Medicare does not cover all health services, most private plans do not either. In planning your health insurance coverage, keep in mind that most nursing home care is not covered by Medicare or private health insurance policies. One important word of caution: for your own protection, do not cancel any health insurance you now have until your Medicare coverage actually begins.

If you have insurance from an employer-provided group health plan

Group health plans of employers with 20 or more employees are required by law to offer workers and their spouses who are age 65 (or older) the same health benefits that are provided to younger employees.

If you are currently covered under an employer- provided group health plan, you should talk to your personnel office before you sign up for Medicare medical insurance.

If you have health care protection from other plans

If you have coverage under a program from the Department of Defense, your health benefits may change or end when you become eligible for Medicare. You should contact the Department of Defense or a military health benefits advisor for information before you decide whether to enroll in Medicare medical insurance.

If you have health care protection from the Indian Health Service, Department of Veterans Affairs or a state medical assistance program, contact the people in those offices to help you decide whether it is to your advantage to have Medicare medical insurance.

For more information on how other health insurance plans work with Medicare, call the Medicare toll-free number 1-800-MEDICARE (1-800-633-4227) and ask for the publication, Medicare And Other Health Benefits: Your Guide To Who Pays First (Publication No. CMS-02179). Or visit www.medicare.gov on the Internet and click on “Publications.”

Social Security Administration
SSA Publication No. 05-10043
ICN 460000
Unit of Issue - HD (one hundred)
September 2004 (Recycle prior editions)

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