Medicare Eligibility and Plan Options

With so much information to absorb when it comes to Medicare, it helps to have an experienced professional there to guide you through the process and determine what options are right for you. With three Medicare agents at Wallace Rice Benefits, we’re here to make sure that you understand and feel confident in your Medicare coverage, taking the time to find the perfect solution for all of your insurance needs and questions.

Medicare Advantage – Medicare Part C

Once you are eligible for Medicare, you’ll have a number of different routes to take when it comes to your coverage. One popular option is enrolling in a Medicare Advantage plan otherwise known as Medicare Part C.

These plans provide the same coverage provided by Original Medicare, such as hospital and medical benefits, but are offered through private health insurance companies. Advantages plans also will often include additional benefits and coverage for items such as prescription drug coverage, routine dental, vision, and wellness programs which are not a part of Original Medicare.

When enrolling in an Advantage Plan, you are effectively removing yourself from Original Medicare, although you are still required to pay your Part B premiums, your coverage will be completely through your new carrier. Due to this, if you enroll in a Medicare Advantage plan, you cannot be sold or enroll in a Medicare Supplement plan (Medigap).

Eligibility for Medicare Advantage

Generally speaking, if you have Medicare Parts A and B, you are considered eligible for a Medicare Advantage plan considering you live within the service area. If you have other health insurance coverage through a union or employer, it is advised that you ask your plan administrator about your plan’s rules prior to enrolling in an Advantage plan.

Enrollment in Medicare Advantage

There are a few different periods in which you can enroll in a Medicare Advantage plan, depending on your circumstances.

Initial Coverage Election Period: When you first become eligible for Medicare, you have a seven month initial election period that begins three months before the month of your 65th birthday and continues for the three months following. If you are under the age of 65 and receive Social Security benefits, you may qualify for Medicare during the 25th month after your benefits begin. During your initial election period, you may enroll in an Advantage plan at any point throughout these seven months with coverage beginning on the first day of the next month. For example, if you are eligible in June, you may enroll between March and September of that year.

Annual Election Period: If you are currently enrolled in Original Medicare, you must wait to enroll in an Advantage plan until the annual enrollment period (AEP). The AEP begins on October 15th each year and ends on December 7th. During this period you may also switch advantage plans. The plan and coverage selected during AEP takes effect on January of the following year.

Special Election Period: Once enrolled on a Medicare Advantage plan, you remain enrolled until the next Annual Election Period unless you experience a life event that might qualify you for a Special Election Period (SEP). Some examples of qualifying life events include:

  • Moving outside of your Advantage plan’s geographical service area
  • Qualifying for a program to help pay for prescription drugs
  • Moving in to an assisted living facility such as a nursing home

Disenrollment: If you change your mind after enrolling in a Medicare Advantage plan, you do have the option to switch back to your Original Medicare plan between January 1st and February 14th. If the switch causes you to lose prescription coverage, you can sign up for a Medicare Part D separate prescription drug plan during this time.

Medicare Supplement Plans (Medigap)

Medicare Supplement plans, otherwise known as Medigap plans, are used to fill in the coverage gaps within Original Medicare in terms of what Medicare pays and your personal out-of-pocket expenses. While Medigap plans are also offered by private companies they work with Medicare, paying secondary, so you would be a member with the carrier as well as Original Medicare. There are several options available, so be sure to work with an agent or broker you trust, like Wallace Rice benefits to help you shop around for the best prices.

Open Enrollment for Medicare Supplement Plans

Individual enrollment for Medicare Supplement plans begins the first day of the month you turn 65 and continues for six months. As long as you enroll within this time frame, the insurance company cannot charge you more due to health problems, refuse coverage, or make you wait for it to start. Some plans, however, do have up to a six month waiting period for pre-existing health conditions. If you choose to wait to enroll on a Supplement plan, you may be required to pass a health questionnaire in order to receive coverage. Medigap plans, like Original Medicare, DO NOT include prescription drug coverage so you will need to enroll in a separate Part D plan to cover any drugs you may be taking and also to avoid any fines.

Medicare Part D Prescription Drug Coverage

Prescription drug coverage, also known as Medicare Part D, is provided by private insurers as it is not included in Original Medicare. Part D is available for anyone who is enrolled in Original Medicare and who permanently lives in the service area of the offered plan. If you choose not to enroll in Part D when you first become eligible for Medicare, you will face a penalty for every month you were not covered with Part D upon your enrollment. This penalty is permanent and carries forth for as long as you have Medicare, so it is important to make sure to enroll during your initial election period. Premiums and out-of-pocket expenses for prescription drugs will vary due to different insurers and different types of plan. By working with an Agent from Wallace Rice, we can effectively determine what plan best suites your current or projected medications and gets you the best coverage.