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Medicare FAQ

If you're 65 or over (or turning 65 in the next 3 months) and not already getting benefits from Social Security, you need to sign up to get Medicare Part A (hospital insurance) and Part B (medical insurance). Part B is optional for Original Medicare; however, it is required when you apply for a Medicare Advantage plan. You can sign up for Medicare online or contact Social Security. Social Security will then review your records to see if you qualify for Medicare.

You are eligible to apply for Medicare 3 months prior to the month you turn 65 and the month you turn 65. If you don't apply for Medicare within 3 months of turning 65, you'll have to wait for the next enrollment period to apply.

Medicare is a federal health insurance program that provides coverage for more than 55 million people with a variety of needs and circumstances. Medicare covers people who are 65 and over, have end-stage renal disease (ESRD), and/or have qualifying disabilities and have received Social Security benefits for more than one year.

One of the biggest differences between an HMO and a PPO plan is that in an HMO you are restricted to using network providers, except for in emergency situations. In a PPO, you are not restricted to using network providers.

PPO stands for preferred provider organization. PPO insurance includes a more open network, giving the member more healthcare providers to choose from, and typically any provider that accepts Medicare will accept the PPO insurance. Members usually pay a slightly higher premium, higher cost shares, and a higher deductible with a PPO plan.

HMO stands for health maintenance organization. HMO has a narrower network than PPO insurance and is usually referral-based. Members typically are required to go to a primary care physician (PCP) first and then be referred to specialists, most likely in their network. Because of the limitations of the network covered, HMO insurance is typically a lower cost plan.

You can choose a Medicare Advantage plan (Medicare Part C) to provide all of the benefits you are entitled to under Medicare—plus extra benefits. Most Medicare Advantage plans include Medicare Part D prescription drug coverage. Medicare Advantage plans, such as Clover Health, provide these benefits through a contract with the government. With a Medicare Advantage plan, you may have to pay more if you see a doctor or provider who is not in the plan’s network. However, with a Medicare Advantage plan, there will be an annual limit to the out-of-pocket costs you pay.

Most Medicare Advantage plans try to include a $0 premium plan, but costs vary from plan to plan, service area to service area.

The Annual Election Period, October 15th to December 7th, is your yearly opportunity to compare your options and choose a Medicare Advantage plan that best meets your needs and budget. To help get you started, here are some things to consider:

— Does the plan offer a $0 monthly premium?
— Are the doctors and specialists that you see included in the plan’s network?
— Does the plan formulary include your prescription drug?

If you are under 65 years old and you or your spouse did not work at least 10 years for which you paid Medicare taxes, you may not be eligible for Medicare. For more information on eligibility, please visit the U.S. Department of Health & Human Services Medicare eligibility page, and to test your own eligibility, visit the Medicare.gov Eligibility & Premium Calculator.

As explained on the Health and Human Services website, generally Medicare is available for people age 65 or older, younger people with disabilities, and people with end-stage renal disease, or ESRD (permanent kidney failure requiring dialysis or transplant). Medicare includes Part A (hospital insurance) and Part B (medical insurance). You are eligible for premium-free Part A if you are 65 or older and you or your spouse worked and paid Medicare taxes for at least 10 years. You can get Part A at age 65 without having to pay premiums if:

— You are receiving retirement benefits from Social Security or the Railroad Retirement Board.
— You are eligible to receive Social Security or Railroad benefits but you have not yet filed for them.
— You or your spouse had Medicare-covered government employment.

You can enroll in Medicare Part A and/or Medicare Part B online at SocialSecurity.gov, over the phone by calling Social Security at 1-800-772-1213 (TTY users 1-800-325-0778) 7 am–7 pm Monday through Friday, or in person at your local Social Security office.

Original Medicare consists of Part A and Part B. Part A is hospital coverage, and Part B is medical coverage. Most Medicare beneficiaries pay a premium for Part B coverage.

You can find a doctor who accepts Medicare by visiting Medicare.gov to search for covered physicians and other clinicians. If you’re a member of Clover Health, find an in-network doctor, pharmacy, and supplemental benefits through cloverhealth.com.

You can purchase a Medicare Supplement Insurance (Medigap) plan in addition to Original Medicare to fill the gaps not covered by Medicare alone. A Medigap plan is different from a Medicare Advantage plan. Generally, people with Medigap plans can see any doctor they want, so they are not limited to a particular insurance plan’s network. Medigap plans do not include prescription drug coverage. For prescription drug coverage, a separate Medicare Part D drug plan must be purchased.