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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 insurance 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 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, 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 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

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.

Medicare Part D is the prescription drug coverage of Medicare. The benefit is administered by commercial insurance plans, either as a stand-alone prescription drug plan or as a part of a Medicare Advantage plan that includes Part D, like Clover Health. Most of your prescriptions will be covered by your Part D benefit, but some are covered as part of your medical benefits. To learn more about how a drug you take is covered, contact Member Services.

Depending on your circumstances, you may be eligible for state and federal programs to reduce your Part D costs. Check with Medicare to see if you qualify for the Low-Income Subsidy (LIS).

Extra help is available to Medicare beneficiaries who need assistance paying for care. We're happy to help you learn more about what's available. Depending on your circumstances, the Medicare Low-Income Subsidy (LIS), State Pharmaceutical Assistance Programs (SPAP), discount programs, Medicaid, and state premium assistance programs like SLMB can all help lower your costs. To learn what's available in your area and how to apply, contact Member Services at 1-888-778-1478 (TTY 711) 8 am–8 pm local time, 7 days a week.*

Medicare places some restrictions on how beneficiaries can join and leave Medicare Advantage plans. These rules are common across all Medicare Advantage (MA) plans.

  • Annual Enrollment Period (AEP) from October 15th to December 7th – when all beneficiaries may join an MA plan. You can also change from:
    • One Medicare Advantage plan to another Medicare Advantage plan
    • Original Medicare or Medicare Supplement Insurance (Medigap) to a Medicare Advantage plan
    • A Medicare Advantage plan to Original Medicare
  • Open Enrollment Period (OEP) from January 1st to March 31st – when all beneficiaries can:
    • Switch to another Medicare Advantage plan
    • Leave their Medicare Advantage plan and return to Original Medicare (Parts A & B)

Note: If you have Original Medicare only, you cannot use the Open Enrollment Period to select a Medicare Advantage plan.

  • Initial Enrollment Period (IEP), the 7-month window when you can first sign up for Medicare Part A and/or Part B. For most, it’s when you turn 65/entitlement. The 7-month period includes:
    • 3 months before you turn 65/entitlement
    • The month you turn 65/entitlement
    • 3 months after you turn 65/entitlement

Outside of these periods, beneficiaries can only change plans under certain circumstances. Under these circumstances, members are qualified for a Special Enrollment Period (SEP), during which they may change plans or enroll in a new plan.

The coverage gap is a period of reduced coverage common across most Medicare Advantage Part D drug plans. There are 4 phases of Part D coverage, including the gap phase. After you pay your plan's deductible, you pay the copays or coinsurance described in your plan benefits until the total cost of your prescriptions reaches a certain amount.

The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,130 (2021 level). Not everyone will enter the coverage gap. If you do reach the gap phase of your coverage, you'll pay more for your prescriptions until you reach the end of that phase. At the end of the gap phase, you'll pay a low, fixed amount through the end of the plan year for all your Part D prescriptions. If you have questions about your own Part D costs or extra help you might be eligible for in paying those costs, please contact Member Services at 1-888-778-1478 (TTY 711) 8 am–8 pm local time, 7 days a week.*