Who Can Get Medicare?

Hospital Insurance (Part A)
 
If you are age 65 or older. 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 railroad retirement or social security benefits. (Although the age requirements for some unreduced railroad retirement benefits have risen just like the social security requirements, beneficiaries are still eligible for Medicare at age 65.)

If you are under age 65. Before age 65, you are eligible for free Medicare hospital insurance if you have been entitled to monthly benefits based on a total disability for at least 24 months. If you are entitled to monthly benefits based on an occupational disability, and have been granted a disability freeze, you are eligible for Medicare starting with the 30th month after the freeze date or, if later, the 25th month after you became entitled to monthly benefits. If you receive benefits due to occupational disability and have not been granted a disability freeze, you are generally eligible for Medicare hospital insurance at age 65. (The standards for a disability freeze determination follow social security law and are comparable to the medical criteria for granting total disability.) You are also eligible for Medicare if you have Lou Gehrig’s disease (amyotrophic lateral sclerosis).

Eligibility for family members. Under certain conditions, your spouse, divorced spouse, surviving divorced spouse, widow or widower, or a dependent parent may be eligible for Medicare hospital insurance based on your work record when he or she turns age 65.

Also, disabled widows and widowers under age 65, disabled surviving divorced spouses under age 65, and disabled children may be eligible for Medicare, usually after a 24-month waiting period.

If you have permanent kidney failure. 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 are receiving monthly benefits under the railroad retirement or social security system.

In addition, your spouse, divorced spouse or child may be eligible, based on your work record, if she or he has permanent kidney failure and receives maintenance dialysis or a kidney transplant.

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. The basic monthly premium in 2010 is $110.50. However, because there was no cost-of-living increase in social security or railroad retirement benefits in 2010, most beneficiaries continue to pay the 2009 basic monthly premium of $96.40. Beneficiaries who do not have premiums deducted from their monthly benefits, beneficiaries who pay income-related Part B premiums and new Part B Medicare beneficiaries pay higher Part B premiums in 2010.

The income-related Part B premiums for 2010 are $154.70, $221.00, $287.30, or $353.60, depending on the extent to which an individual beneficiary’s income exceeds $85,000 (or $170,000 for a married couple), with the highest premium rates only paid by beneficiaries whose incomes are over $214,000 (or $428,000 for a married couple). The income thresholds increase annually by indexing to the Consumer Price Index (CPI).

The Social Security Administration (SSA) is responsible for all income-related monthly adjustment amount determinations. To make the determinations, SSA uses the most recent tax return information provided by the IRS. For 2010, in most cases that is the beneficiary’s 2008 tax return information. If that information is not available, SSA uses information from the 2007 tax return.

How Much Does Medicare Cost?

In addition to the monthly premiums you pay, there are other out-of-pocket costs for Medicare, which may also change each year. These costs, known as “deductibles” and “coinsurance,” are the amounts you pay when you actually receive medical service.

For example, if you are hospitalized, you will be required to pay a deductible amount, and may have to pay coinsurance amounts, depending on how long you stay. In 2010, the hospital insurance deductible amount is $1,100.

If you receive medical services from a doctor, you pay a yearly deductible amount as well as a coinsurance amount for each visit. In 2010, the medical insurance deductible is $155.

If you cannot afford to pay your Medicare premiums and other medical costs, States offer programs for people who are entitled to Medicare and have low income. The State-run programs may pay some or all of Medicare’s premiums and may also pay Medicare deductibles and coinsurance.

To qualify, you must have Medicare 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 a certain amount. Income limits increase slightly each year and are higher in Alaska and Hawaii.

To find out if you qualify, contact your State medical assistance (Medicaid) office. You can get the number to call in your State by dialing 1-800-MEDICARE (1-800-633-4227) and asking for information about the Medicare Savings Program.

Signing Up For Medicare

If you’re already getting railroad retirement or social security benefits, you will be contacted a few months before you become eligible for Medicare and given information about the Medicare program. You will automatically be enrolled in Medicare Parts A and B. However, because you must pay a premium for Part B coverage, you have the option of turning it down.

If you aren’t already getting benefits, you should contact your local Railroad Retirement Board office about 3 months before your 65th birthday to sign up for Medicare. You can sign up for Medicare even if you don’t plan to retire at age 65.

You should also contact your local Board office about applying for Medicare if:

• you’re a disabled widow or widower between age 50 and age 65 but haven’t applied for disability benefits because you’re already getting another kind of benefit;
   
• you had Medicare medical insurance in the past but dropped the coverage;
   
• you turned down Medicare medical insurance when you became entitled to hospital insurance; or
   
• you, your spouse, or your dependent child has permanent kidney failure. (Contact a social security office in these cases to see if you are eligible.)

Initial Enrollment Period for Part B

When you first become eligible for hospital insurance (Part A), you have a 7-month period to sign up for medical insurance (Part B). This is called your “initial enrollment period.” A delay on your part may cause a delay in coverage and result in higher premiums. If you are eligible at age 65, your initial enrollment period begins 3 months before the month of your 65th birthday, includes the month you turn age 65, and ends 3 months after the month of your 65th 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 3 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 4 months, your protection will start from 1 to 3 months after you enroll.

General Enrollment Period for Part B 

If you don’t 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 didn’t enroll.

Special Enrollment Period for People Covered Under a Group Health Plan

If you are age 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 8-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 8-month period, you will have to wait until the next general enrollment period, which begins January 1 of the next year.

People who receive 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.

Medigap

Individuals deciding when to enroll in Medicare Part B must consider how this will affect eligibility for health insurance policies which supplement Medicare coverage. These policies are known as “Medigap” insurance. A Medigap policy is a health insurance policy, sold by private insurance companies, that helps pay some of the costs that the Original Medicare Plan doesn’t cover.

When an individual enrolls in Medicare Part B at or after age 65, a one-time “Medigap open enrollment period” is triggered. The open enrollment period lasts 6 months. During this period, an insurance company can’t deny insurance coverage, place conditions on a policy, or charge more for a policy because of past or present health problems.

Individuals age 65 or older with health coverage through an employer or union based on their or their spouse’s current employment may want to wait to enroll in Medicare Part B and delay their Medigap open enrollment period.

More detailed information about Medigap policies and other supplemental health insurance plans is available in the publication Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare.  To get a copy by phone or online:

At the web site, click on "Find a Medicare Publication."

If You Have Other Health Insurance

As stated earlier, Medicare hospital insurance (Part A) is free for almost everyone, but you pay a monthly premium for Medicare medical insurance (Part B). If you already have other health insurance when you become eligible for Medicare, you should ask whether it is 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.

Private Insurance Plans

Contact 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.

Employer-Provided Group Health Plans

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 human resources office before you sign up for Medicare medical insurance.

Health Care Protection from Other Plans

If you have TRICARE coverage under a program from the Department of Defense, you must have Medicare Part B to keep this coverage. However, if you are an active duty service member, or the spouse or dependent child of an active duty service member, you may not have to get Medicare Part B right away. You can get Part B during a special enrollment period, and in most cases you won’t pay a late enrollment penalty. Call the contractor that handles TRICARE claims at 1-866-773-0404 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 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 by phone or online:

At the web site, click on "Find a Medicare Publication."

Options For Receiving Health Care Services

Medicare beneficiaries have choices for receiving health care services. The Original Medicare Plan is the traditional fee-for-service Medicare plan that is available nationwide. A beneficiary can see any doctor or provider who accepts Medicare and is accepting new Medicare patients. Persons enrolled in the Original Medicare Plan who want prescription drug coverage must join a Medicare Prescription Drug Plan as described under Prescription Drug Coverage, unless they already have drug coverage from a current or former employer or union that is at least as good as the standard Medicare prescription drug coverage.

A beneficiary can choose a Medicare Advantage Plan (also called Medicare Part C) instead. These plans, which are managed by private insurance companies approved by Medicare, combine Medicare Part A and Part B coverage, and are available in most areas of the country. A beneficiary must have both Medicare Part A and Part B to join a Medicare Advantage Plan, and the individual must live in the plan’s service area. Medicare Advantage Plan choices include regional preferred provider organizations (PPOs), health maintenance organizations (HMOs), private fee-for-service plans and others. A PPO is a plan under which a beneficiary uses doctors, hospitals, and providers belonging to a network; beneficiaries can use doctors, hospitals, and providers outside the network for an additional cost. Under a Medicare Advantage Plan, a beneficiary may pay lower copayments and receive extra benefits. Most plans also include Medicare prescription drug coverage (Part D).

You can get more information about your health care options from the publication Medicare & You. This general guide is mailed to people after they enroll in Medicare and an updated version is mailed each year after that.

To get a copy of this, or any other publication by phone or online:

At the web site, click on "Find a Medicare Publication."

Some publications may instruct you to call or visit an office of the Social Security Administration for assistance. Railroad retirement beneficiaries should instead contact a Railroad Retirement Board office.

Medical Insurance Claims

Palmetto GBA, a subsidiary of Blue Cross and Blue Shield, processes medical insurance (Part B) claims for railroad retirement beneficiaries in the Original Medicare Plan. If you are in the Original Medicare Plan, your hospital, doctor, or other health care provider should submit Part B claims directly to:

If you have questions about Part B claims under the Original Medicare Plan, write to Palmetto GBA at the above address; or by phone or online:

Toll Free: 1-800-833-4455 TTY/TDD: 1-877-566-3572 Website: www.palmettogba.com

At the web site under "People with Medicare," click on "Railroad Medicare" and select the “Contact Us" icon.

For those in a Medicare Advantage Plan, information on out-of-pocket costs is available by phone or online:

At the web site, click on "Compare Health Plans and Medigap Policies in Your Area.

PRESCRIPTION DRUG COVERAGE

Medicare offers voluntary insurance coverage for prescription drugs (Part D) through Medicare prescription drug plans and other health plan options. While Medicare prescription drug plans vary, all drug plans offer coverage that, at the very least, meets a minimum standard of coverage as determined by Medicare. These drug plans work with all Medicare health plans, including the Original Medicare Plan and Medicare Advantage Plans.

To enroll, you must have Medicare Part A and/or Part B. You will generally pay a monthly premium (averaging almost $32 in 2010) and an annual deductible (up to $310 in 2010). You must also pay a share of your prescription drug costs. Costs vary depending on the drug plan you choose. If you have limited income and resources, you may qualify for extra help to cover your drug costs.

When persons first become eligible for Medicare, they can enroll in a Medicare prescription drug plan during the period that starts 3 months before the month their Medicare coverage starts and ends 3 months after that month. If you don't join a drug plan when you are first eligible, you may have to pay a higher premium if you choose to join later.

Beneficiaries can generally join or change plans once each year during an “open enrollment period” from November 15 through December 31. Drug coverage would then begin January 1 of the following year.

If you already have prescription drug coverage from other insurance, such as coverage provided by an employer or union, you can keep that coverage. If that coverage offers the same or better benefits than a Medicare prescription drug plan, you will not have to pay a higher premium if you join a Medicare prescription drug plan at a later date. In many cases, your other insurance provider will send you a notice that tells you if your plan covers as much or more than a Medicare prescription drug plan. If you do not receive a notice, you should check with your other provider to see how your coverage compares.

More information about Medicare prescription drug plans is available in the publication Your Guide to Medicare Prescription Drug Coverage.  The Medicare & You handbook lists the Medicare prescription drug plans that are available in your area. You can get either publication by phone or online:

At the web site, click on "Find a Medicare Publication."

Need More Information?

Railroad retirement beneficiaries should contact the Railroad Retirement Board toll-free at 1-877-772-5772 for general information on their Medicare coverage.  They can also use the Board's web site, or the Medicare and Palmetto GBA information sources shown below. 

Medicare Toll-Free Number and Web Site

To get help with your Medicare questions, you can call Medicare's toll-free number or look on the web site.

Palmetto GBA Toll-Free Number and Web Site

Toll Free: 1-800-833-4455 TTY/TDD: 1-877-566-3572 Website: www.palmettogba.com

If you are in the Original Medicare Plan and have questions about Medicare medical insurance (Part B) claims, you can call Palmetto GBA's toll-free number or visit the web site for help.

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