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Understanding Medicare

What is Medicare?

Medicare is a health insurance program for:

  • People who are 65 or older,
  • People under age 65 with certain disabilities, and
  • People of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant, sometimes called ESRD).
  • People who have ALS (Amyotrophic Lateral Sclerosis)

We understand that Medicare can be confusing. With that in mind, we have developed a series of 10 short educational videos that clearly describe how to make sense of the Medicare choices that need to be made and how to make them.

  1. The First Big Decision
  2. Enrollment Periods
  3. Understanding Original Medicare
  4. Understanding Medicare Advantage
  5. How to choose a Medicare Plan
  6. Working with an Independent Medicare Agent
  7. Medicare Prescription Coverage
  8. The Extra Help Program
  9. A Medicare Resource Overview
  10. Understanding the Medicare Drug Formulary

Medicare Part A (Hospital Insurance)

Most people don't pay a premium for Part A because they or a spouse already paid for it through their payroll taxes while working. Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals, including critical access hospitals and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Beneficiaries must meet certain conditions to get these benefits.

Medicare Part B (Medical Insurance)

Most people pay a monthly premium for Part B. Medicare Part B (Medical Insurance) helps cover doctors' services and outpatient care. It also covers some other medical services that Part A doesn't cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary. If a Medicare beneficiary decides not to enroll in Medicare Part B coverage when initially available, there may be a penalty to enroll at a later date.

Medicare Part C (Medicare Advantage Plans)

A type of Medicare health plan offered by a private company (like ATRIO Health Plans) that contracts with Medicare to provide you with all your Part A and Part B benefits. Part C Medicare Advantage Plans cover all the benefits you receive with Part A and Part B and may offer additional benefits such as dental care, gym memberships, vision care and prescription drug coverage (Part D).

Medicare Part D (Prescription Drug Coverage)

Medicare Part D is Prescription Drug Coverage. Private companies (like ATRIO Health Plans) provide the coverage and beneficiaries choose the drug plan and pay a monthly premium. ATRIO Health Plans offers Medicare PPO plans with or without prescription drug coverage. If a beneficiary decides not to enroll in a drug plan when they are first eligible, they may pay a penalty if they choose to join later.

When Can I Enroll?

Initial Enrollment Period (IEP)

You can sign up for a Medicare Advantage Plan during the 7-month period that begins 3 months before the month you turn 65 and ends 3 months after the month you turn 65. You must be enrolled in Medicare Part B to be eligible to enroll in a Medicare Part C Medicare Advantage Plan.

General Enrollment:

If you don’t sign up for Part A (if you have to buy it) and/or Part B (for which you must pay premiums) during your initial enrollment period, and you don’t qualify for a Special Enrollment Period, you can sign up between January 1st - March 31st each year. Your coverage won’t start until July 1 of that year, and you may have to pay a higher premium for late enrollment in Part B if you don't have prior qualifying coverage.

Annual Election Period (AEP)

The Annual Election period is the most common time of the year to elect plan changes and occurs every year from October 15 - December 7th. If you don't currently have prescription coverage (Part D) you can also elect to add it during this time. If you're happy with your current coverage, you don't need to do anything and will be automatically re-enrolled in your current plan for the next calendar year. Any changes you elect will take effect January 1 of the next calendar year.

You can do any of the following during the Annual Election Period:

  • Change from Original Medicare to a Medicare Advantage Plan.
  • Change from a Medicare Advantage Plan back to Original Medicare.
  • Switch from one Medicare Advantage Plan to another Medicare Advantage Plan.
  • Switch from a Medicare Advantage Plan that doesn’t offer drug coverage to a Medicare Advantage Plan that offers drug coverage.
  • Switch from a Medicare Advantage Plan that offers drug coverage to a Medicare Advantage Plan that doesn’t offer drug coverage.
  • Join a Medicare Prescription Drug Plan.
  • Switch from one Medicare Prescription Drug Plan to another Medicare Prescription Drug Plan.
  • Drop your Medicare prescription drug coverage completely.

Open Enrollment Period (OEP)

The Open Enrollment Period occurs each year from January - March. The OEP allows beneficiaries who are enrolled in a Medicare Advantage Plan to make a one-time change. Beneficiaries can use the Medicare OEP to:

  • Switch from one Medicare Advantage plan to another Medicare Advantage plan
  • Disenroll from a Medicare Advantage plan and return to Original Medicare, with or without a Part D drug plan

Special Enrollment Periods (SEP)

You can make changes to your Medicare Advantage and Medicare prescription drug coverage when certain events happen in your life, like if you move out of area or you lose other insurance coverage. These changes are called Qualifying Events which makes you eligible for Special Enrollment Period (SEP). Rules about when you can make changes and the type of changes you can make are different for each Qualifying Event.

Special Enrollment Periods include:

  • You change where you live
  • You lose your current coverage
  • You have a chance to get other coverage
  • Your plan changes its contract with Medicare, and
  • Other special situations

For a full list of Qualifying Events go to medicare.gov.