Adding More Medicare Benefits to Your Coverage

Traditional Medicare is administered by the Centers for Medicare and Medicaid Services and consists of four parts; A, B, C, and D.

Medicare Part A and Part B form what is known as Original Medicare. Together, they provide a foundation of health benefits for millions of Americans and help defray much of the associated costs. However, not all health-related services and costs are covered with only Part A and Part B.

Without additional coverage, enrollees are not covered for some services, or they will have to pay out-of-pocket costs for several types of services.

Costs and coverage gaps can be minimized by adding several other types of Medicare plans, like Part C, Part D, and supplement plans.

Understanding what Original Medicare covers versus what enhanced coverage will provide, as well as what the associated costs are, is critical to managing your finances and healthcare issues as effectively as possible.

To understand what might be the best options for you, first, let’s take a quick look at what Original Medicare does and does not cover.

What Part A Covers

Part A, which is sometimes called Medicare hospital insurance, covers hospital costs and other related inpatient expenses. This includes hospice, skilled nursing facilities, and some home-based health circumstances.

Coverage includes a semi-private room, hospital meals, nursing services, intensive care, drugs and medical supplies used during your stay, lab tests, and x-rays, operating and recovery services, some blood transfusions, rehabilitation, and symptom management.

When you enter a nursing facility, you must require a level of care that can’t be provided at home or from your primary care doctor. Nursing care must be ordered by a doctor and be administered daily by a professional nurse or therapist.

Hospice care is covered when you agree that you are accepting palliative care instead of other Medicare-covered treatments. You agree you have been given six months or less to live, and you are only seeking assistance to live comfortably until you pass.

Hospice coverage does not include any treatment to cure your condition or your room and board. Your coverage does include some doctor and nursing services, medical equipment, prescription drugs for pain and discomfort, homemaker services, some therapy services, and counseling.

If you enter recovery during hospice and want to switch from hospice back to regular treatments, you can do that at any time without losing coverage.

When you’re housebound, or a doctor orders home health care for you, you may be covered by a combination of Part A and Part B benefits.

What Part B Covers

Part B covers a wide range of services.

Some of those include wellness and preventative services, some of which are covered 100%.

When you first enroll in Part B, you can make a “Welcome to Medicare” visit with your doctor for a comprehensive overview to discuss your specific healthcare needs and concerns. You are also covered for an Annual Wellness Visit that includes a full health risk assessment, a review of your current vital information (weight, blood pressure, BMI, etc.), mental health, and additional discussions about your current state of health and concerns.

You are also covered for some preventative vaccines. But not all vaccines are considered preventative and would not be covered under Part B, but may be covered under Part D.

You are also covered for preventative treatments related to high blood pressure, glaucoma, obesity, HIV, cardiovascular, and some cancers, among others.

Women are covered at 100% for pap smears, pelvic exams, and breast exams every two years.

Part B covers outpatient mental health services such as depression screenings, psychotherapy, psychiatric evaluations, some prescriptions, and partial hospitalization.

Lab tests and X-rays are covered when your doctor orders a test to help diagnose a condition or as part of your annual checkup. Medically necessary blood tests, urine tests, tissue lab work, and some screenings are also covered. X-rays are covered at 80% of the Medicare-approved amount. You are responsible for the other 20%.

Emergency transportation is covered if other transportation could put you in danger or you are having a medical emergency and need immediate assistance. Coverage only includes transportation to the nearest medical facility that can give you the type of help you need.

Transportation is covered at 80% of the Medicare-approved amount, and your Part B deductible will apply.

Durable medical equipment (DME) is covered, but for coverage to apply, a DME must be able to withstand repeated use for at least three years. It must also be usable at home and must be used for a medical purpose only. Medicare will cover 80% of the cost.

Some examples of DME include canes, crutches, hospital beds, infusion supplies, nebulizers, commode chairs, CPAP devices, and more.

Part B also covers some home health care, but only that which is relatively short-term and related to a limited period of recovery due to an illness, injury, or condition.

What Part A and Part B do not Cover

In most cases, Part A and Part B coverage will meet the vast majority of medical insurance needs. But there are also many things Original Medicare does not cover. You’ll have to pay these costs unless you get additional coverage.

Some things Part A and Part B do not cover include:

• Hearing aids and related exams
• Long-term custodial care
• Most dental care and dentures (unless medically necessary)
• Alternative medicine, such as homeopathy, acupuncture, and acupressure.
• Elective and cosmetic surgery
• Eye exams for prescription glasses and most contact lenses
• Chiropractors are covered but only on a limited basis.
• Routine foot care unless it is the result of diabetes, cancer, multiple sclerosis, inflammation due to blood clots, chronic kidney disease, malnutrition, or related conditions.
• Most prescription drugs coverage
• Medically unnecessary amenities such as private hospital rooms, private nurses, and personal care items that hospitals may provide (shower supplies, TV, etc.).
• Custodial care includes daily activities such as bathing, grooming, dressing, meals, etc.
• Part A only covers skilled nursing, but not long-term nursing, either at home or in a nursing facility.

Medical services, for the most part, outside of the United States and its territories are not covered as well. A Medicare Advantage plan is required for international coverage.

Part B also only covers drugs you can’t self-administer. You’re only covered if you must receive medications in a hospital, doctor’s office, or health clinic. Part D coverage extends to nonprescription drugs, and remedies are also not covered under Part B.

Do I Need Additional Health Insurance If I Have Medicare?

Medicare provides a very basic level of coverage. That’s why millions of Medicare beneficiaries choose to enroll in a variety of additional health plans to get extra benefits. These additional Medicare plans may also allow you to see additional healthcare providers, like dentists and specialists, without incurring astronomical costs.

These plans generally have low enough premiums that it is reasonable to pay a bit more each month for these additional benefits. In fact, some people might qualify for $0 premiums!

Adding a Medicare Advantage Plan (Part C)

Medicare Advantage plans, also called Medicare Part C plans, can lower your out-of-pocket costs and provide more coverage when bundled with Original Medicare.

You must be enrolled in both Part A and Part B before you can sign up for a Part C plan.

Some Part C plans also cover prescription drugs that you take at home. You will need to check each plan’s formulary to see if the specific drug you need is covered by a plan. Typically, Part C coverage also will provide routine dental care, vision care, hearing care and hearing aids, and fitness benefits such as Silver Sneakers or other types of exercise classes.

Part C plans come in many forms, but the most popular varieties are PPO plans and HMO plans. The difference between Medicare Advantage PPOs and HMOs is that HMOs come with very strict physician networks and you’ll have to select one primary care physician, while PPOs allow you the freedom of a wide network. While PPOs may seem like the obvious choice, that flexibility can come with a higher price tag – so choose carefully!

Because not all plans provide the same levels of coverage, you may pay a higher premium for more coverage.

The Medicare Advantage marketplace is highly competitive, and it can be confusing to determine which policy is the best one for you. Your best bet is to work with an experienced agent who can answer all of your questions and guide you along the way.

You can enroll in Medicare Advantage either when you initially sign up for Medicare, during the Annual Enrollment Period (October 15 through December 7), or in some cases during the Open Enrollment Period (January 1 through March 31).

$0 Premiums and Special Needs Plans

Some people may be eligible for a $0 premium Medicare Advantage plan.

There are three types of Special Needs Plans:

• Chronic Special Needs Plans (CSNP) for people who have certain chronic conditions and need more coverage.
• Institutional Special Needs Plans (ISNP) for people who have been living in an institution such as an inpatient medical facility for 90 days or more.
• Dual Eligible Special Needs Plans (DSNP) are for people who are dual-eligible for both Medicare and Medicaid.

Adding a Medicare Prescription Drug Plan (Part D)

Prescription drug costs can be expensive, especially if you need highly specialized treatment or you’re on a fixed income. Adding a Medicare Part D prescription drug plan can be one of the smartest economic decisions you can make.

Just like with Part C plans, you’ll need to shop and compare Part D plans. A good place to start is to look at a possible plan’s formulary. This is the complete list of all prescriptions covered by that particular plan.

Match your existing and anticipated needs to the formulary for maximum savings.

Because formularies can change from year to year, also be sure to closely review your Annual Notice of Change every fall, to make sure your current coverage still best meets your needs.

You may still have some deductible and copayments to make, but typically you can save thousands of dollars depending on your situation.

Also, once you’ve paid a certain annual amount out of your own pocket, you are entitled to automatic catastrophic coverage. From that point on, your prescription drug costs are greatly reduced, and you’ll only pay a small copayment or coinsurance.

You may have heard of the “donut hole” with Part D coverage. This is the coverage gap that may require you to pay all drug costs yourself after Part D coverage has paid a certain amount for your prescription drugs. The good news is that federal healthcare legislation has been working to reduce the donut hole over several years, and in 2020, the gap is completely closed.

There are several times throughout the year you can sign up for Medicare prescription drug coverage. The first is during your Initial Enrollment Period. You can also enroll or make changes in your Part D plan during the Annual Enrollment Period that runs from October 15 through December 7 annually.

Additionally, a Special Enrollment Period occurs when you have a qualifying life event such as losing drug coverage or when you move from a particular plan’s area.

When you qualify for Medicare Extra Help you can also enroll in a Part D plan.

There are hundreds of private insurance companies offering Part D plans for Medicare beneficiaries – but they may not all be available in your area. It’s best to speak with an insurance agent to learn about all of the options available to you and to get guidance from a professional.

Adding a Medicare Supplement (Medigap) Plan

Medigap plans do what they sound like…they close the coverage gap in your existing Medicare Part A and Part B policies.

Medigap plans are also called Medicare Supplement plans. They are designed to cover your out-of-pocket Medicare Part A and Part B costs, including deductibles and copayments.

Medicare Supplement insurance plans are lettered A through N. Each lettered policy provides a different level of coverage offered by private companies contracted with Medicare. However, each Medigap plan with the same letter must offer the same core benefits, no matter which carrier you choose.

For example, if you choose Plan G to plug your coverage gap, the coverage will be the same no matter which insurer you pick.

Premium costs will differ, which is why you’ll need to shop around for the best insurance plans. Costs may also differ a bit because a carrier could offer services above the core benefits, or your location could cause a price fluctuation as well.

The ten Medigap plans are:

• Plan A
• Plan B
• Plan C
• Plan D
• Plan F
• Plan G
• Plan K
• Plan L
• Plan M
• Plan N

These apply to every state except Massachusetts, Minnesota, and Wisconsin. Wisconsin only has one Medigap plan option, and Massachusetts and Minnesota only have two.

Plan C and Plan F are not accepting new members after January 1, 2020. If you’re already enrolled in one of these plans, you can keep your coverage.

If you apply during your IEP (beginning three months before you turn 65 and ending three months after) and you have Medicare Part B, you have “guaranteed issue rights.” You can’t be denied Medicare Supplement enrollment or charged more based on your age, health status, or pre-existing conditions.

However, if you do have pre-existing conditions, carriers can impose up to a six-month waiting period before your benefits begin.

Most Medigap plans do not offer dental, prescription drug, vision, or hearing coverage. You will need a Medicare Advantage plan if you want coverage for those services.

You can purchase Medigap during any time of the year, but your IEP is when a plan will

be the cheapest and easiest to enroll.

Can I Add a Medicare Supplement at Any Time?

Technically, yes! Medicare Supplement plans are a bit different from Medicare Advantage plans in that you can enroll at any time of year. However, when you enroll can make a big difference in what you pay. Unlike Medicare Advantage plans, Medicare Supplement insurance companies can charge you more based on preexisting health conditions if you wait too long to enroll. If you are enrolling in Medigap right when you become eligible or due to circumstances beyond your control, you won’t have to go through medical underwriting. However, if you wait until you’re older to enroll just because you weren’t sure, you could face higher premiums than expected.

Who Qualifies for Additional Medicare Benefits?

Anyone who is already enrolled in Medicare Part A and Medicare Part B can start looking at additional Medicare benefits (Medicare Advantage, Medicare Supplements, Part D). Keep in mind that Medicare guidelines stipulate that you cannot have Medicare Advantage and Medicare Supplements at the same time, and you cannot have Medicare Advantage and Part D at the same time.

Getting Help With Your Medicare costs

In some cases, you may be able to get help paying for your Medicare costs through a Medicare Savings Program (MSP).

Eligibility for MSPs is based on your income, assets, and current Medicare coverage. Most states use the Federal Poverty Level as a guideline. Income limits are based on this and can change annually.

Resources such as stocks, bonds, or money in checking or savings accounts are included. Your home, one car, furniture, personal and household items, life insurance with a cash value of less than $1,500, a burial plot, and up to $1,500 set aside for burial expenses are not included.

Limits and restrictions vary from state to state. To find out if you qualify, call your local Medicaid office or State Health Insurance Programs (SHIP). Alabama, Arizona, Connecticut, Delaware, DC, Mississippi, New York, and Vermont do not apply asset limits.

There are four MSPs, each with slightly different requirements and types of coverage for your health care costs.

They include:

Qualified Medicare Beneficiary Program (QMB)

The income limit for QMB in 2020 is $1,061/month for individuals and $1,430/month for married couples. The resource limit is $7,730 for individuals and $11,600 for married couples.

• Helps pay for Medicare Part A and Part B premiums, deductibles, coinsurance, and co-payments.
• In 2019, gross monthly income limits were 100% of the Federal Poverty Level plus $20 (may vary depending on your state).
• When you qualify for the QMB, you automatically qualify for Extra Help assistance to pay for prescription drug coverage.

Qualified Individual Program (QI)

The income limit for QI in 2020 is $1,426 for individuals and $1,923 for married couples. The resource limit in 2020 is $7,730 for individuals and $11,600 for married couples.

• Helps pay Part B premiums if you have Part A and meet income and asset restrictions.
• When you start receiving QI aid, you may be reimbursed for your Part B premiums for up to three months before your QI Program effective date.
• QI assistance is awarded on a first-come, first-serve basis. Priority is given to people who got QI benefits the previous year.
• You must also reapply every year.
• QI benefits are not awarded to those who qualify for Medicaid.
• Income limits are slightly higher in Alaska and Hawaii.
• When you qualify for the QI Program, you automatically qualify for Extra Help assistance to pay for prescription drug coverage.

Specified Low-Income Medicare Beneficiary Program (SLMB)

The income limit for SLMB in 2020 is $1,269 for individuals and $1,711 for married couples. The resource limit in 2020 is $7,730 for individuals and $11,600 for married couples.

• Administered by individual states. Helps pay Medicare Part B premiums for people who have Medicare Part A and meet income and asset limitations.
• Receive reimbursement for up to three months of Part B premium payments from before your SLMB effective date.
• Slightly higher income limits in Alaska and Hawaii.
• When you qualify for the SLMB program, you automatically qualify for Extra Help assistance to pay for prescription drug coverage.

Qualified Disabled and Working Individuals Program (QDWI)

QDWI income limits in 2020 are $4,249/month for individuals and $5,722/month for married couples. The resource limits for QDWI in 2020 are $4,000 or less for individuals and $6,000 or less for married couples.

• Helps pay Part A premiums.
• You may be eligible for QDWI benefits if:
  • You’re a working disabled person under 65
  • You lost your premium-free Part A when you went back to work
  • You aren’t getting medical assistance from your state (mainly Medicaid)

Applying for Medicare Savings Programs

When you apply for MSPs, you will apply for all of the MSPs (QMB, QI, SLMB, QDWI) at the same time through your state Medicaid program. Each state has a different application process because MSPs are tied directly to state-funded Medicaid.

When you apply for health insurance assistance, you may need legal documentation such as your Social Security Administration card, your Medicare card, your birth certificate (or passport/green card), and proof of your address and income. If you have qualifying assets and resources, you may need proof for those as well (bank statements, life insurance policies, stocks, etc.).

After you file an MSP application, you should receive a “Notice of Action” within 45 days to tell you whether or not you have been approved.

If your application is approved, you will be automatically enrolled in the program that most aligns with your qualifications. Your benefits begin on the month indicated on your Notice of Action (usually the following month).

What is the Extra Help Program for Medicare?

The Extra Help program, also called “LIS” or Low-Income Subsidies, is a program that helps qualifying Medicare beneficiaries afford their Part D prescription drug costs.

About Extra Help/Low-Income Subsidies (LIS)

Extra Help provides prescription drug plan assistance such as costs for Part D premiums up to a state-specific benchmark amount, as well as deductibles, coinsurance, and co-payments.

Extra Help also eliminates Part D late enrollment penalties you would have incurred if you held off signing up for Part D.

If you qualify for QMB, SLMB, or QI, you also automatically qualify for Low-Income Subsidies (LIS). If you’re already enrolled in Medicaid, Supplemental Security Income (SSI), or a Medicare Savings Program (MSP), you automatically qualify for Extra Help even if you don’t meet Extra Help’s eligibility requirements. If you don’t get any of these benefits, you can apply for Extra Help through the Social Security Administration either online or with a printed application.

You can qualify for full or partial Extra Help depending on your income level and assets. If you are denied Extra Help assistance, you have the right to appeal the decision.

There are several ways to apply for Extra Help:

• Online
• Print and mail form SSA-1020 to Social Security
• Call Social Security at 1-800-772-1213 (TTY 1-800-325-0778)
• Visit your local Social Security Office

What does Social Security Extra Help Pay For?

Extra Help can cover some of your prescription drug costs. The Medicare/Social Security Extra Help program is estimated to be worth about $5,000 per beneficiary. That’s because you could save about $5,000 in prescription drug costs by enrolling in Extra Help.

Medicare Costs in 2020

Let’s start with the Original Medicare program (parts A and B). If you qualify, you can get premium-free Part A Medicare. Most beneficiaries are still responsible for paying deductible and coinsurance costs.

You get free Part A premiums if you or your spouse worked and paid Medicare taxes for at least 40 quarters (10 years) during your working life, and you sign up for Part A during your IEP.

If you paid Medicare taxes for 30 to 39 quarters, your premium is $252 per month in 2020. If you worked and paid Medicare taxes for less than 30 quarters of your life, your premium will be $458 per month in 2020.

In 2020, the standard Part B premium is going up by about 7% to $144.60 due to increased program costs. The standard deductible is $198.

After you meet your deductible, you’ll pay 20% for most Medicare Part B services, other than preventative and wellness services.

If you have a high gross income, you could pay an Income-Related Monthly Adjustment Amount (IRMAA).

Now let’s look at costs for additional Medicare benefits.

Part D plan costs can range from $15 to $80 per month.

Two additional ways to save money on your prescription drugs are through mail-order deliveries and prescription savings cards. You can add to your monthly savings if you get in the habit of buying your prescription medications using these tools.

If you have Medicare but also have either Social Security benefits or Medicaid, your prescription coverage will still come from Medicare. You’ll need either Medicare Advantage with prescription coverage or a Part D plan.

Medigap plan costs vary from insurer to insurer but generally range from about $100 to $400 per month and will often depend on the carrier and the location.

Medigap providers typically use one of three methods to determine the pricing of their plans:

• Community-rated: Everybody pays the same rate each month per location regardless of their age.
• Issue-age-rated: You pay a premium based on the age you are when you sign up for the plan. The younger you are, the less you pay. Premiums may increase each year based on inflation, but they will increase as you age.
• Attained-age-rated: Your premium is based on your age at the time you enroll, and it increases every year based on your age and inflation.

Understanding Medicare Part B – Coverage and Costs for 2020

What Is Medicare Part B?

Medicare is a federal government health insurance program for seniors 65 and older and others who meet qualifying conditions.

Medicare consists of four parts, labeled A, B, C, and D. Parts A and B make up the government-funded “Original Medicare” program. Part C refers to “Medicare Advantage” plans, which provide additional medical insurance. Part D refers to separate prescription drug Medicare plans. 

Part A covers costs associated with hospitals and other inpatient services. It’s complemented by Part B, which covers outpatient services, preventative care, and durable medical devices.

Some people are automatically enrolled in Parts A and B while others must enroll on their own. 

What is the difference between Part A and Part B Medicare?

Part A is often referred to as Medicare “hospital insurance,” while Part B Medicare coverage is often referred to as “medical insurance.” What this means is that while Part A can cover hospital stay charges, Part B can cover your doctor’s appointments and preventative care. If you had Part A only, you would have coverage for hospital care, but not any of your doctor’s appointments, so it’s important to enroll in both. 

Medicare Part B Coverage

At this point, you’re probably wondering, “what does Part B of Medicare pay for?” 

Medicare Part B covers ambulance services, doctor visits, preventative services, mental health, women’s health services (like mammograms), lab tests and X-rays, some medical equipment, and more. It does NOT cover hospital stays or most prescription drugs. The only time that Part B will cover drugs is if the drug is administered by a medical professional.

Medicare Part B Drugs

Here is a list of drugs covered by Medicare Part B:

• Drugs used with durable medical equipment, like nebulizer supplies
• Antigens, when prepared and administered by a doctor
• Injectable osteoporosis drugs if medically necessary 
• Erythropoiesis-stimulating agents for those with ESRD or anemia related to other conditions
• Oral ESRD drugs
• Blood clotting factors for those with hemophilia
• Other injectable and infused drugs when given by a medical professional

Preventative Services and the Annual Wellness Visit

Medicare Part B includes 100% coverage for several preventative services.

For example, when you first enroll in Part B, you can make a “Welcome to Medicare” appointment with your doctor. This will be a comprehensive overview conversation with your doctor about your healthcare needs and concerns.

You will also be eligible for an Annual Wellness Visit. This is more in-depth and includes a health risk assessment, a review of your and your family’s medical history, measurements (height, weight, BMI, blood pressure, etc.), mental health screenings, and a general conversation about your daily health concerns.

Also included under Part B at 100% coverage are your preventative vaccines, such as annual flu shots. However, some vaccines that are not considered preventative measures are not included under Part B coverage.

For example, the Shingles vaccine would be covered under Part D coverage instead of Part B.

Preventative services are also covered for:

• high blood pressure
• high blood sugar
• abnormal cholesterol
• obesity
• glaucoma
• depression
• cardiovascular disease
• HIV
• smoking and alcohol cessation
• various cancers

Women are covered at 100% for pap smears, pelvic exams, and breast exams every two years. If you are diagnosed as at-risk for gynecological conditions, you may be able to receive screenings every year instead.

Mental Health

Medicare Part A covers inpatient mental health care. Part B covers outpatient mental health services, including:

• No-cost yearly depression screenings
• Both individual and group psychotherapy (including family counseling)
• Psychiatric evaluations and diagnostic tests
• Certain prescriptions
• Medication management
• Limited partial hospitalization
• Partial hospitalization refers to psychiatric hospital treatments that don’t require an overnight stay. Items like meals, transportation, and support groups are not included.

You will only receive coverage when you see a doctor or specialist who accepts Medicare. You will be responsible for 20% of most of these services. There may be additional co-payments or coinsurance for partial hospitalization.

IMPORTANT: If you or a loved one is in immediate crisis, call the National Suicide Prevention Lifeline immediately at 1-800-273-8255 (TTY 1-800-799-4889). Help is available 24-7.

Laboratory Tests and X-Rays

When your doctor orders a lab test to help diagnose a condition or as part of your annual checkup, you are covered under Part B. Medically necessary blood tests and other diagnostics sent to a lab are covered.

They include blood work, urine tests, tissue lab work, and some screenings at no cost to you.

Blood for transfusions is handled differently. If you get a transfusion through a blood donation, you may not have to pay anything. Otherwise, you may have to pay 20% of the Medicare-approved amount.

X-rays are also covered but at 80% of the Medicare-approved amount. You are responsible for the other 20%.

Emergency Transportation

Part B can cover emergency transportation if other transportation could put you in danger or you are having a medical emergency and need immediate assistance. It will only cover an ambulance ride to the nearest medical facility that can give you the type of care you need.

You cannot request to visit a hospital that is further away.

Air transportation is covered only if you need to get to a facility quickly and cannot do so by ground transportation (heavy traffic, inaccessible road conditions, etc.)

Transportation is covered at 80% of the Medicare-approved amount, and your Part B deductible will apply.

In some cases, Part B may cover non-emergency ambulance transportation if there is no other safe way for you to get to a hospital or other provider office for medically necessary services.

You will need to schedule your ambulance transportation in advance by reaching out to a non-emergency ambulance transportation company like ACC Medlink and Lifeguard.

The company you select may charge a fee and can contact Medicare to request authorization for coverage.

Durable Medical Equipment

Part B will only cover durable medical equipment.

For an item to be considered durable medical equipment (DME), it must be able to withstand repeated use for at least three years, must be usable at home, and must be used for a medical purpose only. Medicare will cover 80% of the cost.

In some cases, you may be able to choose whether you want to rent or purchase the equipment you need.

Some examples of DME include:

• Blood sugar test strips and monitors/glucose control
• Canes, crutches, scooters, walkers, and wheelchairs
• Continuous passive motion machines
• Continuous positive airway pressure devices (CPAP)
• Commode chairs
• Hospital beds
• Infusion supplies
• Lancets and lancet devices
• Nebulizers and related medication
• Nutrition supplies/equipment

Check with your doctor or Medicare to see if an item is considered a DME or not.

Long-Term Care

Part B covers some home health care, but only that which is relatively short-term and related to a limited period of recovery due to an illness, injury, or condition. Part B does not cover long-term care, either at home on in a nursing facility, that people may need due to frailty or because they need help with daily activities (bathing, grooming, eating, etc.)

What isn’t covered by Medicare Part B

Medicare Part A and Part B are structured to work together to provide maximum coverage at an affordable cost for most Americans.

This coverage is enhanced by adding optional Part C Medicare Advantage or Medicare Part D drug plan coverage.

In general terms, Part A covers in-hospital expenses, and Part B only covers outpatient expenses, durable medical equipment, and wellness activities.

Medicare does not cover anything not considered medically necessary. That includes elective and cosmetic surgery and several forms of alternative medicine such as homeopathy, acupuncture, and acupressure. Chiropractors are covered on a limited basis.

Other than flu and pneumonia shots, Medicare does not cover vaccinations and immunizations. The exception is if there is a health emergency, and vaccinations are required to stem the risk of infection through a contagious disease.

Part B also only covers drugs you can’t self-administer. Coverage is only provided if you receive medications in a hospital, doctor’s office, or health clinic. This is where Part D coverage can come in handy. All nonprescription drugs and remedies are also not covered under Part B.

General dental work is also not covered, unless it would need to be performed by a physician, meaning the treatment would be considered medical vs. dental

Part B also does not cover vision care, hearing aids, or contact lenses, except those required after cataract surgery. But if your eyes are affected by an illness or injury other than a routine loss of vision, you will be covered for ophthalmological services.

Routine foot care is also not covered unless a foot condition is the result of conditions such as diabetes, cancer, multiple sclerosis, inflammation due to blood clots, chronic kidney disease, malnutrition. Care must be diagnosed as medically necessary.

Except in rare circumstances, medical services outside of the United States and its territories are not covered as well. You will need to enroll in a Medicare Advantage plan for international coverage.

Medicare Part B costs in 2020/2021

Medicare premiums, copayments, and deductibles are adjusted annually according to the Social Security Act. What will Medicare Part B cost 2020 enrollees?

In 2020, the standard monthly premium is rising by about 7% due to increased program costs, up to $144.60. If you already get Social Security or Railroad Retirement benefits, your premium can be deducted from those. Social Security Medicare Part B payments will be automatic for most people. 

The standard deductible is $198. After you pay your deductible, you’ll have to pay 20% for most Medicare Part B services, other than preventative and wellness services detailed above.

There is no income limit for Medicare Part B, but if you have a high gross income, you could be required to pay an Income-Related Monthly Adjustment Amount (IRMAA).

Some people may purchase a Part C plan that offers low deductibles and copays. You will pay a Part C premium, but you could wind up with more comprehensive coverage that will significantly augment existing Part A and B coverage and provide Part D prescription drug coverage as well.

Who qualifies for free Medicare B?

Unlike Medicare Part A, the amount of time you’ve worked does not affect your Part B premiums. Most people will have to pay a premium for Medicare Part B. To qualify for free Part B, you’ll have to qualify for one of the following programs:

• The Qualified Medicare Beneficiary Program (QMB) helps pay premiums for Part A and Part B, as well as copays, deductibles, and coinsurance.
  • Individual monthly income limit = $1,060
  • Married couple monthly income limit = $1,430
  • Individual resource limit = $7,730
  • Married couple resource limit = $11,600
• The Specified Low-Income Medicare Beneficiary Program (SLMB) offers premium assistance for Part B. If you are eligible for an SLMB, you also are automatically eligible for an Extra Help program to assist in Part D prescription drug coverage.
  • Individual monthly income limit = $1,269
  • Married couple monthly income limit = $1,711
  • Individual resource limit = $7,730
  • Married couple resource limit = $11,600
• The Qualified Individual Program (QI) also helps pay Part B premiums. To apply, which you must do every year, contact your state Medicaid program. Enrollments are on a first-come, first-served basis.
  • Individual monthly income limit = $1,426
  • Married couple monthly income limit = $1,923
  • Individual resource limit = $7,730
  • Married couple resource limit = $11,600

Eligibility for Medicare Part B

Medicare Part B eligibility is based on age, citizenship, retirement benefits, and qualifying illnesses. You are eligible for Medicare Part B if:

• You are 65 or older and a U.S. citizen or permanent legal resident.
• You are younger than 65 and have qualifying disabilities or suffer from End-Stage Renal Disease or Amyotrophic Lateral Sclerosis (ALS, Lou Gehrig’s disease).
• You are eligible to receive, or you’re currently receiving Social Security or Railroad Retirement Board benefits.

Check your eligibility by going to the Medicare Eligibility and Premium Calculator.

Medicare Part B Enrollment

If you are aging into the Medicare program, you should enroll in Part B any time between three months before your 65th birthday to three months after. 

One question we hear a lot is, “I already have Part A, can I add Medicare Part B anytime?” Unfortunately, it’s not that simple. If you choose to forgo Medicare Part B when you first became eligible, you could face a late enrollment penalty fee later. Additionally, if you don’t enroll when you first become eligible, you’ll have to wait for the open enrollment period from January 1 through March 31 to enroll.

If you get Social Security or Railroad Retirement Board benefits for at least four months before your 65th birthday, you’ll automatically be enrolled in Part A and Part B coverage. Coverage starts the first day of the month you turn 65.

When you’re under 65, you have a disability, and you have been getting SSDI benefits for at least 24 months, you are automatically enrolled in Part A and Part B. If you suffer from Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s disease), you are automatically enrolled in Part A and Part B the month your disability benefits begin.

If you have been diagnosed with End-Stage Renal Disease (ESRD), you can enroll in Part A and Part B. To get full benefits that cover dialysis and kidney transplant benefits, you’ll need to be covered by both.

Check with Medicare.gov, because there are several stipulations regarding coverage for ESRD.

You can enroll in Part B during your Initial Enrollment Period (IEP), the General Enrollment Period (GEP), or during Special Enrollment Periods (SEP) if you qualify.

You can sign up for Part B benefits the following ways:

• Apply online at Social Security.
• Enrolling at your local Social Security office.
• Call Social Security at 1-800-772-1213 (TTY: 1-800-325-0778).
• If you worked for a railroad, call the Railroad Retirement Board at 1-877-772-5772.

Medicare Part B phone number: For questions about Medicare Part B billing, call 1-800-833-4455.

What happens if you don’t sign up for Medicare Part B?

While you are technically not required to sign up for Medicare Part B, you may face a late enrollment penalty fee if you wait too long to enroll. This will come in the form of a premium increase of as much as 10%. 

Can I delay Medicare Part B coverage?

You can delay signing up for Part B coverage, but if you enroll at a later date, you may have to pay an enrollment penalty. This penalty will be in force for the entire time you have Part B coverage.

When you delay Part B coverage, it also means you can’t sign up for a Part C Medicare Advantage plan. One of the requirements for Part C is that you must currently be enrolled in Parts A and B.

Additionally, if you miss your initial enrollment period for enrolling in Part B, you’ll have to wait until the enrollment period from January 1 through March 31 to enroll. 

Can I decline Medicare Part B coverage?

Is it mandatory to have Medicare Part B? No. But make sure you do your homework first and take into consideration your long-term health needs.

Although you have to pay a premium in many cases for Part B coverage, it still makes sense to enroll for a vast majority of people.

Is Medicare Better Than Individual Plans?

Is Medicare Better Than Individual Plans?

One survey about Medicare satisfaction vs. private insurance satisfaction found that people with Medicare were happier with their health plans than people with individual plans. Will you find the same to be true?

Types of Plans

As you turn 65 or otherwise become eligible for Medicare, you probably have a lot of questions. What’s going to change? Will I lose or gain new benefits? The good news is that signing up for Medicare does not necessarily mean giving up your plan flexibility or your favorite doctors. There are plenty of Medicare options available, and we’ll explain why it’s worth it to go ahead and get signed up as soon as you can. 

Employer Coverage

You can purchase health insurance through your employer, as long as it meets the coverage limits set by the federal government. If you’re retiring but aren’t eligible for Medicare yet, you can use COBRA to hold you over. COBRA allows you to continue receiving your employer coverage for a short period of time (but your employer likely won’t help you pay for it except for in some unique cases). 

You can also technically have Medicare and employer coverage at the same time, if you become eligible for Medicare while you are still employed. That might make sense for some people and not others. 

Private Coverage

You can purchase insurance from an exchange like Healthcare.gov, directly from your state, or directly from a health insurance company. Generally, purchasing private insurance is more expensive than employer coverage, and much more expensive than Medicare and Medicaid.

TRICARE/VA Coverage

Veterans and veteran’s families may be eligible for free or low-cost healthcare through the Department of Veteran’s Affairs (VA). You or your spouse must have served for at least 24 continuous months or teh full length of time that you were called to serve for. You can also qualify if you were honorably discharged. To get TRICARE, you must already be enrolled in Medicare Part A and Medicare Part B. Click here to read more about coverage for veterans.

Medicaid

Medicaid is a federal health program. Each state has slightly different rules and each state has its own funding. The program can cover any person of any age with low income (according to the Federal Poverty Level and with some adjustments in each state). Most Medicaid beneficiaries will have either no or very small premiums. If you have a low monthly income AND are over 65, you may qualify for both Medicaid and Medicare! In that case, you can get what is called a “Dual-Eligible Special Needs Plan,” which is low-cost and tailored to your needs. 

Medicare

Original Medicare is a federally funded health program that can cover any adult over the age of 65 as well as some adults with disabilities, such as end-stage renal disease.

 Most people with Medicare will start with parts A and B. Part A provides hospital coverage, and Medicare Part B provides medical coverage. Anyone who wants more coverage can opt to enroll in either a Medicare Advantage plan or a Medicare Supplement (also called Medigap) plan. Medicare Advantage is sometimes referred to as “Part C” because you have to have Part A and Part B first to enroll in it, and it can cover a lot of services that parts A and B do not.

Unless you enroll in a Medicare Advantage plan that includes prescription drug coverage, you’ll want to enroll in a separate drug plan. These plans are referred to as “Medicare Part D,” because they are completely separate from the other “parts.” Part D plans only cover prescription costs. 

Some people may qualify for no or low-cost Medicare coverage, but others will have to pay premiums. Most people will not have to pay nearly as much for Medicare as they would with an individual or private health plan.

You may think that individual plans provide more coverage due to the higher premiums, but that is not always the case. All Medicare plans include preventative services. Plus, you can choose to enroll in Medicare Advantage, which is like a private plan for Medicare. With Medicare Advantage, you can roll all your benefits – medical, dental, vision, prescription drugs, and even fitness – into one convenient plan. 

How is Medicare different from other health insurance?

Medicare is vastly different from other health insurance options for a lot of reasons, ranging from the way you pay for your coverage to when you can enroll. 

For starters, the Medicare enrollment period is different from the ACA enrollment periods and your employer’s enrollment periods. The Medicare Annual Enrollment Period runs from October 15 through December 7, but be sure to not confuse it with the ACA Open Enrollment Period, which runs from November 1 through December 15 of each year. 

Another thing that is different is that some people can have their Medicare Part A payments automatically deducted from their Social Security check. 

Employer Health Insurance vs. Medicare

It’s hard to even compare Medicare vs. employer health plans because the only thing they have in common is that they provide health insurance. If you’re turning 65 or otherwise preparing to make the switch from your employer plan to Medicare, you should know the pros and cons of each option. 

For starters, Original Medicare is the same for everybody. Technically, there are not separate plans to choose from within the government Medicare program. Once you’ve enrolled in Original Medicare, you can decide to add coverage through a private Medicare Advantage or Medicare Supplement plan. Some people may see this as a great thing because you can enroll right away without stressing about all your options. Others don’t like it, because one plan clearly cannot work for everybody. However, that’s what the private plans are for (and many of them are incredibly cheap compared to employer plans – some even have $0 premiums). 

The advantage of private health insurance for Medicare (Medicare Advantage or Medicare Supplement) is that you can pick and choose which benefits are most important to you so that you aren’t paying for coverage that you don’t need. Plus, some people will qualify for Medicare Special Needs Plans which are specifically designed for people with special financial or medical needs and are usually relatively low-cost plans. Private Medicare plans can closely resemble individual marketplace plans or employer plans. 

The disadvantages of private health insurance for Medicare-eligible people are that they sometimes have limited doctor networks and that some areas might have a limited number of plans to choose from. Typically, people who live in rural areas may have fewer plan options when it comes to private Medicare coverage. 

Medicare vs. Medicaid

Both Medicare and Medicaid are government programs that are regulated by CMS (Centers for Medicare and Medicaid Services). They both provide health insurance for medically necessary services.

The main difference between Medicare and Medicaid is who qualifies. It is possible to qualify for both programs, but Medicaid qualifications are based on income while Medicare qualifications are based on age and disability. Another difference is that while the Medicare qualification rules are federal, Medicaid qualification rules can change slightly by state. 

Medicare Versus Spouse Insurance

A lot of people who are newly qualified for Medicare wonder if it might be better to stay on their spouse’s insurance plan. The fact is, it depends on how good your spouse’s insurance is. However, if you do qualify for Medicare, Part A (the part that covers hospital costs) has a $0 premium for anyone who has worked and paid Medicare taxes for at least ten years. If you haven’t worked that long but your spouse has, you might still qualify. If that’s the case, there’s no reason not to go ahead and enroll in Medicare Part A as soon as you become eligible. 

Additionally, if you wait too long to seek out further Medicare coverage, your costs may go up. You can be charged a penalty of up to 10% of your premium if you don’t enroll in Medicare Part B when you first become eligible. Plus, Medicare Supplement plans can charge more or deny coverage based on preexisting conditions if you wait too long to enroll. So if you think you might want to enroll in a Medicare Supplement plan, don’t wait too long to start looking. 

Medicare vs Other Health Insurance: The Benefits

If you are eligible for Medicare coverage but considering alternative health insurance, you should start by learning what Medicare does and does not cover. Medicare Part A and Part B are the same for all who enroll. They cover preventative healthcare, like your annual wellness visits and flu shots at 100%. 

Part A also covers 60 consecutive hospital days at 100%. After the 60th day, you’ll start to owe co-payments. Part B covers mental health, lab tests and X-rays, emergency transportation, and medical equipment. 

Medicare A and B do not include prescription drug coverage, dental, vision, hearing, podiatry, or any service that is not deemed medically necessary either for treatment or prevention. For additional health coverage, millions of Medicare beneficiaries enroll in Medicare Advantage. 

Since Medicare Advantage plans are owned by private companies, they can add in benefits like dental, vision, hearing, etc. – any of those extra benefits that you might be accustomed to from having private health insurance. Some Medicare Advantage plans also cover prescriptions. If you want prescription coverage but don’t care about all of the extra benefits, you can enroll in a stand-alone prescription drug plan instead. However, you cannot have both a Medicare Advantage plan and a Medicare prescription drug plan at the same time, so choose wisely. 

Medicare vs Other Health Insurance: The Costs

The good news about Medicare is that as long as you or your spouse have worked and paid Medicare taxes for a certain number of years, your Part A Medicare costs will be low. 

• If you or your spouse has worked and paid Medicare taxes for at least 40 quarters, you’ll owe $0 in Part A premiums.
• If you or your spouse has worked and paid Medicare taxes for 30-39 quarters, you’ll owe $252/month in 2020 in Part A premiums.
• If you or your spouse has worked and paid Medicare taxes for less than 30 quarters, you’ll owe $458/month in 2020 in Part A premiums.

Part B premiums are standard for all Medicare beneficiaries. It can change each year, but the Part B monthly premium in 2020 is $144.60, and the deductible is $198. Most services that Part B covers are covered at 80%, so you may owe 20% coinsurance or doctor co-payments.

If you choose to enroll in a prescription drug plan, a Medicare Advantage plan, or a Medicare Supplement plan, you may face an additional premium. 

Medicare vs. Private Insurance Costs

If you’re choosing between enrolling in Medicare Part B versus private insurance, remember that delaying your Part B enrollment can leave you with up to a 10% increase in your premium when you do decide to enroll.

If you decide to add on private Medicare insurance through a Medicare Advantage or Medigap plan, remember that you’ll still have to pay your Medicare Part A and B monthly premiums (unless you qualify for a savings program such as QMB). You cannot enroll in MEdicare Advantage without enrolling in Medicare parts A and B first. 

Medicare Advantage and Medicare Supplement plans are completely separate and therefore come with separate bills. You’ll owe a premium (which in some cases can be $0), and you’ll likely have a deductible as well as co-payments for certain services. 

Many private health insurance plans also have out-of-pocket maximums, which means that if you have a lot of health care costs, you can reach a point where you stop having to pay out-of-pocket for services. Those out-of-pocket expenses can really start to add up even with Medicare if you’re someone who needs a lot of medical care!

Why is Medicare cheaper than private insurance?

A lot of new Medicare beneficiaries do find that their Medicare costs are cheaper than what they were paying before they qualified. The biggest reason for that is the way Medicare is funded. While you or your spouse were working hard for all those years, you were paying Medicare taxes. Your low premiums today are because of all that hard work! Plus, the Medicare office does not incur nearly the same amount of administrative costs that many healthcare companies do. 

Is it better to have Medicare or private insurance?

Is Medicare a good insurance option? Is private health insurance better? It depends on who you ask. This is a great question to ask an insurance agent who knows what sort of medical expenses you have and what your budget is. 

The main difference you have to remember when you’re wondering if private insurance or Medicare is better is that private insurance gives you more plan options. To get a private Medicare Advantage plan, you’ll have to enroll in Medicare A and B, first. Then, you can choose if you want to personalize your coverage and add benefits by enrolling in additional medical insurance. 

If you’re stuck between Medicare and keeping your employer plan, remember that you could face penalties if you don’t enroll in Medicare when you first become eligible – and nothing says you can’t keep both!

Is Medicare or private insurance better for people with dependents?

If you have dependents, Medicare isn’t going to help you. But that doesn’t mean you shouldn’t enroll. Medicare only provides individual coverage – there are no family plans or spouse Medicare plans. However, your Medicare Part A might be free. If that’s the case, you might want to consider enrolling in Medicare for yourself first, and then taking a look at options for your dependents. 

If you have access to an employer plan, do the math to figure out if it may be more cost-effective for you to have your group vs. individual Medicare Advantage coverage. In some cases, it might even make sense for you to keep both. If your Medicare Advantage premium is low enough, you can keep that for yourself but also hang onto your group coverage for as long as you can to support your family. An insurance agent can help you figure out what’s best for you. 

Can I drop my employer health insurance and go on Medicare?

If you become eligible for Medicare while still receiving employer health insurance, you can and should still enroll in Medicare to avoid penalty fees. 

First, find out if you’re currently in one of the Medicare enrollment periods. Medicare open enrollment is different from your employer’s open enrollment period. 

If you just became eligible, you’ll have a few months for your “Initial Enrollment Period.” If you’re aging into the program, this period begins three months before your 65 birthday and ends three months after. If you’ve already missed that period, don’t panic – you can enroll for the first time from January 1 through March 31 of each year. 

Once you’re enrolled, the “Annual Enrollment Period,” is when you can add or make changes to your Medicare coverage. It runs from October 15 through December 7 of each year. This period is not for enrolling in Medicare for the first time – it’s only for adding or making changes to your private Medicare coverage. 

According to Medicare.gov, some people will be automatically enrolled in Medicare Part A upon becoming eligible. If you are not automatically enrolled, you can apply for Medicare on the Social Security website.

How Medicare Works with Other Insurance

Millions of Medicare beneficiaries opt to enroll in Medicare Advantage or Medicare Supplements on top of their Medicare coverage. In these cases, the private insurance companies act as the “secondary payers.” Health benefits that Medicare does not cover will be automatically billed to the private company, but anything else will go to Medicare first. If you have both employer insurance and Medicare, Medicare might actually be the secondary payer. Check with your employer or your employer’s health insurance plan to be sure. 

Both Medicare and private insurance coverage will have limitations – so having both is a great way to keep yourself and your families financially covered in case of a medical emergency.

How Medicare Plan Finder Can Help You

We specialize in Medicare and serving the underserved senior and Medicare-eligible population. Do you or a loved one need help selecting a Medicare plan that truly helps? Set up a free appointment with one of our licensed agents in your area to get bias-free assistance. Call us to set it up at 1-844-431-1832.

Spouse Medicare 101

Spouse Medicare 101

Medicare is different from other forms of insurance in a lot of ways. One of the biggest differences is that there are no family plans in Medicare. All Medicare coverage is individual-based. 

However, even though Medicare and marriage are not directly related, your marital status can impact your Medicare costs in a few special ways. 

Does Medicare Offer Spouse Coverage?

Medicare does not offer health coverage for spouses. You would have to be eligible on your own to qualify for Medicare – your spouse’s eligibility does not affect yours. 

According to the rules set in place by the Centers for Medicare & Medicaid Services, marriage can affect your Medicare in the following ways:

1. Eligibility for Medicare cost savings can change due to your spouse’s income
2. Your Part D (prescription drug plan) premiums can be higher due to your spouse’s income
3. Premium-free Part A eligibility can be determined based on your spouse’s work history if they worked more than you.

So, can you get Medicare through your spouse? Not technically, no – but your marital status is not irrelevant.

Medicare if Spouse is Disabled

If one spouse is 65 and begins receiving Medicare and the other is not yet 65, there may be other ways to qualify. If you are diagnosed with ESRD or ALS or if you have been receiving SSDI (Social Security Disability Insurance) for at least two years, you can qualify for Medicare regardless of your age. 

The good news is that if you do qualify for Medicare based on a disability, you may also qualify for a Medicare Special Needs Plan at a low cost.

Medicare Eligibility Requirements

The “main” Medicare program is called “Original Medicare.” You can qualify for Original Medicare by:

• Turning 65
• Having ALS (Lou Gherig’s Disease)
• Having ESRD (end-stage renal disease)
• Receiving SSDI for at least 24 months

Unlike Medicaid, income does not impact Medicare eligibility. Additionally, unlike ACA plans, pre-existing conditions do not affect your Medicare costs or coverage. The only exception to this is in private Medigap (or Medicare Supplement) plans. If you do not enroll in a Medigap plan when you first become eligible for Medicare, you can be charged more based on your health history. Medigap plans are completely optional and are there for additional financial protection.

You can qualify for additional health and drug coverage through Medicare Advantage plans or Medicare prescription drug plans after you’ve enrolled in Original Medicare. Those plans cannot charge more based on your age or preexisting conditions. 

Spouse Social Security Benefits

Even though the Social Security Administration manages Medicare enrollments, Social Security and Medicare are two vastly different things. There are a few differences in how your marital status affects your benefits. 

For Social Security, your benefit is calculated based on your total household income according to your tax returns. That includes both your and your spouse’s income. Both you and your spouse can benefit from Social Security, even after one spouse has passed away. 

Medicare does not work like that. Your marital status and income do not impact your eligibility, and there are no additional Medicare benefits given to a spouse after a Medicare beneficiary passes. 

Medicare & Health Insurance Options for Spouse of a Medicare Recipient

If one spouse is ineligible for Medicare and needs to find a different health plan, don’t panic – there are plenty of options for health insurance for the spouse of a Medicare recipient. You might want to start by checking to see if that spouse is eligible for Medicaid based on your total household income. If the answer is no, you’ll want to start looking at individual health plans in your area, which you can do through healthcare.gov/. 

If the Medicare spouse has insurance through an employer when they become eligible for Medicare, the non-Medicare eligible spouse can also try getting COBRA until they are also eligible for Medicare. COBRA allows an individual, couple, or family to continue health coverage after leaving a job. However, keep in mind that even if you’re able to keep your health plan through COBRA, your costs may go up because your employer won’t be sponsoring the plan for you anymore. 

Can my Wife get Medicare at 62?

To get Medicare, you have to either be 65 or have a qualifying disability. 

If your husband or wife is just a few years short of Medicare eligibility, they can select an ACA plan or enroll in a short-term health plan. Short-term medical insurance can be renewed for up to 36 months, so it’s a good option if you’re within 36 months of becoming eligible for Medicare. Since these plans are designed for such short periods of time, they tend to be a bit cheaper than long-term plans, like the ones offered by your employer or the ACA. 

Can a Non-Working Spouse Qualify for Medicare?

People often wonder if Medicare is available for their non-working spouse. In short: yes, as long as they meet the age or disability requirements. However, your spouse’s costs may be different from yours. Your employment status does not determine your Medicare eligibility – but it can determine your Medicare costs as such:

• If you or your spouse has worked and paid Medicare taxes for at least 40 quarters, you can qualify for premium-free Medicare Part A
• If you or your spouse has worked and paid Medicare taxes for 30-39 quarters, you can qualify for a discounted Medicare Part A premium of $252/month in 2020
• If you and your spouse have worked and paid Medicare taxes for less than 30 quarters (or have not worked at all), your Medicare Part A premium will be $458/month in 2020

Can my Wife get Medicare if she Never Worked?

Employment and marital status do not impact Medicare eligibility. Even someone who has never worked a day in their life can get Medicare, but their costs may be higher than someone who has been paying Medicare taxes.

Medicare vs. Medicaid

Unlike Medicare, your Medicaid coverage can be impacted by your marital status. While each state has somewhat different regulations, most of Medicaid eligibility is based on the Federal Poverty Line. Your income is calculated using your total household income, which is verified with your tax returns. Both your and your spouse’s income are included. That means that even if you qualify for Medicaid based on your income, you won’t be eligible if you and your spouse’s total income together is higher than your state’s limits.

How to Apply for Medicare Through a Spouse

You cannot apply for Medicare through your spouse. You’ll have to wait until you are eligible and then apply during your Initial Enrollment Period. If you qualify by turning 65, this period begins three months before your 65th birthday and ends three months after. If you miss that period, you can apply during the Open Enrollment Period from January 1 through March 31. To apply for Medicare online, visit the Social Security website, not medicare.gov. 

How do I Apply for Spousal Medicare Benefits?

There are no spousal Medicare benefits – but you can apply for spousal Social Security benefits, here.

What is Not Covered Through Your Spouse’s Medicare?

Your spouse’s Medicare plan won’t provide health coverage for you. If you’re looking for Medicare for spouses, you’ll have to wait until the other spouse is eligible. Then, you can talk to an agent about finding separate plans that work for both of you and both fit into your household monthly budget. 

Medicare Family Coverage

In general, Medicare is not available to non-qualifying spouses or dependants. However, if your child has a qualifying disability, they may be eligible for a Medicare plan of their own. Note that except for in the cases of ALS and ESRD, you will have to receive disability benefits for at least two years before you can enroll in Medicare. 

How Does Getting Married Affect Medicare?

Getting married? Congrats! A new marriage often involves complicated discussions about finances, and you might be wondering, “will getting married affect my Medicare benefits?” The good news is that no, marriage does not affect your current Medicare benefits – but it CAN impact your eligibility for Medicare cost savings programs. For example, Medicare Savings Programs and Low-Income Subsidies for Medicare prescription coverage base eligibility on total household income. If your new spouse causes your household income to increase, you could become ineligible for these programs. 

If you’re not yet 65, you might be wondering, “will I lose my disability Medicare if I get married?” No! Even if you are qualifying for Medicare based on disability and not age, your Medicare coverage won’t change based on your marital status. 

Medicare Premium Payments: How Much Does Medicare cost for a Married Couple?

How much does a married couple pay for Medicare? Medicare is 100% individual, so each spouse will have to pay their own premium. There are no joint plans with joint costs.

Your Medicare Part A monthly premium will depend on your and your spouse’s work history and will range between $0 and $458 per month in 2020. Your Medicare Part B premium will be $144.60 in 2020 (unless you qualify for savings programs or have your premium covered by a Medigap plan). If you have Medicare Part D prescription drug coverage or either a Medicare Supplement or Medicare Advantage plan, you’ll pay a separate premium for those plans.

Do Husband and Wife pay Separate Medicare Premiums?

Yes – families and spouses cannot have joint Medicare plans. All premiums will be separate. Some people will have their premiums automatically deducted from their Social Security benefits. 

How Your Spouse Might Affect how Much you Pay

Your spouse can reduce your Part A premium amount if they have worked more than you. Additionally, your spouse’s income can affect your eligibility for assistance programs such as Medicare Savings Programs, Medicaid, and Medicare Extra Help.

Medicare Plan Spousal Discounts

While Medicare does not provide spousal benefits, there are some plans that offer household discounts for plan premiums. You should always confirm with your agent whether or not a household discount exists as some companies may have specific requirements regarding spousal discounts.

Medicare Extra Help and Income Limits

The one thing that marriage will affect when it comes to Medicare is whether or not you qualify for the Extra Help Program, otherwise known as Low-Income Subsidy (LIS). LIS exists to help people with limited income pay for their prescription drugs. Those who qualify for the program pay less in drug premiums, copayments, and coinsurances.

Single and married beneficiaries have different requirements for what constitutes a low-income level. For example, to qualify for LIS (a prescription drug savings program) in 2020, single beneficiaries must make less than approximately $19,000 per year, but married couples must make less than approximately $26,000 per year.

Meet with one of our agents to find out if you qualify for savings.

Joint Meeting with a Licensed Agent

Even if you and your spouse have different Medicare plans, you can still share an agent! Sharing an agent will make your enrollment process easier and help you build a relationship with someone who knows everything about Medicare plan options and can help you find savings.

Do you have a licensed agent? Have more questions about spouse Medicare? Give us a call today to set up a free meeting. Our agents are licensed to sell several different insurance plans, so they can offer you an unbiased opinion and help you find the plan that truly works best for your needs. Call us at 1-844-431-1832.