WHATS MEDICARE

frequently asked questions

- Information about Medicare -

This is the best answer: Call Social Security and ask. Make sure you note who you talk to, the date and what they advise. There is something called Equitable Relief. So if you are given incorrect information, you can appeal based on the information you were given by the government worker but you will need notes with details! 


Should I sign up for Medicare if I am still working?
It really depends on a few things and it matters a lot! If you or your spouse are working for a company that has more than 20 employees then you don’t have to sign up for Part A and Part B. The government recommends that you sign up for premium free Part A but if you are on a HSA plan and contributing, then you don’t want to sign up for Part A or Part B.

If you are working for a company that has less than 20 employees then you should check with the HR department. When you are working for a company that has less than 20 employees Medicare is the primary payer and the employer plan is secondary. It's very important to know who pays first. You don’t want to have a claim and find out that your Insurance Company says Medicare should have paid but won’t because you didn’t enroll. The insurance company may not pay anything or perhaps only a small amount! You may be subject to the Part B penalty too.


What if I am automatically enrolled in both Part A and Part B?

You should call Social Security Administration and tell them your circumstances to make sure you can turn down Part B without any penalty.


How do I know what Part of Medicare covers my Prescription drugs?

You would really think that Part D would cover all since it is the Prescription Drug Plan but that’s not how it really works. Part D covers outpatient drugs through private insurance companies. Part B covers drugs administered by your doctor or from a dialysis center, including oral cancer drugs-chemotherapy and a limited number of outpatient drugs. Part A would cover your drugs when you are in a Medicare covered stay in either a skilled nursing facility or hospital. This link explains in greater detail what Part covers each type of prescription.

Can they really charge me more for my Part B and Part D premiums?

Yes they can. It is called an Income Related Monthly Adjustment Amount (IRMAA for short). You will pay more depending on your income from two years ago. The government checks your IRS tax returns. Most people pay the $134.00 per month in 2018. That’s the amount that is either deducted from your Social Security check or, if you are not receiving SS,  will be billed quarterly. The threshold is currently $85,000 for individual and $170,000 for couples filing a joint return. If you show more income then you pay higher Part B and Part D premiums!​​

I have group coverage through my employer (there are less than 20 employees) do I have to sign up for Medicare when I turn 65? 

The Answer is yes. You need to sign up for Parts A & B. Remember the Initial Enrollment Period is three months before you turn 65, the month you turn 65 and three months after you turn 65. Here is why: Medicare becomes the Primary Payer when the company has less than 20 employees. If you don’t sign up for Medicare and have a claim, The Insurance Company can deny payment because Medicare should be the primary payer and the Insurance Company is secondary.

What if I am working for a large company and they provide group health insurance. Do I need to sign up for Part A and Part B of Medicare?

Depends. The government recommends that you enroll for Part A because it is premium free. If you are contributing to an HSA bank account then you don’t want to sign up for Medicare. The IRS says you cannot fund an HSA if you are over 65 and on Medicare.

How do I know when Medicare pays primary (first) and my plan pays secondary (second)?
There are so many scenarios that you need to know especially relating to group coverage. I could go on but Medicare has a great easy to understand booklet on Who Pays First. Pages 5-8 really do a good job of giving you examples of different scenarios.

Medicare seems to be all acronyms. What do they mean and where can I find all of these Medicare terms defined?

Instead of publishing 25 pages of terms and initials, I found a great resource that alphabetizes many Medicare terms.

I am so confused about the Part D Rx Plan. How does it really work and what is the donut hole I keep hearing about?

You are not alone. Most agents can’t explain how Part D really works. In 2018, here is how it works: The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs. Member pays the first $405. That's the deductible. In 2018, once you and your plan have spent $3,750 on covered drugs (the combined amount plus your deductible), you're in the coverage gap. When you are in the gap or donut hole as they used to call it you will pay 35% of the cost on brand name drugs and 44% of cost on the generic drugs. After your total out of pocket costs have reached $5,000, you pay $3.35 for generic drugs and $8.35 for all other drugs or 5% coinsurance, whichever is greater! Simple right? Just check this link out for an EZ explanation. 

I’m afraid to call any government agency. What if I feel I was discriminated against, unsure if my claim was processed incorrectly, think someone was committing Medicare fraud or just don’t understand anything? Are there any Medicare rights that I have? 

You shouldn’t fear calling any government agency except for the one with 3 initials (that’s IDK in case anyone is checking!) You have a ton of rights and you should not take no for an answer. If you disagree with someone from Medicare or Social Security you need to call and ask for a supervisor. You have the right to file a complaint or appeal. You have a right to know what’s covered and what isn’t.

Can Medicare just decide not to cover a service or procedure that I already received or am about to have done?
No. If the Doctor or health care provider thinks that Medicare won’t pay for something then you will be given an “Advance Beneficiary Notice of Noncoverage”. They have to show you ahead of time what they believe Medicare will not pay for. If you disagree you can always appeal. Remember, don’t take NO for an answer!



I really encourage you to call 1-800 Medicare (800) 633-4227 with any questions. REMEMBER: Always take good notes on who you talk with, date and time you called. You will be glad you did if you receive misinformation.