Understanding Medicare – What is Medicare and How Can I Have It?

Medicare is a national healthcare program that applies to a wide majority of older Americans throughout the United States, potentially available to anyone who fits a select set of parameters:

  • If you are over the age of 65…
  • If you are disabled (and have been disabled for longer than 24 months…)
  • If you, or a spouse, have paid applicable federal taxes for a minimum period of 10 years or more…
  • Or if you are under 65 with either End-Stage Renal Disease or ALS…

You may currently have, or be ready to apply for, federal Medicare coverage.

This baseline of healthcare provided by Medicare, commonly referred to as “Original Medicare,” consists of two potential halves that fully define its coverage – a hospital coverage, titled Part A, oriented towards inpatient hospital care, skilled nursing facilities, home health care, and hospice care, and a medical coverage, titled Part B, that highlights a wide listing of medical services ranging from work received from a licensed health professional in an outpatient setting to various other assistance opportunities through ambulance, preventive, therapy, or mental health services (to name a small few.) This “Original Medicare” puts you initially under the direct wing of the government, providing the partial assistance for costs to be federally direct, and allowing the ability to survey and select any doctor (or facility) that would accept traditional Medicare nationwide for proper coverage.  (Dumb it down)

However, the responsibility for enrollment into Original Medicare depends on the individual’s situation – in the case of an individual getting Social Security or Railroad Retirement benefits 4 months before turning 65, Medicare enrollment may happen automatically, not requiring them to take any action to be mailed their federal “red, white, and blue” Medicare card and start receiving hospital (Part A) and medical (Part B) coverage immediately after their 65th birthday. For the others who would not be, or are not currently, going to be receiving benefits from either Social Security (or Railroad Retirement) in the 4 months prior to their 65th birthday, responsibility to properly complete enrollment falls to the individual. Additionally, persons who are subject to either 1) end-stage renal disease (ESRD) or 2) ALS, may be required to have their provider send documentation for verification when properly applying – the start date for coverage will depend on current status and treatment plan. Individuals who are interested in (or are currently receiving) Original Medicare coverage may also wish to consider the alternate options for obtaining their federal assistance – a Medicare Advantage Plan, known as Part C, provides very similar coverage to the servicing one would get through their original Medicare, with certain trade-offs such as paying lower copays or coinsurances, getting additional benefits, and working within smaller, occasionally non-nationwide networks of doctors and facilities. 

Manually performing enrollment for coverage under Medicare operates particularly, taking different forms between certain intervals of time each year, with 2019 being unique comparatively to conceptions you may have had before about properly signing up for coverage – with the year divided into separate parts for certain enrollments, rules follow along with how and why individuals may be applicable for a correctly associated enrollment period:

  • The Initial Enrollment Period is defined as the first time an individual can sign up for Medicare and is a one-time opportunity – it includes your 65th birth month, along with the 3 months prior and after, and typically has a varying effective date based on when the individual has selected to enroll within the period. 
  • A Special Enrollment Period involves signing up for Medicare coverage through certain particular circumstances that allow an individual to have enrolled based on their contextual situation – these include when you unexpectedly lose coverage through an employer or union, recently changed address, if you currently live in a nursing home, if you will leaving or entering a nursing home, you receive state assistance through Medicaid or federal assistance for your prescriptions from Extra Help, and so on. Generally, it is recommended to talk to a Medicare professional to understand what special enrollment periods may be available to you, so that you may take advantage of their limited windows of potential.
  • The Annual Enrollment Period takes place during the relatively small window between October 15th to December 7th – while the General Enrollment Period serves primarily as the flexible consideration for individuals seeking to capitalize on obtaining their Original Medicare (Part A or Part B,) this enrollment period is specifically in consideration of a few important factors that can only otherwise be done through Initial Enrollment or Special Enrollment; for example, a person can freely switch between or enroll into Part C plans at will, switch back to their Original Medicare, or take the opportunity to sign up for Part D prescription drug coverage. 
  • The General Enrollment Period, running from January 1st to March 31st, operates as a catch-all for individuals who, for one reason or another, may have missed their opportunity to properly and completely enroll in Original Medicare during their Initial Enrollment Period and who may not have an applicable Special Enrollment Period otherwise. 

When seeking more information regarding your Medicare status, especially with any potential intent to enroll or seek further coverage, there are several available sources most capable to giving you a clear, concise picture of benefits that may be available to you – knowing and understanding resources that can provide you assistance and answers to your questions may be the first step towards a satisfactory enrollment. The Centers for Medicare and Medicaid Services, known in short as CMS, is a federal agency that has responsibility overseeing multiple outlets of the entire public healthcare system for Americans; as such, CMS acts as a federal head of authority that helps guide and direct the assistance you get ultimately get choosing to enroll in Medicare through the government’s Social Security Administration. To get assistance enrolling into Medicare Part A and Part B, you will want to contact this federal Social Security Administration – certain preferences can define how you selectively choose to ultimately enroll, but confirmation of your current coverage, as well as application for newcomers, can be complete by phone, online via the Social Security Administration’s website, or at your local Social Security office. Remember, it is important to consider and ask about your applicable enrollment periods when attempting to make any changes or obtain coverage.