Medicare Overview

Signing Up for Medicare

There are different ways to get Medicare. For people with disabilities, Medicare eligibility is based on getting Social Security Disability Insurance (SSDI) or Disabled Adult Child (DAC). These are government programs that supply income for people who can’t work because of a disability.

So, when you can’t work because of a disability, SSDI supplies you with income and Medicare supplies you with health insurance. For more information on SSDI, read the DB101 article on SSDI.

Medicare for seniors

This article focuses on Medicare for people with disabilities, but people 65 or older also can qualify for Medicare. Generally, you can get Medicare if you (or your spouse) worked for at least 10 years at a job that qualifies you for Medicare. You also need to be 65 or older, and a citizen or permanent resident of the US. Learn more about Medicare for seniors on Medicare.gov.

The 2 Year Waiting Period

When you apply for SSDI, the Social Security Administration figures out the day when your disability began. You’ll start getting benefits from Social Security 5 full months after that date. Once you start getting SSDI benefits, you generally have to wait 24 months (2 years) before getting Medicare.

For example, if your date of disability is June 15, 2011, your first SSDI benefits payment will begin in December, 2011 (5 full months after your date of disability). And your Medicare benefits will begin in December, 2013 (24 months after your first SSDI benefits payment).

Illustration: Medicare's 24-month waiting period

During the waiting period you may be able to get help paying for medical costs either through:

  • Your current or former employer
  • A spouse’s employer-sponsored coverage
  • An individual health insurance plan through MNsure or a private company
  • Enrolling in Medical Assistance or another Minnesota health care program
  • Military health benefits
  • Indian Health Service
  • Workers Compensation, or
  • COBRA, which allows you to continue employer-sponsored health coverage from a job

The only exceptions to the 2-year waiting period are if you have Lou Gehrig’s disease (amyotrophic lateral sclerosis, or ALS) or end-stage kidney disease (ESRD).

The two year waiting period also applies to Disabled Adult Child (DAC).

Getting Medicare Through SSDI: Enrollment Options

In most cases, when you get Medicare because of SSDI or other eligibility, you’ll automatically be signed up for Original Medicare. You’ll have to decide:

Original Medicare

How It Works

If you get Medicare through Social Security Disability Insurance (SSDI) or Disabled Adult Child (DAC), you are automatically signed up for Original Medicare. You’ll get a Medicare insurance card when your Medicare benefits start, and you’ll be signed up for Medicare Part A Hospital Insurance and Medicare Part B Medical Insurance.

With Original Medicare, you can go to any hospital or doctor that accepts Medicare and is taking new Medicare patients. Medicare’s general rule is that they will help pay for things they think are reasonable and necessary. Medicare comes up with an amount that they think is reasonable for a provider to charge for a service. In Minnesota, all providers (with the exception of ambulance providers) can only charge the Medicare-approved amount.

What You Pay

Most people do not have to pay anything to get Part A (since you've already paid for coverage with your payroll taxes). Part B, on the other hand, requires you to pay a monthly premium (for most people that's $109.00 in 2017). Because of this, you can decide not to keep Part B coverage, although 2 things are important to keep in mind about declining Part B:

  • If you decline Part B at first, and then want to sign up for it later, you may have to pay a penalty.
  • You might qualify for help with paying for the premium and other Part B costs. For more information on enrollment, premiums, and declining Part B coverage, see DB101's section on Part B

For certain Part A and Part B services, you'll pay a certain amount (called a deductible) before Medicare will begin to help pay. You may also have to pay a certain amount (called a copayment) or a percentage of the cost (called coinsurance) for the service before Medicare will begin to help. If you get a service that Medicare doesn’t cover, you will have to pay for it yourself, unless you have other health insurance.

DB101's sections on Medicare Part A and Part B give you more details on what services Medicare will help pay for and what portion of the bill Medicare will pay.

If you want services that Original Medicare doesn't help pay for, such as a hearing test, you can pay out of pocket for those services. In this situation, some doctors may ask you to sign a private contract, which means that you agree that Medicare won’t help pay for any services you get from that provider.

Before signing a private contract, make sure that you understand what it means. If you need help understanding it, call Minnesota's Senior LinkAge Line® at 1-800-333-2433. The Senior LinkAge Line® is the federally designated State Health Insurance Assistance Program (SHIP) for Minnesota.

Appeals

You may think that Medicare should have helped pay for a service that they didn't help with, or that they should have paid more than they did. When you disagree with the amount that Medicare helped pay, you can file an appeal.

If you are on Original Medicare, you can file an appeal by following the instructions on your Medicare Summary Notice. You have 120 days (4 months) from the time you get your notice to file an appeal.

When you get care from a hospital, Skilled Nursing Facility, home health agency, comprehensive outpatient rehabilitation facility, or hospice care, you might be able to file a fast appeal if you think your services are ending too soon.

Your provider will give you instructions on how to file a fast appeal, but you can also get information from Minnesota's Senior LinkAge Line® at 1-800-333-2433.

How will I know how much Medicare paid for my medical expenses?
If you get fee-for-service Medicare, every 3 months you’ll get a Medicare Summary Notice (MSN) in the mail. It will tell you the amount that Medicare paid for services you got. You can also view your MSN on Medicare.gov.

Prescription Drug Coverage

With Original Medicare, you have to decide if you want to get Medicare’s Prescription Drug Coverage, which is known as Part D.

Medicare Part D is offered through private companies that have agreed to follow Medicare's rules. You pay premiums, coinsurance, and copayments, although help is available for those who can’t afford these costs. The DB101 section on Part D goes into more detail.

Medicare Supplements

As you learn more about Original Medicare (Medicare Parts A and B), you’ll notice that there are certain things that it will not pay for.

Medicare supplement policies (also called Medigap) are private health insurance policies that can help pay for these gaps in Original Medicare coverage. These policies are offered by licensed insurance companies. The Minnesota Department of Commerce is in charge of making sure these companies follow the rules.

Examples of gaps in Original Medicare coverage:
  • Parts A and B may not pay for the first 3 pints of blood when you need a transfusion
  • For most Part B services, you pay for 20% of the cost and Medicare pays for 80%
  • Hearing and eye exams are not covered

To buy a Medicare supplement, you must have both Medicare Parts A and B. In general, Medicare supplement policies do not offer any Medicare Part D Prescription Drug Coverage.

Medicare supplements in Minnesota:

In terms of Medicare supplements, Minnesota is unique in several important ways:

  • You cannot be charged a higher premium for having a medical condition.
  • Every Medicare supplement policy that companies sell to people on Medicare who are age 65 and older must be available to people on Medicare who are under 65.
  • Medicare supplement insurers can’t deny coverage to people under 65 because they have a medical condition.
    • This is true if you sign up for a Medicare supplement policy within six months of Part B enrollment. If you miss that 6 month window, you can be denied a Medicare supplement based on a health condition. (Note: If you have Medicare when you are under age 65, you do get another open enrollment window to sign up for a supplement policy when you turn 65.)
  • Minnesota offers two Medicare supplement plans: the Basic Plan and the Extended Basic Plan. These plans are standardized, which means that one company’s Basic Plan has the same services as another company’s Basic Plan. The only difference may be cost.
  • Minnesota also offers 5 supplement plans called alpha plans (Plan K, Plan L, Plan M, Plan N, and Plan F) with high deductibles. Each of these have different cost sharing requirements and limit your benefits if you pay a lower premium.

  • Minnesota allows people to add extra benefits to their Basic Plan. These extra benefits are called riders. The riders available to add to a Basic Plan include:
    • Paying for the Part A deductible.
    • Paying for the Part B deductible.
    • Paying for most (80%) or all (100%) of what you’re charged over the Medicare approved amount. Keep in mind that in Minnesota, only ambulance providers are allowed to charge over the Medicare approved amount.
    • Paying for preventive services.
    • Paying for at-home recovery services.

For more information about your Medicare options, including your Medicare supplement options, call the Senior LinkAge Line at 1-800-333-2433 and ask for a copy of Health Care Choices for Minnesotans on Medicare.

So, for example, the Basic Plan usually won't pay your $183 Part B deductible. But you could pay a higher premium for your Medicare supplement policy and add the Part B deductible rider. The policy will then pay for that cost.

You can get just one rider, or any combination of them. The Extended Basic Plan in Minnesota includes all of the available riders listed above. It also has a limit on how much money you have to spend each year. Extended Basic policies are sometimes referred to as the "Cadillac of Medicare supplements." They cost the most and give the most comprehensive and flexible coverage available.

If you are thinking about buying a Medicare supplement policy or switching Medicare supplement policies, call the Senior LinkAge Line® at 1-800-333-2433.

Medicare and Other Health Coverage

When you get Medicare, you may already have health coverage from another source. In some cases, this other health coverage can help pay for costs that Medicare doesn’t pay for.

The interactions between Medicare and other coverage can be complicated, so it’s important to check with both Medicare and your other health coverage plan when you have a question.

One source of other health coverage might be from an employer. If you’re still working, this could be health coverage from a current employer. You may also have health coverage through a spouse’s employer. Medicare’s interactions with employer-sponsored health coverage can be complicated, so be sure to contact your plan’s coordinator to learn about the details.

Another source of health coverage is Medical Assistance (MA), Minnesota’s Medicaid program. You cannot get income-based MA at the same time as Medicare, but you can get disability-based MA.

Disability-based Medical Assistance interacts with Medicare in a number of ways:

  • You have to enroll in Medicare Parts A and B if you are eligible.
  • Generally, Medicare gets the bill for the service first and pays for whatever it covers. Medical Assistance then pays for the rest.
  • Medical Assistance may pay for some of your Medicare costs, like Part B premiums, either through the Medicare Savings Programs, or by deciding that it is cost effective to do so. Unless you have a higher-than-normal Part B premium, Medicare is usually considered cost effective.

Besides employer-sponsored coverage and disability-based Medical Assistance, there are a number of other types of coverage that interact with Medicare. These include retiree benefits, Veterans (VA) benefits, military (TRICARE) benefits, and individual health insurance. To get more information on how Medicare interacts with all of these types of coverage, read Medicare and Other Health Benefits: Your Guide to Who Pays First.

If you are eligible for Medicare, you cannot be enrolled in MinnesotaCare, which is health coverage for low to moderate income Minnesotans who can’t get other health coverage. Children under 21 are an exception to the rule and can, in some cases, get both Medicare and MinnesotaCare.

For more information, read DB101's section on MinnesotaCare or call 651-297-3862 (Twin Cities) or 1-800-657-3672.

How Medicare Benefits Might Change Over Time

If you are under 65 and getting benefits because of a disability, there are a number of different ways that your benefits could change over time.

Transition from SSDI and Medicare to Retirement Benefits

For example, let’s say you are 50 years old and have been getting disability benefits payments for the past 5 years. You are currently on Medicare Parts A and B through Original Medicare. One possibility is that you stay disabled and can’t ever return to work. In this scenario, your disability benefits would continue until you reach full retirement age, at which point your SSDI would automatically change to retirement benefits. Your Medicare benefits wouldn’t change.

Returning to Work

Another possibility is that you return to work before you reach what Social Security considers your full retirement age. When you go back to work, you may eventually lose your free Part A coverage. This doesn’t happen until almost 8 years after you go back to work and, once it does, you may be eligible to have the state pay for Part A coverage. For more information, read the DB101 section on Part A and Medicare Savings Programs.

Deciding to Change Your Medicare Coverage

Another possibility is that you will want to change your Medicare options. You may, for example, want to switch to Medicare Part C (Medicare Advantage), buy a Medicare supplement policy, or enroll in Parts B or D.