If you qualify for Medicare, some of the choices you need to think about include:

• If you want Original Medicare, a Medicare Advantage plan, or a Medicare Cost plan.
• If you want Original Medicare: Which Part D prescription drug plan to sign up for (if any), whether to decline Part B because you or your spouse is still working and can get employer-sponsored coverage, and whether to sign up for a Medigap (Medicare Supplement) policy.
• If you want a Medicare Advantage or Medicare Cost plan: Which plan to choose.

People make these choices when Medicare coverage starts, but can change their minds and their Medicare coverage at certain times.

Comparing Original Medicare, Medicare Advantage, and Medicare Cost Plans

To understand what Medicare options are right for you, it’s important to get a sense of how Original Medicare, Medicare Advantage, and Medicare Cost plans work.

Note: Medicare Advantage is sometimes called Medicare Part C. Medicare Cost plan are considered "Other Medicare plans."

The bottom line: Original Medicare and Medicare Advantage are both good ways to get Medicare benefits. In Minnesota, 48% of Medicare beneficiaries choose Original Medicare and 52% choose Medicare Advantage or Medicare Cost plans.

How Other Coverage Can Affect Your Medicare Choices

Having another form of health coverage, such as employer-sponsored coverage or Medical Assistance (MA), is one of the biggest factors that can affect how you should get Medicare. Answer these questions to see how they might affect your Medicare choices.

If you need to talk with someone about these questions, call the Senior LinkAge Line® at 1-800-333-2433.

Do You Have Private Coverage That Covers What Parts B and D Cover?

If you or your spouse are working and get employer-sponsored coverage that covers what Medicare Parts B and D cover, you may want to opt out of Parts B and D, so that you don’t have to pay their premiums. (You still have Part A coverage, which usually has no premium.)

However, you might have to pay monthly penalties if you opt out and want Parts B and D later:

• For Medicare Part B, you can only opt out without paying penalties later if you have an employer-sponsored insurance policy through your employer or your spouse's employer (retiree plans don't count). If you do, make sure to check with your employer or insurer whether it's safe for you to opt out of Part B.
• If Medicare Part D says the other coverage you have is “creditable,” which means it meets certain standards, you can opt out of Parts D and you don’t have to pay a penalty if you decide to sign up for it later, within certain time limits. For Part D, creditable coverage can be an employer-sponsored plan or a retiree plan.
• If you opt out of Parts B and D and your coverage doesn't meet these standards, you may have to pay monthly penalties if you want Parts B and D later. The longer you go without coverage, the higher the penalties might be.

Note: If your income is below certain levels, you may qualify for a Medicare Savings Program (MSP), which would help pay your Part B premium, and the Low Income Subsidy (LIS), which would help pay your Part D premium. Look into these before you opt out of any parts of Medicare.

The bottom line: Don’t opt out of any Medicare coverage without carefully researching your options. Also, if you decline Part B, you cannot sign up for a Medicare Advantage plan. If you have any questions, contact the Senior LinkAge Line®.

Do You Also Have MA Coverage?

People who qualify for both Medicare and MA coverage are called “dual eligibles.” Most dual eligibles do not have to pay Medicare premiums, because either MA pays them or because the person also qualifies for a Medicare Savings Program (MSP). MA, including Medical Assistance for Employed Persons with Disabilities (MA-EPD), may also help pay for Medicare co-insurance and deductibles, as well as some services Medicare doesn’t cover. That’s why you shouldn’t decline Medicare Parts B or D if you also qualify for MA.

If you qualify for both Medicare and MA, there are different ways to get your medical coverage:

• You can have separate Original Medicare and MA coverage. This gives you more flexibility to choose your medical providers, but some may not accept MA or Medicare as payment, which could mean you have to pay more.
  • Do not decline Part B or Part D coverage. If you decline them, MA (or MA-EPD) won't pay for what they would have covered.
• You can have a Medicare Advantage plan with separate MA coverage. This can be a problem if you have a MA managed care plan with a different provider network than your Medicare Advantage network.
• You can have a Medicare Advantage plan that is integrated with MA coverage. These plans include all the coverage that Medicare Parts A, B, and D offer plus what MA covers. They are called Special Needs Plans (SNP) plans if you are 18 – 64 years old; Minnesota Senior Health Options (MSHO) if you are 65 or older. With these plans, there’s less paperwork (you only have one insurance card) and you don’t have to worry so much about which of your benefits pays for which medical services. They also offer care coordination as a core part of the plan.

The bottom line: An SNP or MSHO plan could make it easier for you to deal with your combined MA and Medicare health coverage and may let you get more benefits than Medicare usually offers, such as dental, vision, and hearing aid coverage. However, if you want more flexibility than a managed care program, look into Original Medicare.

Is Medicare Your Only Health Coverage?

If you do not have any private health insurance, don’t qualify for MA, and don’t have any other medical coverage besides Medicare, then you need to make sure that your Medicare coverage is good enough for all of your health needs.

If Medicare is your only health coverage:

• Do not decline Parts B and D. They provide coverage you need, since you don’t have any other insurance that will pay for those medical expenses. Furthermore, if you turn them down, you have to pay premium penalties if you want them later.
• See whether you would prefer a Medicare Advantage plan. Medicare Advantage plans have to offer at least the basic benefits that Original Medicare offers, but some Medicare Advantage plans might also offer coverage for things that Original Medicare doesn’t cover. Use the Medicare Plan Finder to see if there’s a Medicare Advantage plan that meets your needs.
• If you don’t want Medicare Advantage, think about a Medigap policy (Medicare Supplement Insurance). If you get Original Medicare, you can pay an extra monthly premium to get a private Medigap policy that covers some of the expenses that Medicare Parts A and B won’t cover, such as co-insurance, copayments, and deductibles. Medigap policies do not cover prescription drugs (you need Part D for that). Learn more about Medigap policies or find one in your area.

The bottom line: If you don’t have other coverage, make sure that your Medicare coverage meets your needs.

If you get Medicare coverage, it helps with many different types of medical expenses. The exact coverage you have depends on:

• Whether you have Original Medicare, Medicare Advantage, or a Medicare Cost plan
• If you have a Medicare Advantage or Medicare Cost plan, which plan you have
• If you have Original Medicare, whether you have Part B and Part D, and, if so, which Part D plan you have

What Full Medicare Coverage Usually Offers

This list presents many of the medical expenses that Original Medicare Parts A and B help pay for. Medicare Advantage plans also pay for all of these services, but some plans also pay for more services not listed here. For all of these, you may have to pay copayments, co-insurance, or a deductible. Learn more about what Medicare costs and how to get help paying for it.

Part A, Medicare Advantage, and Medicare Cost plans all cover hospitalization expenses, including:

• Medical care when you are admitted to the hospital
• Hospital stays
• Short-term stays in a skilled nursing facility
• Hospice care
• Home health care
• Blood

Part B and Medicare Advantage plans both cover outpatient expenses, including:

• Outpatient care, including observation services
• Preventive screenings and services, including an annual checkup and some vaccines
• Lab tests, such as X-rays, MRIs, and blood tests
• Home health care
• Emergency services, including ambulance transit and emergency room treatment
• Medical and surgical services and supplies
• Mental health care
• Urgent care
• Doctor and practitioner services
• Rehabilitation, such as physical therapy, occupational therapy, or speech therapy
• Supplies and equipment, such as prosthetics, orthotics, durable medical equipment, diabetes supplies, or wheelchairs
• In some situations, other things like chiropractic services, diabetes management, and injectable cancer or immunosuppressive drugs.

Part D, as well as Medicare Advantage and Medicare Cost plans that include drug coverage, pay for prescription drugs on a plan’s formulary. Formularies are reviewed by Medicare and must cover certain types of medications.

Get more information about what Medicare covers:

• For Original Medicare, read Medicare & You or download Medicare's "What's Covered" app from Google Play or the Apple App Store.
• For Part D, a Medigap policy, or Medicare Advantage, contact your private insurance company.
• See Medicare.gov’s list of services that Original Medicare doesn’t cover, such as dental care, eye exams, hearing aids, cosmetic surgery, and acupuncture.
• Check out the Minnesota Board on Aging's Health Care Choices for Minnesotans on Medicare. You can call the Senior LinkAge Line® at 1-800-333-2433 to ask for a paper copy.

Medicare doesn’t pay for all of your medical expenses. You may have to pay:

• Premiums, monthly payments you must make whether or not you use any medical services. Medicare premiums may be deducted directly from your Social Security Disability Insurance (SSDI) or Social Security retirement benefits.
• Copayments, a set amount you have to pay for a medical visit or service. The amount depends on the service.
• Co-insurance, a set percentage of the cost of a visit or service that you must pay.
• A deductible, a set amount of money that you pay out of your own pocket each year before Medicare begins to pay for certain services. Once you have paid the deductible, you do not have to pay it again until the next calendar year.

The exact amounts you have to pay vary:

• With Medicare Advantage, you need to make sure you understand your plan, because each plan is different. All Medicare Advantage plans have an out-of-pocket maximum of at most $8,300 for covered services and treatment, not including prescription drugs.
• With Original Medicare, the costs are more standardized for Parts A and B. For a Part D or Medigap plan (Medicare Supplement Insurance), costs may vary. Original Medicare does not have an out-of-pocket maximum. Learn more about Original Medicare expenses.
• With Medicare Cost plans, you need to make sure you understand your plan because each plan is different. You need to understand the plan's provider network and also what your costs would be under Original Medicare if you see an out-of-network provider.

Help Paying for Medicare

You may qualify for help paying for your Original Medicare or Medicare Advantage expenses. There are two main types of help: Medicare Savings Programs (MSPs) and the Low Income Subsidy (LIS) for prescription drug coverage.

Note: If you qualify for an MSP or the LIS and later start working, they still might help you with your Medicare expenses.

Medicare Savings Programs (MSPs)

An MSP may help you pay Medicare premiums and other expenses, such as copayments, co-insurance, and deductibles, if:

• Your countable income is 135% of the Federal Poverty Guidelines (FPG) or less ($1,641 per month or less if you live alone; $2,219 for couples); and
• You have less than $10,000 in assets ($18,000 if you live with someone else). You also must approve the use of the Account Validation Service (AVS) so that the MSP can make sure your assets are below the limit.

If you also have Medical Assistance (MA) coverage, you may be automatically signed up for an MSP.

If you qualify, an MSP may help with Parts A and B of Original Medicare, or with any Medicare Advantage plan.

The three main Medicare Savings Programs help in different ways. Generally speaking, the less income you have, the more they help:

• The Qualified Medicare Beneficiary (QMB) program helps people with countable income that’s 100% of FPG or less ($1,215 per month or less if you live alone).
  • If you have Original Medicare, QMB helps pay for your Part B and Part A premiums, copayments, and deductibles.
  • If you have a Medicare Advantage plan, QMB helps pay your premium, copayments, and deductibles.
• The Service Limited Medicare Beneficiary (SLMB) program helps people with countable income that’s more than 100% of FPG, but at or below 120% of FPG ($1,458 per month or less if you live alone).
  • If you have Original Medicare, SLMB helps pay the Part B premium.
  • If you have a Medicare Advantage plan, SLMB helps with the premium.
• The Qualified Individual (QI) program helps people with countable income that’s more than 120% of FPG, but at or below 135% of FPG ($1,641 per month or less if you live alone).
  • If you have Original Medicare, QI helps pay for the Part B premium.
  • If you have a Medicare Advantage plan, QI helps with the premium.

You can apply for a Medicare Savings Program by filling out the Minnesota Health Care Programs Application for Certain Populations and taking it or mailing it to your local county or tribal human services office.

Many people who qualify for an MSP or the LIS never apply. You should apply, even if you think you don’t qualify, because MSPs and the LIS only look at your countable income, which may be a lot lower than you realize. For example, they count less than half of your earned income. If you have any questions, call the the Senior LinkAge Line® at 1-800-333-2433.

Your Countable Income:

Your Monthly Earned Income	$
Your Monthly Unearned Income (not including SSI)	$
Your Monthly Impairment Related Work Expenses (IRWEs)	$
	$1,215
	$20
	$65
	$914
Your Monthly Countable Income
Your Annual Countable Income
	$14,580
Federal Poverty Guideline
Your Countable Income as a Percent of FPG

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Low Income Subsidy (LIS)/Extra Help for Prescription Drug Coverage

The Low Income Subsidy, often called Extra Help, may help you with Medicare prescription drug expenses, such as copayments and deductibles, if:

• Your countable income is $21,870 per year or less if you live alone ($29,580 or less for couples), and
• You have less than $16,660 in assets if you are single ($33,240 or less for couples).

If you also get Supplemental Security Income (SSI) benefits, have MA coverage, or are in an MSP, you automatically qualify for the LIS.

The LIS helps with Part D plan expenses or helps pay for Medicare Advantage plans that include prescription drug coverage, sometimes called Medicare Advantage Prescription Drug (MA-PD) plans.

The LIS has two levels and will help you more if your income and assets are lower:

• The full subsidy is for people who also get MA coverage or who are in a Medicare Savings Program. You may also qualify if your countable income is less than $19,683 per year and your assets are less than $10,590 if you are single (the limits are higher for larger households).
  • If you have Original Medicare and a Part D benchmark plan, you don’t have to pay a Part D premium or deductible, and there may be lower copayments.
  • If you have a Medicare Advantage plan that includes prescription drug coverage, it helps with your premium and deductible, and there may be lower copayments. The exact amount it helps depends on your plan.
• The partial subsidy is for people who can’t get the full subsidy, but have less than $21,870 in annual countable income and less than $16,660 in assets if you are single (the limits are higher for larger households).
  • If you have Original Medicare and a Part D benchmark plan, you pay 0%, 25%, 50%, or 75% of the Part D premium, depending on your income, and only have to pay a $104 deductible before you get help paying for drugs. You do have to pay co-insurance and copayments for your medications, but they are lower than without the partial subsidy.
  • If you have a Medicare Advantage plan that includes prescription drug coverage, the partial LIS helps with your premium and deductible, and there may be lower copayments, but it doesn’t help as much as the full subsidy. The exact amount the partial LIS helps depends on your plan and your income.

You can apply for the Low Income Subsidy online or at your local Social Security office.

How Work Affects Your Medicare Costs

If you currently qualify for an MSP or the LIS, money you make at work might cause your MSP or LIS eligibility to change or end. However, they count less than half of your earned income, so getting a job does not always mean that you lose the help you get.

The other way work could affect Medicare is if you get SSDI, because your Medicare coverage is based on your SSDI eligibility. However, even if you stop getting SSDI, you may be able to keep your Medicare coverage:

• With SSDI, you can try out working without losing your SSDI or Medicare benefits. First, you go through a Trial Work Period. Once you use nine Trial Work months, your Trial Work Period is over. Get more detailed information about the Trial Work Period on DB101’s SSDI and Work page.
• After your Trial Work Period ends, you still get at least 93 more months (7 years and 9 months) of Medicare coverage at the regular cost, as long as Social Security finds that you still have a medical disability.
• After the 93 months are over, you may still be able to get Medicare through the Qualified Working Disabled (QWD) Medicare Savings Program, if your countable income is 200% of FPG or less ($2,430 per month or less if you live alone) and you have less than $4,000 in assets if you live alone ($6,000 if you live with someone).
  • With Original Medicare, QWD helps pay for the Part A premium that you otherwise would have to pay. With Medicare Advantage, it also helps with the premium.
  • If your income is higher, you may need to pay a higher premium for Medicare, but you still keep your coverage. With Original Medicare, the Part A premium is up to $506 per month. With a Medicare Advantage plan, your premium may go up a similar amount.
  • You can apply for QWD by filling out the Minnesota Health Care Programs Application for Certain Populations and taking it or mailing it to your local county or tribal human services office.

Note: If you get Medicare and are 65 years old or older, you keep your Medicare eligibility, no matter how much you earn. However, as your earnings go up, you may need to start paying higher premiums.

What you have to do to sign up for Medicare depends on how you qualify and if you want Original Medicare, Medicare Advantage, or a Medicare Cost plan.

Original Medicare is automatic for some people, but not others, while anybody who wants a Medicare Advantage or Medicare Cost plan has to sign up. And, even if you get Original Medicare automatically, you still need to sign up for a Part D plan.

You should also think about applying for a Medicare Savings Program (MSP) and the Low Income Subsidy (LIS) — many people lose out on this help because they never bother to apply.

If you need help, call the Senior LinkAge Line® at 1-800-333-2433 or Medicare at 1-800-633-4227 or 1-800-325-0778 (TTY).

Signing Up for Original Medicare

Some people automatically start getting Original Medicare coverage without having to sign up. This includes anybody who:

• Gets Social Security Disability Insurance (SSDI) or Disabled Adult Child (DAC) benefits for two years (24 months)
• Turns 65 and already gets Social Security retirement benefits, or
• Has ALS (amyotrophic lateral sclerosis, also called Lou Gehrig’s Disease).

If you are in one of these situations, you get a notice in the mail three to four months before your Medicare is supposed to start. The notice will tell you:

• The exact date your automatic Original Medicare Part A and Part B coverage starts
  • You don’t have to pay a premium for Part A
  • You probably have to pay a $164.90 monthly premium for Part B (it could be a bit less, depending on your situation).
• How to decline Part B, if you have employer-sponsored coverage and don’t want to pay the premium for Part B
• How to sign up for Part D prescription drug coverage, and
• How to switch to a Medicare Advantage plan instead of Original Medicare.

If you do not automatically start getting Medicare benefits, you can sign up for Original Medicare Parts A and B:

• Online at the Social Security website, or
• At the local Social Security office or by calling Social Security at 1-800-772-1213 or 1-800-325-0778 (TTY).

Learn more about signing up for Original Medicare.

Signing Up for Private Plans: Part D, Medigap, Medicare Advantage, and Medicare Cost Plans

If you have government-run Original Medicare, you have the options of also getting a privately managed Part D prescription drug policy and a privately run Medigap policy (Medicare Supplement Insurance). Note: Medigap policies do not include prescription drug coverage.

Or, you may decide that you want a privately run Medicare Advantage or Medicare Cost plan that includes all the benefits you need. If you choose a Medicare Cost plan, you also get to keep Original Medicare coverage for out-of-network expenses. Note: Most Medicare Advantage and Medicare Cost plans include prescription drug coverage, but some allow you to sign up for a separate Part D plan instead.

Important: Medicare Cost plans are not an option in most counties and are being phased out. If you have any questions about this, call the Senior LinkAge Line® at 1-800-333-2433.

For all of these types of privately managed Medicare benefits, the signup process is basically the same:

1. You decide which types of plans you want to sign up for.
2. You research the private plans you are looking at:
   • Compare Medicare Advantage, Medicare Cost, or Medicare Part D plans
   • Compare Medigap policies
3. You sign up:
   • On Medicare.gov
   • By calling Medicare at 1-800-633-4227 or 1-877-486-2048 (TTY)
   • By calling the Senior LinkAge Line® at 1-800-333-2433
   • By completing a paper application with the plan, or
   • By contacting the plan directly.

Note: If you qualify for Medicare and also get MA or MA-EPD, you are automatically signed up for a Part D plan.

When to Sign Up for Part D, Medicare Cost, or Medicare Advantage Plans

When you should sign up for a Part D, Medicare Cost, or Medicare Advantage plan (or switch from Medicare Advantage back to Original Medicare) depends on your situation:

1. You can sign up, switch, or drop plans at any time if you:
   • Get both Medicare and either Medical Assistance (MA) or Medical Assistance for Employed Persons with Disabilities (MA-EPD) benefits
   • Get help from a Medicare Savings Program (MSP)
   • Qualify for the Part D Low Income Subsidy (Extra Help)
   • Move into or leave a skilled nursing facility, or
   • In certain other situations, like if you move outside of your plan’s service area.
2. If your Medicare coverage is just starting, you can sign up anytime during the three months before and after your Medicare coverage starts. This is called the initial enrollment period.
3. You can add, drop, or switch plans every October 15 - December 7. This is called the annual election period. Any changes you make start on January 1 of the following year. Note: If you want to switch from Medicare Advantage to Original Medicare with Part D, you can do so until February 14.
4. For Medicare Cost plans, as long as the plan has open enrollment, you can enroll at any time and return to Original Medicare at any time. Note: Medicare Cost plans are not an option in most counties.

Applying for Help to Pay for Medicare

You can apply for a Medicare Savings Program by filling out the Minnesota Health Care Programs Application for Certain Populations and taking it or mailing it to your local county or tribal human services office.

You can apply for the Low Income Subsidy online or at your local Social Security office.

Note: If you have Medical Assistance (MA) coverage as well as Medicare, you may already be getting help from an MSP and the LIS automatically.

Learn more about MSPs and the LIS. If you want to talk with someone about them, call the Senior LinkAge Line® at 1-800-333-2433.

Robert’s Story

Robert is 38 years old and became paraplegic after a diving accident a couple of years ago. He’s been getting Social Security Disability Insurance (SSDI) benefits for the last 18 months and private health coverage through MNsure, because he gets too much in SSDI to qualify for Medical Assistance (MA) health coverage.

However, Robert knows that he gets Medicare soon, once he’s been on SSDI for two years, and he’s starting to plan for that. This is a big deal, because once his Medicare coverage starts, he wants to stop his expensive private insurance.

Comparing Original Medicare with Medicare Advantage

As Robert starts looking into Medicare, he realizes that he has to choose between Original Medicare or a Medicare Advantage plan. If he does nothing, he’s automatically signed up for Original Medicare Part A and Part B, but he isn’t sure that’s what he wants.

Robert gets online and learns that with Original Medicare, he can choose from more doctors and see specialists when he wants to. He calls up his current medical providers and they all confirm that they accept Original Medicare. He also learns that he doesn’t have to pay a monthly premium for Part A, but he has to pay $164.90 each month for Part B.

The Medicare Advantage plans he looks at limit him to choosing his doctors from specific networks and require him to see a primary care physician before seeing specialists. However, most of the plans he looks at have lower copayments than Original Medicare and an out-of-pocket maximum, meaning that beyond the premium, he never has to pay more than $8,300 in a year for medical care. Furthermore, Medicare Advantage seems a little simpler, since it’s one unified plan, instead of multiple parts. For some Medicare Advantage plans, he has to pay $164.90 per month, the same as with Original Medicare Part B, while for other plans he has to pay higher premiums. After doing some math, he figures that overall, most Medicare Advantage plans are a bit cheaper than Original Medicare.

After exploring the pros and cons of Original Medicare and Medicare Advantage plans, Robert decides to stick with Original Medicare, because it’s more like his current private health coverage, a PPO that lets him see specialists at different medical facilities. Even if Original Medicare ends up costing him a little more, it’s worth it to him because he can see the same doctors he has been visiting ever since his accident.

Since he wants Original Medicare, Robert doesn’t have to worry about signing up: Original Medicare coverage starts automatically after he’s been getting SSDI for two years.

Prescription Drug Coverage

However, Robert has to sign up for a separate Part D prescription drug plan, because Original Medicare Parts A and B don’t cover prescriptions and Part D coverage doesn’t start automatically.

Robert reads up on Part D and learns that all Part D plans are privately run, but they must follow some basic rules set by the government. Robert has to pay a monthly premium for his coverage, an annual deductible, and copayments or co-insurance for his medications.

Robert takes four different medications and he knows they aren’t cheap, so he starts to worry, until a friend tells him that some companies may offer better Part D plans for Robert’s needs.

Learning about MA-EPD

Robert enrolls in Part D and is happy with his overall Medicare coverage, because it is pretty comprehensive and costs less than his old private insurance. Even so, he wishes it were cheaper. After a few months, he calls up the Senior LinkAge Line® at 1-800-333-2433 to see if there’s any way for him to save some money.

They tell him that if he also qualifies for MA health coverage or for a Medicare Savings Program (MSP), his total medical expenses go down. However, Robert knows he doesn’t qualify for those because his SSDI payments are too high. That’s when the Senior LinkAge Line® counselor tells him about a special program called Medical Assistance for Employed Persons with Disabilities (MA-EPD).

Robert qualifies for MA-EPD if he starts working, and there's no earned income limit. He'd have to pay a monthly premium for MA-EPD, but it'd then help pay some of his Medicare co-insurance and deductibles. Overall, he'd be better off.

Robert wants to go back to work part-time in the future, so he makes a note to himself that when he starts working, he’ll Chat with a Hub expert to learn more about it.