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(Parts A & B)
Original Medicare is the federal health insurance program that consists of two parts:
Part A (Hospital Insurance) which covers all or part of:
Part B (Medical Insurance) which covers all or part of:
No. You must have a separate qualifying drug plan through a private insurance company. You are required to have one in place once when you become eligible for Medicare, otherwise you could face permanent penalties.
See the Prescription Drug Plan FAQ section below for more detailed information about Part D.
Original Medicare is designed for those who are:
Individuals who took Social Security prior to turning 65, those who have been disabled for two or more years, or those who have certain qualifying diseases are auto-enrolled into Medicare.
Those who have delayed taking their Social Security benefits until after they turn 65 will need to enroll themselves.
The recommended way to enroll is to first register for a free MySSA account by following these steps:
To enroll in Original Medicare:
If you'd like some assistance, we are available to help guide you through the process at no cost to you. Simply book an appointment and we'll discuss what you need to do to get started
While Original Medicare covers some healthcare costs, it doesn't cover everything.
Here is a breakdown of the common costs you need to be aware of:
Technically no, however, by carrying Original Medicare alone, you are exposed to the possibility of much higher out-of-pocket costs since it has no cap in place to limit your expenses.
To fix this, it is recommended that you add on either a:
Learn more about these options in the FAQ sections below
IRMAA, or Income-Related Monthly Adjustment Amount, is an additional amount tacked onto Part B & Part D premiums for beneficiaries who exceed certain income limits.
Here's some important points to know:
For seniors turning 65, once you become eligible for Medicare, the Initial Enrollment Period(IEP) is a 7-month timeframe that includes the 3 months prior to your 65th birthday, the month of your birthday, and the 3 months after your birthday.
For those with disabilities, it is the 7 months that includes the month you receive your 25th disability check, the 3 months before and the 3 months after.
For those delaying Medicare until after 65, you have 8 months from the time you either lose employer coverage or you stop working, whichever comes first. For more on this topic, see the "Can I delay Medicare?" & "What else should I know about delaying Medicare? FAQs below.
*Note: If your IEP happens to run concurrently with the Medicare Annual Enrollment Period (October 15-December 7), your IEP will have priority. This means that you can ignore the annual enrollment dates for that year, because they do not apply to you
Yes, you can, but only under certain circumstances:
If your employer plan meets these requirements, then you may delay Medicare until you stop working without penalty
There are some important points you should know when considering whether or not to delay Medicare:
If you have any other questions, or would like assistance with this process, please book an appointment with us so we can help you navigate the transition.
There are two programs that may be available to you if you meet certain income requirements:
1.) Medicare Savings Program (MSP)
2.) Low Income Subsidies(LIS), also called "Extra Help with Part D"
If you'd like some assistance, we are available to help guide you through the process at no cost to you. Simply call or book an appointment and we'll discuss what you need to do to get started.
COMING SOON! Yeesh! There sure is a lot to learn about Medicare, amirite? That's why we're hard at work putting together an easy to understand webinar for you to learn about the basics of Medicare, whenever and wherever you want. Sign up to get on the waiting list now and be the first to know when it goes live!
(Part C)
Medicare Advantage plans are a "bundle of services" offered by private insurance companies that include your Part A & B coverage, and sometimes Part D.
Medicare Advantage plans also have added benefits* not included in Original Medicare, such as:
*Benefit availability varies by plan and county of residence
Most Part C plans have a $0 monthly premium.
As long as you are up to date with paying your Medicare Part B premium, you will stay enrolled in your Advantage plan
Anyone who is actively enrolled in Original Medicare Parts A & B can enroll into a Medicare Advantage Part C plan.
See the "Who is eligible for Medicare" FAQ above for more info on who qualifies for Original Medicare
Most of the time, yes. The Kaiser Family Foundation estimates that 89% of all Medicare Advantage plans include prescription drug coverage. These plans are referred to as MAPDs
In an HMO, or Health Maintenance Organization plan:
In a PPO, or Preferred Provider Organization plan:
Yes. Some employers offer a Medicare Advantage plan as part of their retirement package, but you are not obligated to take it.
Here's some important things to consider:
If you'd like a no obligation cost comparison or have other questions about switching to a private Part C plan, please call or book an appointment and we'd be happy to help
Yes. If you have TRICARE for Life(TFL) or are VA connected, you may also have a Medicare Advantage plan.
Think of it like this:
Here are some other important things to know:
If you'd like additional guidance regarding TFL/VA & Medicare Advantage, please call or book an appointment and we'd be honored to assist
* Scroll down the page and expand the "If I already have VA healthcare benefits, should I still sign up for Medicare when I turn 65?"
**Benefit availability varies by plan and county of residence
Only during certain times of the year, or under qualifying circumstances.
If you are New to Medicare or decide your Part C plan is no longer a good fit, you may switch during the following:
Initial Enrollment Period (IEP)
Medicare Annual Enrollment Period (AEP)
Medicare Advantage Open Enrollment Period (OEP)
Special Enrollment Period (SEP)
For further guidance on this topic, or if you believe you have experienced a qualifying event, please call or book an appointment and we'd be happy to help
When you are within a qualifying enrollment period, there several ways:
Or, if you'd prefer a more tailored approach, here's how AYIS is different:
If you're ready to discuss your options, please call or book an appointment to get started. We look forward to hearing from you
You easily view and compare Medicare Advantage plans in your area by going here.
Simply input your doctors, meds and any health conditions to get a list of options that could be a good fit for you.
And remember, we're only a phone call away if you get stuck
(Part D)
Yes, you are required to have a qualifying drug plan in place while in Medicare, regardless of whether or not you take any prescriptions.
You will need to either enroll in a standalone drug plan or a Medicare Advantage plan with drug coverage (MAPD).
Failure to do so means you may face a permanent penalty if you are without qualifying drug coverage for too long
No. Prescription drug plans are offered by private insurance companies and are separate from Original Medicare
*See IRMAA FAQ above regarding part D premium adjustments
Prescription drugs that are covered by your insurance will fall into 1 of 5 different tiers.
It's important to understand which tier your prescriptions are in because it also affects how much you pay at the pharmacy:
Tier 1: Preferred Generic Drugs -
Tier 2: Generic Drugs -
Tier 3: Preferred Brand Name Drugs -
Tier 4: Non-Preferred Name Brand Drugs -
Tier 5: Specialty Drugs -
Plans update which drugs they cover on an annual basis, so it's important for you to review if there have been any changes to your insurance company's list of covered drugs, especially if you are prescribed a new one, in order to help keep your costs down
The Donut Hole is one of 4 phases of coverage for prescription drugs. These are important to know about because depending on which phase you are in will determine how much your out-of-pocket costs are.
They occur in this order:
The Deductible Phase -
You pay 100% of the full retail cost of covered prescriptions until you meet the deductible. The most a deductible can be in 2024 is $545, and for some plans it is as low as $0.
Once you have met the deductible, you enter the Initial Coverage Phase.
The Initial Coverage Phase -
The insurance company picks up the majority of the cost, and you only pay a pre-set copay or percentage.
If the full retail value of your total drug costs (split between you and your insurer) have reached $5030 for the year, you enter the Donut Hole.
The Donut Hole Phase - You must pay 25% of the full retail cost of your prescriptions until you have paid $2970 out-of-pocket.
As an example, if the retail price of X prescription is $1500/fill, you would pay $375 (25% of $1500) at the pharmacy for 8 fills before you would exit the donut hole for the year, since:
In 2024, once you meet a total of $8000 in drug costs($5030 retail price + $2970 out-of-pocket), you enter the Catastrophic Coverage Phase.
The Catastrophic Coverage Phase - Once you have exited the Donut Hole, 100% of your prescription costs are covered, with the exception of your premium if you have one
The Inflation Reduction Act, which was signed into law in 2022, requires that covered out-of-pocket prescription drug costs will be capped at $2000/year beginning in 2025.
This amount will be adjusted yearly based on inflation
It depends.
Each insurance company has a formulary - which is a list of all the prescriptions they cover. If you take a prescription drug that is not on your insurance's formulary, you will be charged full price at the pharmacy.
It's also important to note that insurance companies update their lists of covered drugs annually, and sometimes a drug that was covered in the past is no longer and vice versa.
There is good news though! See the FAQs below to learn the ways you can save on your prescription drug costs
Most of the time, yes. The Kaiser Family Foundation estimates that 89% of all Medicare Advantage plans include prescription drug coverage.
These plans are referred to as MAPDs and typically have $0 monthly premium
See the "When Do I enroll in Medicare Advantage" FAQ in the section above
You may only be enrolled in a standalone Part D plan during certain qualifying periods:
Initial Enrollment Period (IEP)
Medicare Annual Enrollment Period (AEP)
Special Enrollment Period (SEP)
You can easily view and compare Part D drug plans & prices in your area by going here. (TX, WI, SC, MI, AZ only)
Simply input your doctors, meds and any health conditions to get a list of options that could be a good fit for you.
And remember, we're only a phone call away if you get stuck
You may qualify for Low Income Subsidies(LIS), also called "Extra Help with Part D", if you meet certain low-income requirements.
LIS is a federal program that:
The good news is that there are many overlooked ways to get your prescription drug costs down.
*This is not to be interpreted as medical advice. Please consult your doctor regarding any healthcare changes or needs
(Plans A - N)
Medicare Supplement Insurance, also called Medigap, are optional standalone plans that work alongside your Original Medicare Parts A & B.
These plans "fill in the gap"of your healthcare where Original Medicare may not cover.
You become eligible to enroll in a Medigap Supplement when you turn 65. There are NO enrollment period restrictions, meaning, you may enroll or choose a new plan at anytime of the year. However, you may be asked a series of health questions, and it is possible to be denied coverage for those 66 and older. Beneficiaries who are age 65 are guaranteed acceptance into a Medigap policy.
Set up your free account at secure.ssa.gov to get an estimate of your Social Security benefits and to register for your A & B benefits. Remember, you must also buy a standalone Part D drug plan, otherwise you may incur a penalty.
Plan benefits are structured uniformly across all 50 states, however the monthly premiums will vary from company to company. As an example, a Plan N Supplement in New York state must have the same coverage benefits as a Plan N in Nevada, however the monthly premium will vary between those states. Similarly, a Plan N in the same state may be offered by many companies, but the premium prices will likely differ. And keep in mind, Medigap Supplement plan premiums are paid separately and in addition to your Medicare Part B & D monthly premiums.
*Also, as a special note, if you are enrolled in a Medigap Supplement, you may elect to switch to a a different insurance company at any time of the year without penalty. Underwriting may be required.
Click any link below to download helpful information regarding your Medicare benefits:
The purpose of this website is the solicitation of insurance. The plans we offer are currently limited to TX, WI, SC, MI, AZ. You may be contacted (within reason) by a licensed agent/our agency.
Medicare TPMO Disclaimer:
We do not offer every plan available in your area. Currently, we represent 9 organizations which offer 64 plans in your area. Please contact Medicare.gov, 1–800–MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
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