chat icon Chat with Us

Health Coverage Based on Age, Disability, or Diagnosis (Medicare)

Last Modified: 07/16/2020

Medicare is a federal health insurance program for people 65 or older, as well as some younger people under certain situations. Medicare coverage plays an important role in managing your medical costs as you age. While it does not cover all medical expenses, Medicare can significantly help with the cost of healthcare. 

Medicare is a completely different program than Medicaid, because it is a Federal program determined by age, disability, or diagnoses whereas Medicaid is determined by whether the person is low income and meets priority areas as determined by the state. 

Medicare is operated by the Centers for Medicare & Medicaid Services (CMS) but applications and public information for Part A and B (also known as “original Medicare”) are handled by the Social Security Administration (SSA). Medicare Part C and Part D coverage is provided through private insurers.

If you have been wrongly denied Medicare coverage contact CLSMF for legal advice.

WHAT ARE YOUR RIGHTS?

To qualify for Medicare, you must be 65 years of age. Medicare is mandatory at age 65 and not an optional benefit so long as you reside in the U.S. and are a U.S. citizen or lawfully permanent resident for at least five years. You may also be eligible for Medicare if you are 65 and you or your spouse worked long enough to receive Social Security or Railroad Retirement benefits or if you or your spouse did not pay into Social Security but did pay Medicare payroll taxes as a government employee.

You may qualify for Medicare before you are 65 years old if:

  • You have been receiving disability benefits from SSA for 24 consecutive months; or
  • You have End Stage Renal Disease requiring dialysis or transplant; or
  • You have Lou Gehrig’s Disease (ALS).

For more information on Medicare and End-Stage Renal Disease, including kidney transplants and children with ESRD, go to https://www.medicare.gov/manage-your-health/i-have-end-stage-renal-disease-esrd.

 

Medicare Part A (hospital insurance) generally covers:

  • Inpatient care in a hospital;
  • Inpatient subacute care in a skilled nursing facility (not including long-term or custodial care);
  • Hospice care; and
  • Home health care.

If you are unsure if Medicare Part A covers something you need, you can use the coverage search tool on the Medicare website.

 

You do not need to do anything if you already get Social Security retirement benefits. You will automatically be signed up for Part A the instant you become eligible, and should receive a “Welcome to Medicare” packet in the mail prior to turning 65. 

 

If you are not already getting retirement benefits or planning on retiring when you turn 65, you can still enroll for Medicare part A during the Initial Enrollment Period. Enrolling later could make your lifetime Medicare costs more expensive, as prices may go up while you wait.

Applications can be made by contacting the Social Security Administration or online (under some circumstances) at https://www.ssa.gov/benefits/medicare/

Your coverage will usually begin the first day of the month that you turn 65.

If you have ESRD and are on dialysis, Medicare is generally effective the first day of the fourth month from when you started dialysis.  Medicare coverage will end 12 months after the month you stop dialysis treatments.

If you have ESRD and are eligible for Medicare due to needing a kidney transplant, Medicare is effective from the date of admission into the hospital for the transplant.  Medicare coverage will end 36 months from the month of the transplant.

If you have ALS, you will begin receiving Medicare coverage the same month your Social Security disability benefits start.

 

Generally, the premium is free for Medicare Part A, as long as you have worked for the required amount of time. 

How much you must have worked is determined by “quarters of coverage” (QCs) which usually equal to 4 for every year you have worked. The exact number of QCs needed is dependent on whether you are applying for Medicare based on age, disability (including ALS), or end stage renal disease.  

Generally, if you are receiving Social Security or Railroad retirements, Social Security Disability Insurance (SSDI), or Railroad disability, you will meet the required number of QCs for premium free Medicare Part A.

If you do not meet these requirements, you’ll have to pay for Medicare Part A. The amount you’ll need to pay will be decided by how long you or your spouse has worked (how many QCs you or your spouse have earned). This monthly premium changes every year, so visit the Medicare Part A page online for the current amount. 

 

 

Medicare Part B (medical insurance) covers medically necessary services and preventative services. Medically necessary services are things which are needed to diagnose or treat your medical condition, while preventative services are things that help you avoid getting ill or help detect an illness so you can treat it early. These may include:

  • Ambulance services;
  • Clinical research;
  • Durable medical equipment (DME);
  • Mental health (inpatient, outpatient, and hospitalization); and
  • Limited outpatient prescription drugs.

You must use doctors that accept Medicare. Generally, most doctors accept “assignment,” meaning that they have agreed to accept the Medicare-covered amount as full payment. Always make sure to ask your doctor if they accept assignment.

If you are unsure if Medicare Part B covers something you need, you can use the coverage search tool on the Medicare website.

You will automatically be signed up for Part B the instant you become eligible and should receive a “Welcome to Medicare” packet in the mail prior to turning 65.  Your coverage will usually begin the first day of the month that you turn 65.

If you decide you do not want Part B, follow the instructions that come with the “Welcome to Medicare” packet and mail any Medicare card you may have received back to the Social Security Administration.

Those who live in Puerto Rico will not automatically be signed up for Part B, and need to sign up for it themselves during initial enrollment or pay a penalty.

If for some reason your enrollment is not automatic or if you refuse Part B and later change your mind, you can enroll in Part B benefits through your local Social Security office.  Keep in mind your monthly rate may go up 10 percent for every 12 months that you were eligible for Part B but chose not to receive it.

Applications can be made by contacting the Social Security Administration or online (under some circumstances) at https://www.ssa.gov/benefits/medicare/

If you already have Medicare Part A and want to sign up for Part B, you can download the application for Part B at https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS40B-E.pdf, or download the Spanish version at https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS40B-S.pdf.

There is no maximum out-of-pocket ceiling, meaning that you will always have to pay any portion not paid by Medicare for Medicare-covered expenses.

Medicare Part B has fewer restrictions/exclusions than Part C Advantage plans, but Part C Advantage plans do set a limit so that after you have paid a certain amount in out-of-pocket expenses Medicare will start covering 100% of the costs (not including your monthly premium or prescriptions).

If you are eligible to buy Medicare Part A at no cost, you can buy Part B by paying a monthly premium, which will be deducted from the monthly Social Security or Railroad benefits you receive.

Part B has a standard monthly premium, which changes yearly, but some may pay extra if they earn a high enough amount each year. 

For information about additional charges (called “Income Related Monthly Adjustment Amounts”), premium costs, and other Part B covered costs are, visit Medicare.gov’s Part B Costs page.  

 

Medicare Part C is a private insurance plan regulated by Medicare. These plans are often referred to as “Medicare Advantage” plans. 

Medicare Advantage plans replace original Medicare. You select Medicare Part C coverage instead of, not in addition to, Part A and B. 

Advantage plans essentially cover the same expenses as Part A with B, and sometimes Medicare prescription drug (Part D) medications depending on the plan. 

 

Some Medicare Advantage Plans offer coverage for things not included with original Medicare, such as vision, hearing, or dental coverage.

You must use a doctor in the network. 

Compare plans and make sure you fully understand the costs and coverage before you commit to one. Remember that some Advantage plans include prescription drug plans and some do not, so you may need to sign up for an Advantage plan and a separate prescription drug plan, depending on your needs. To search and compare, Use Medicare’s Plan Finder: https://www.medicare.gov/plan-compare/#/?lang=en

 

You should read the fine print for exclusions. Private insurers employ staff who closely monitors those exclusions to coverage. 

 

Once you have found a plan that you believe meets your healthcare needs and fits within your financial means, visit the plan’s website to see if you can apply online or fill out a paper enrollment form (all plans must have one available).

Medicare Part C plans representatives or employees are not allowed to call you or visit your home for enrollment purposes or to ask you for personal information unless you have specifically requested that they do so. If you are receiving unsolicited calls or visits from someone claiming to be a Medicare-approved provider call 1-800-MEDICARE to report the situation.

 

Most plans have Health Maintenance Organizations (HMO) and Preferred Provider Organization (PPO) choices. PPO plans have less restrictions but usually cost more than HMO plans. Part C may also include Private Fee-for-Service (PFFS) plans or Special Needs Plans (SNPs).

Medicare Part C plans offer several choices for co-pays for hospitals, doctors, and labs with maximum out-of-pocket limits. A maximum out-of-pocket limit means that once you have paid a certain amount of your own money for Medicare-covered expenses, your Medicare Advantage plan will cover 100% of future out-of-pocket costs.

Although Part C takes the place of Parts A and B, you will still have to pay the Part B monthly premium. Medicare takes that premium and gives it to the private insurance provider connected to your plan. This makes your Medicare private insurance plan significantly less expensive than a standard private insurance plan. 

The Part B premium will still be deducted from your Social Security benefits and will then get sent to your insurer. Depending on the plan you choose, you may have a higher premium to pay than Part B costs.

Medicare Part D plans are prescription drug plans. Medicare Part D plans are needed because the other Medicare parts do not cover out of hospital prescriptions. 

 

Anyone eligible for Medicare Part A or B also qualifies for Part D.

Medicare Part D plans have different lists (called “formularies”) of the drugs that are covered. These plans must all abide by a standard of coverage set down by Medicare, which means that plans will generally:

  • Cover both brand-name and generic drugs;
  • Cover all commercially available vaccines;
  • Include at least 2 drugs in the most commonly prescribed categories; and
  • Allow you to ask for an exception if you and your doctor believe that none of the drugs on the list are right to treat your condition.

These formularies may change yearly, and drugs may immediately be removed from the list if:

  • The Food and Drug Administration has found the drug to be unsafe;
  • The manufacturer has stopped selling the drug; or
  • Your insurance provider has decided to replace a brand-name drug with a generic drug.

For any other changes that involve a drug you are currently taking, your plan must:

  • Give you 30 days written notice before the change becomes effective; and
  • Provide you written notice and at least a month’s supply of your current drug when you request a refill.

Medicare prescription plans may have additional coverage rules and requirements, such as:

  • Safety checks related to opioid pain medications;
  • Prior authorization requirements for certain drugs;
  • Limiting the quantity of certain drugs for safety reasons; or
  • Step therapy, or beginning with an inexpensive generic drug before moving you to more expensive alternatives.

The first step to enrolling in a Part D plan is finding one. You will want to compare plans and make sure you fully understand the costs and coverage before you commit to one. Remember that some Advantage plans include prescription drug plans and some do not, so you may need to sign up for just an Advantage plan and a separate prescription drug plan, depending on your needs. To search and compare, Use Medicare’s Plan Finder: https://www.medicare.gov/plan-compare/#/?lang=en

Once you have found a plan that you believe meets your healthcare needs and fits within your financial means, visit the plan’s website to see if you can apply online or fill out a paper enrollment form (all plans must have one available).

You can sign up for Medicare Advantage or prescription drug plans either during your initial Medicare enrollment period, the Medicare Open Enrollment, or during the Annual Election Period (also known as the Annual Coordination Period).

There is a late enrollment fee for Medicare Part D which will be added to your monthly premium if you do not enroll in it within the first two months from when you are first eligible for Medicare benefits.  

Costs you may run into with Medicare Plan D could include:

  • A monthly premium;
  • A yearly deductible;
  • Copayments or coinsurance; and
  • Costs in the coverage gap.

For more information on costs and descriptions of what each one means, go to https://www.medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-coverage.

 

There are also Medigap insurance supplement plans sold by private insurers to help cover costs not covered by Parts A and B.  To get Medigap you must have Medicare Part A and Part B and cannot have Part C (an Advantage Plan).

Medigap plans will cover extra out-of-pocket costs that original Medicare doesn’t, such as:

 

  • Copayments;
  • Coinsurance; and
  • Deductibles.

 

You still pay your Part B premium as normal, but you also pay a private insurer a separate premium for your Medigap coverage.

 

Medigap plans stopped offering prescription drug coverage in 2006, so if you want Medigap and you need drug coverage you will have to apply for Medicare Part D.

You can buy a Medigap policy from any insurer who is licensed to sell one in your state.

Medigap does not cover spouses, only the person with the policy. If you also want Medigap for your spouse, an additional plan would have to be purchased.

WHAT TO CONSIDER BEFORE ENROLLING?

While the goal of Medicare is to help people cover their health expenses, the costs not covered by Medicare may still be too much to afford. Along with Medicaid there are other programs to help ease the burden of costs not covered by Medicare for those that qualify, such as:

Medicare Savings Programs: These are state-run programs designed to help with out-of-pocket costs like deductibles, coinsurance, and copayments. To find out if you qualify and how to apply, go to https://www.medicare.gov/your-medicare-costs/get-help-paying-costs/medicare-savings-programs.

Extra Help (Medicare Part D): This program helps low-income prescription drug plan recipients cover the costs associated with their plan such as premiums, deductibles, and coinsurance. To find out if you qualify and how to apply, visit https://www.medicare.gov/your-medicare-costs/get-help-paying-costs/find-your-level-of-extra-help-part-d

For more information on how to get assistance paying costs not covered by or related to Medicare, go to https://www.medicare.gov/your-medicare-costs/get-help-paying-costs.

If you already have health care coverage through your employer, it is a good idea to speak with your current health care provider to find out how Medicare coverage would affect your current plan.

If you are about to turn 65 you might be able to delay signing up for Medicare Part A and Part B without suffering the usual penalties depending on the size of your employer, as long as you are not already receiving Social Security benefits.

If you are over 65 you usually do not need to enroll in Medicare until you retire or your employer health care coverage ends. If you did not enroll when you first became eligible you may or may not have to pay the usual penalty, depending on the size of your employer.

For more information about penalties for delaying Medicare enrollment or what to do when your employer coverage ends, head to https://www.medicare.gov/sign-up-change-plans/how-do-i-get-parts-a-b/should-i-get-parts-a-b.

The initial open enrollment period for all plans is 3 months prior to the month of your 65th birthday through 3 months following the month of your 65th birthday.  You can decide on which plan or plans you want during your initial enrollment period.

During the Medicare Advantage Open Enrollment Period (January 1st — March 31st) you can:

Switch to another Medicare Advantage Plan (with or without drug coverage) if you are currently enrolled in a Medicare Advantage Plan; or

Drop your Medicare Advantage Plan and return to Original Medicare, and be able to join a Medicare Prescription Drug Plan.

During the Annual Election Period, also known as the Annual Coordination Period (October 15th — December 7th) you can:

  • Change from Original Medicare to a Medicare Advantage Plan;
  • Change from a Medicare Advantage Plan back to Original Medicare;
  • Switch from one Medicare Advantage Plan to another Medicare Advantage Plan;
  • Switch from a Medicare Advantage Plan that doesn’t offer drug coverage to a Medicare Advantage Plan that offers drug coverage;
  • Switch from a Medicare Advantage Plan that offers drug coverage to a Medicare Advantage Plan that doesn’t offer drug coverage;
  • Join a Medicare Prescription Drug Plan;
  • Switch from one Medicare drug plan to another Medicare drug plan; or
  • Drop your Medicare prescription drug coverage completely. 

There are Special Enrollment Periods (SEPs) that you can qualify for under certain conditions, such as if you move or become eligible for Medicaid. To see the full list of circumstances that would qualify you for an SEP and a chart explaining them, read this pamphlet from Medicare: https://www.medicare.gov/Pubs/pdf/11219-Understanding-Medicare-Part-C-D.pdf.

WHAT TO DO IF YOU ARE DENIED MEDICARE BENEFITS?

 

You can appeal a Medicare or Medicare Advantage plan decision if you have been denied any of the following:

  • Medicare benefits; 
  • Health care items, services, or drugs;
  • Payment for health care items, services, or drugs; or 
  • A request to change the amount you pay for any of the above.

 

The Medicare appeals process has a maximum of 5-levels — your issue could be resolved quickly or take more time depending on the results of each step of this process.

If you have been denied Medicare coverage or services contact Community Legal Services of Mid-Florida, Inc. for legal advice.

You must file your appeal within 120 days of your Medicare Summary Notice (MSN). The Medicare Summary Notice is a list of all of the services or items that were billed to Medicare on your behalf in a 3-month period, what Medicare paid, and how much you still owe. You will be mailed an MSN every 3 months, except for any 3-month period where you don’t use any Medicare-covered services. This notice only applies to Medicare Part A and Part B-covered services.

The Medical Summary Notice has an “Appeals Information” section where you can find the address for the company that handles their claims. Fill out a Redetermination Request Form and send it to the address listed. You can download the form here –https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/CMS20027.pdf

You can also send a written request to the company that handles Medicare’s claims (listed on the MSN). Include the following information:

  • Your name, address, and Medicare Number (as stated on your Medicare card);
  • The items and/or services you disagree with (circle them on a copy of the MSN or list them and their dates of service);
  • The reasons you believe the services or items services should be covered;
  • The name of your representative (if you have appointed one); and
  • Any other information that may help your case.

Doctors and other health care providers can be an important source of information as you provide reasons to support your appeal. Speak with them before and during the appeals process.

You should receive an answer to your appeal, called a “Medicare Redetermination Notice,” within 60 days of filing your appeal. If you are unsatisfied with the results of this notice you can continue to appeal throughout the next 4 levels of the appeals process. In these cases we recommend that you contact CLSMF for legal advice.

Appeals of Medicare Advantage denials are made through your health care coverage  plan. Follow the appeal directions given in the initial denial notice you received from your plan.

You, your representative (if you have appointed one), or your doctor must file an appeal within 60 days of the coverage determination, or provide a valid reason for filing late. Your written request should include:

  • Your name, address, and Medicare Number (as stated on your Medicare card);
  • The items or services for which you’re requesting a reconsideration (include dates of service); 
  • The reasons you believe the items or services should be covered;
  • The name of your representative and proof of representation (if you have appointed a representative); and
  • Any other information that may help your case.

Doctors and other health care providers can be an important source of information as you provide reasons to support your appeal. Speak with them before and during the appeals process.

When you receive a response will depend on what type of request you have made:

  • Expedited request — 72 hours (Ask for this if you or your doctor believe your health may be seriously harmed by waiting for the standard service response.)
  • Standard service request — 30 calendar days
  • Payment request — 60 calendar days

If you are unsatisfied with the results of this response you can continue to appeal throughout the next 4 levels of the appeals process. In these cases we recommend that you contact CLSMF for legal advice.

Appeals in Medicare prescription drug plan denials are done through your prescription drug plan.

A “coverage determination” is any decision your plan provider makes regarding coverage or payment for prescription drugs.

You or your prescriber must make a request in writing if you have already purchased drugs and want to be paid back for them. You can write them a letter or fill out and send them a “Model Coverage Determination Request” form, which you can download at the bottom of this CMS.gov page: https://www.cms.gov/Medicare/Appeals-and-Grievances/MedPrescriptDrugApplGriev/CoverageDeterminations-.

You or your prescriber can ask for a coverage determination or an exception if you are appealing to get prescription drug benefits you have not received yet. 

You can write them a letter, call them, or fill out and send them a “Model Coverage Determination Request” form, which you can download at the bottom of this CMS.gov page: https://www.cms.gov/Medicare/Appeals-and-Grievances/MedPrescriptDrugApplGriev/CoverageDeterminations-.

If you are asking for an exception, your prescriber must provide a statement explaining the medical reason why the exception should be approved.

When you receive a response will depend on what type of request you have made:

  • Expedited (fast) request — 24 hours (Ask for this if you have not received your prescription yet and you or your prescriber believe you may be seriously harmed by waiting for the standard service response.)
  • Standard service request — 72 hours 
  • Payment request — 14 calendar days

If you are unsatisfied with the results of this response we recommend that you contact CLSMF for legal advice.

Learn more about Medicare by calling 1-800-MEDICARE or 1-800-633-4227. You can also click here to get help with your Medicare questions.

For additional assistance, click on the following link: SHINE, Serving Health Insurance Needs of Elders, also known as the Florida State Health Insurance Assistance Program (SHIP) or call their toll-free number at 1-800-963-5337.

Florida Legal Services Prescription Drug Helpline – 1 (800) 436-6001 – is a statewide, toll-free helpline which provides assistance to Medicaid and low-income Medicare beneficiaries whose necessary medications have been denied.

For more info on Medicare, visit https://www.medicare.gov/coverage.

Next Steps

Chat Icon

Chat with us.

Still have questions? We are available to chat online right now.

Newsletter Icon

Check your eligibility.

Find out if you are eligible for free legal assistance.

Chat Icon

Give Us A Call

If you still need assistance, give us a call at (800) 405-1417

Was this information useful?

Please tell us why this information wasn't useful.



Thank you for your feedback!