October 05, 2021 How-To

Navigating Medicare Eligibility

The day you turn 65 is one of the most important milestones in terms of your health. Sure, it’s not as exciting as the day you became eligible for a driver’s license, but 65 does mean a new kind of eligibility: Medicare!

Baby boomers are reaching this milestone at a rate of more than 10,000 per day. And just like studying for your road test, preparing for Medicare eligibility means doing your homework and understanding what’s coming around the bend.

First and foremost, you’ll want to determine your eligibility and calculate your premium at www.medicare.gov. Those who have a special condition, disability, or receive benefits from Social Security or the Railroad Retirement Board may qualify prior to turning 65. Everyone else should apply at a Social Security office or online at www.ssa.gov/medicare starting three months before turning 65 and no later than three months after to avoid late penalties that can be permanent.

If you or your spouse are still working, and you’re covered by the employer’s plan, check with the benefits administrator to see if they require you to sign up for Medicare. If not, you can sign up later during a Special Enrollment Period without a penalty. Also, be sure any prescription drug coverage you receive through an employer after turning 65 is “creditable” – considered by Medicare to be at least as good as its drug coverage – or you’ll be liable for more late penalties.

Once you’ve determined your eligibility, it’s important to understand the fundamental parts of Medicare. Medicare Part A offers hospital insurance for inpatient stays, skilled nursing facilities, and hospice care, while Medicare Part B provides medical insurance for doctor services, outpatient care, medical supplies, and preventive care. Excluded from Parts A and B (Original Medicare) are a number of value-added benefits and services like routine vision and dental visits, health management programs, and more. These costs would be out-of-pocket. Prescription drugs also are not covered by Original Medicare and require a separate Medicare prescription drug plan (Medicare Part D). If you’ve worked and paid taxes for 10 years or more, you wouldn’t have a premium for Part A, but there are separate premiums for Parts B and D.

Alternatively, Medicare Advantage plans (Medicare Part C) are offered by health plans – like CDPHP – to replace Medicare Parts A and B while providing additional coverage. Medicare Advantage plans include everything covered by Parts A and B as well as important services such as dental, hearing, vision, annual physicals, case management, medication reviews, nutrition and wellness classes, and even no-cost gym memberships. Many Medicare Advantage plans also provide prescription drug coverage (Part D) and the convenience of having one plan administer all of your Medicare benefits.

It’s important to note that there is an open enrollment period, called AEP or Annual Election Period, for making changes to your Medicare plan that spans from October 15 to December 7. While you can sign up for Original Medicare up to three months before turning 65, and have the coverage begin on the first day of your birthday month, changes to your plan can only be made between those dates. You must be enrolled in Original Medicare Parts A and B to join a Medicare Advantage plan, so get that squared away first even if you know you’ll be replacing it.

If you’re about to overheat, take a minute to cool down. Medicare can be overwhelming because it requires learning a new system with its own timelines, rules, and terminology. That’s why I suggest starting the process early, asking questions, and reading the information you receive in the mail. Educating yourself now will allow you to make the right choices for yourself and your health, so you can cruise into this important stage of life without so much as a glimpse in the rearview.

Want to learn more about your Medicare options? CDPHP can help!

John D. Bennett, MD, FACC, FACP
About Author

John D. Bennett, MD, FACC, FACP, is president and CEO of Capital District Physicians’ Health Plan, Inc. (CDPHP), an award-winning, physician aligned, not-for-profit health plan based in Albany, NY. Bennett has held the position since 2008 after serving more than 10 years as chair, vice chair, and board member for CDPHP. During his tenure, CDPHP has been ranked among the top-performing health plans in New York and the nation, most recently named #1 in Customer Satisfaction in the J.D. Power Member Health Plan Study 2021. Under his leadership, CDPHP has also become known as a model employer regionally and nationally, and was recently named among the top three Best Companies to Work for in New York by the Society for Human Resource Management, as well as Forbes Best-in-State Employers 2021. Prior to joining CDPHP, Bennett served as founding member and CEO of Prime Care Physicians, PLLC. During his tenure, he co-led a team of 25 cardiologists and helped grow the practice to a 100-physician multi-specialty group. Bennett is board certified by the National Board of Medical Examiners and the American Board of Internal Medicine, with subspecialties in internal medicine and cardiology. He earned his medical degree at SUNY-Downstate Medical Center, Brooklyn, and a Bachelor of Science degree at Rensselaer Polytechnic Institute. Bennett completed an internship and residency in internal medicine and a fellowship in cardiovascular disease at Albany Medical Center. He is a Fellow of the American College of Cardiology and the American College of Physicians. Bennett is currently board chair for the Center for Economic Growth, and vice chair for the Palace Theatre. Bennett also serves on the boards of the Capital Region Chamber, the New York eHealth Collaborative (NYeC), the Alliance of Community Health Plans (ACHP), America’s Health Insurance Plans (AHIP), Rensselaer Polytechnic Institute, and Russell Sage Colleges. Bennett is a member of the New York Public Health and Health Planning Council, where he helps shape decisions related to New York State's public health and health care delivery system. Well-known locally and nationally for advancing health care innovation, Bennett was recently named to Crain’s New York Business 2021 Notable in Health Care, as well as the Albany Business Review’s Power 50 list.

2 Responses to “Navigating Medicare Eligibility”

  1. Thomas Ballantyne

    What does vision or dental cover?

    • Natalia Burkart

      Hi, Thomas – Vision and dental coverage varies depending on your plan. Please call CDPHP member services at (518) 641-3700 for more information specific to your coverage.

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