If you're younger than 65 and have been on Social Security disability benefits for a while, you may have already navigated the process of using Medicare as your health insurance provider.
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But what happens when you celebrate your 65th birthday? Do you start the sometimes laborious process all over again? Let's walk through how the system works and what to expect.
What Is Medicare?
Medicare, the federal health insurance program established in 1965, was designed to provide coverage for American adults over age 65. At the time, most Americans retired at about that age, so Medicare was meant to kick in when coverage from an employer-based insurance plan ended.
In 1972, Medicare was expanded to cover people younger than 65 – if they receive Social Security disability benefits. Since then, qualifying for such benefits has meant meeting several requirements and completing a 24-month waiting period before coverage kicks in.
Two specific conditions are exempt from the 24-month waiting period: Those with end-stage kidney disease and those with Lou Gehrig’s disease, which is more formally called amyotrophic lateral sclerosis, or ALS. Individuals with these diseases can qualify for Medicare no matter their age and without having to fulfill the two-year waiting period.
No matter which disability you have, once you meet the outlined requirements, you can access federally subsidized health insurance coverage via Medicare. This way, you can help you get the care you need when you're unable to secure health insurance through an employer.
Read: Your Guide to Medicare Coverage.
Medicare Parts and Programs
Medicare is broken into four parts, explains Dr. Meena Seshamani, deputy administrator and director of the Center for Medicare at the Centers for Medicare & Medicaid Services in Washington, D.C.
Part A, the so-called hospital portion, covers inpatient care in hospitals, skilled nursing facilities and some types of in-home health care or hospice care.
Part B, on the other hand, covers services from doctors and other health care providers, Seshamani says. These services include physical therapy, preventive care, outpatient care and some medical devices, such as wheelchairs.
Parts A and B together are considered “Original Medicare” and have been around since the beginning.
In 2003, Medicare Part C, also called Medicare Advantage, rolled out. This part includes health plans offered by private companies approved by Medicare. This coverage is optional and intended to supplement the coverage offered by Parts A and B.
Part D is the prescription medication piece of Medicare.
Another program, Medigap, includes both Original Medicare and a supplemental plan to pay for coinsurance deductibles, explains Kathleen Holt, a Connecticut-based attorney and associate director for the Center for Medicare Advocacy. Medigap plans help reduce out-of-pocket expenses for individuals who opt for this additional coverage.
So, what happens when individuals with qualifying disabilities turn 65 and become eligible for Medicare because of their age? In short, nothing.
“Your Medicare coverage will remain the same because you’ve already met the eligibility requirements for premium-free Part A and Part B coverage by receiving disability benefits for at least 24 months,” explains Javier Sanchez, executive director of Medicare programs for CalOptima Health, a community-based health insurance plan serving low-income residents in Orange County, California.
He adds that “your 65th birthday doesn’t bring any new requirements or things to do. You don’t need to re-enroll or complete any paperwork to continue getting Medicare benefits for a disability.”
However, if you want to make changes to your enrollments, your 65th birthday would be the time to do it, says Bob Rees, vice president of Medicare sales and member loyalty with eHealth Inc., a health insurance broker and online resource provider headquartered in Santa Clara, California.
"If you’re already enrolled in Medicare pre-65 due to disability, turning 65 essentially gives you a second enrollment opportunity,” he explains.
More specifically, aging up means you can take another look at the coverage you’ve been getting and make changes or additions to better suit your needs going forward. For example, if you declined Medicare Part B when you first enrolled in Medicare, “you will be automatically enrolled in Part B now,” Rees explains. You can enroll in Medicare Advantage, Part D or a Medicare supplement plan as well, he points out.
Seeking Help With Selections
Medicare can seem complicated, and the dizzying array of options and parts can make you wonder if you’re getting the coverage you need.
“It may be beneficial to seek advice from a Medicare consultant or counselor to make sure you're taking full advantage of the programs and benefits available to you as an age-based Medicare recipient,” Rees says.
A free resource for such consultation is the State Health Insurance Assistance Program, or SHIP, a grant-based program in every state, D.C., Puerto Rico, Guam and the U.S. Virgin Islands. SHIP programs are staffed by experts who are trained in working one-on-one with individuals to match them with the appropriate Medicare options for their specific needs. You can find your local program and set up an appointment at the SHIP website.
Medicare.gov is also a great resource for learning more about the options and navigating the process of enrollment or changing your selections. CMS also staffs a 24/7 call center at 1-800-Medicare where you can check your eligibility and get help getting oriented around Medicare, Seshamani notes. Helping people figure out the best options for them “is really a top priority for us,” she says.
Benefits of Plans F and G
The benefits associated with Plans F and G include:
• Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up.
• Part A deductible.
• Part B coinsurance or copayment.
• Part B excess charge, which is a charge by your provider beyond the Medicare-approved amount.
• Blood (first three pints).
• Skilled nursing facility care coinsurance, as well as hospice care coinsurance or copayment.
• 80% of the cost of health care costs incurred while traveling in a foreign country, up until your plan’s limits.
Who Qualifies for Plans F and G?
Importantly, Plan F is only available for those who turned 65 or qualified for Medicare before January 1, 2020. In 2015, Congress passed the Medicare Access and CHIP Reauthorization Act, also called MACRA, that blocked access to Plan F for those people who became eligible after January 1, 2020.
Although many people sign up for Medicare when they're first eligible at or around age 65, others may wait. For instance, if you were working at a place that offered health insurance benefits when you turned 65, you may have opted to stay on that insurance coverage rather than switching to Medicare. Once you retire, you may want to start taking advantage of your Medicare benefits.
Plan F vs. Plan G Deductible
The other major difference to consider when comparing Plans F and G is that F covers the annual Part B deductible of $226, but Plan G doesn’t, explains Valerie Osborn, director of Medicare sales at MVP Health Care and based in Albany, New York. That deductible amount can change from year to year.
“For a long time, Plan F was considered the gold standard, providing the most comprehensive coverage,” says Bob Rees, vice president of Medicare member loyalty for eHealth, an online brokerage for Medicare based in Santa Clara, California. “Plan F is being phased out for new beneficiaries. Plan G is the closest thing to Plan F that’s currently available to new beneficiaries.”
Costs of Plan F vs. Plan G
Most people signing up for Medicare won’t have the option to choose between supplement Plans F versus G because of MACRA. No matter what your plan choices are, you’d be wise to consider your total annual out-of-pocket costs for deductibles, copays and premiums. Compare those side by side for any plan you’re considering. There are online tools on websites, such as eHealth, to help give you a side-by-side comparison.
To compare costs, make sure you're looking at the deductible and the monthly premium. For instance, if you qualify for both Plans F and G, Plan F may seem advantageous at first because you don’t have to pay the $226 deductible for Part B. However, a typical monthly premium with Plan F is $234 a month for a 65-year-old female who does not use tobacco, says Jennifer Byrd, an insurance broker specializing in Medicare who’s based in Lakewood Ranch, Florida. Although premiums will vary by your location and other factors, a premium for that same person would be roughly $192 under Plan G.