Important Note: The information provided herein is for general informational purposes and does not constitute legal advice or counsel. The information provided herein is not comprehensive and is also subject to change.
  • Eligibility for Medicare

    Medicare is a federal government health insurance program designed for retired adults. Individuals aged 65 or older are eligible for Medicare coverage. Those under 65 who have received Social Security or Railroad Retirement Board disability benefits for 24 months are also eligible for Medicare.

    The Medicare.gov website offers a tool to determine eligibility for Medicare.

  • Enrollment Process

    Recipients of Social Security or Railroad Retirement Board benefits typically receive Medicare Part A and Part B automatically. During this time, they can opt for Medicare Advantage (Part C) and/or Part D plans. If someone is 65 but not yet receiving Social Security or Railroad Retirement Benefits, they must contact Social Security or the Railroad Retirement Board to enroll.

    People who delay Part B enrollment upon eligibility may face higher premiums due to late enrollment penalties, especially if they weren’t covered under a group employer plan initially. Those who qualify can avoid this penalty by applying for the Medicare Savings Program.

  • Medicare Part A – Hospital Insurance

    Medicare Part A provides coverage for hospital care costs, skilled nursing facility care, hospice care, and home health care. Most individuals don’t pay a Part A Premium if they or their spouse paid Medicare taxes during their working years. Those not eligible for free Part A coverage may have the option to purchase it.

    Coverage Gaps in Part A
    Medicare doesn’t cover all expenses. Key coverage gaps in Part A include:

    Inpatient Hospital Stay

    $1,408 deductible per benefit period.
    Days 1–60: Fully covered.
    Days 61–90: $352 coinsurance per day of each benefit period.
    Days 91 and beyond: $704 coinsurance per each “lifetime reserve day” after day 90 for each benefit period (up to 60 days over a lifetime).
    Beyond lifetime reserve days: All costs. source

    Skilled Nursing Facility Stay

    Days 1–20: Fully covered.
    Days 21–100: $176 coinsurance per day of each benefit period.
    Days 101 and beyond: All costs. source

    Medigap Policies
    Many opt for supplemental policies called Medigap to bridge the coverage gaps in Medicare. These policies vary in coverage and extent. Thoroughly review a policy’s details before purchase. Medicare.gov provides a tool to find a Medigap plan in your area.

    Part A Enrollment
    Recipients of Social Security or Railroad Retirement Board benefits typically receive Medicare Part A and Part B automatically. Those aged 65 who aren’t receiving Social Security or Railroad Retirement Benefits must contact the respective agency to enroll.

  • Medicare Part B – Medical Services

    Medicare Part B covers medical services like doctor visits, outpatient hospital care, and lab tests. The standard monthly premium for Part B is $144.60 (higher for some based on income). Some may qualify for Medicaid’s Medicare Savings Program to cover Part B premiums.

    Coverage Gaps in Part B
    Medicare doesn’t cover all expenses. Notable gaps in Part B include:

    Annual deductible: $198
    Patient pays 20% of the Medicare-approved amount for most doctor services (both outpatient and inpatient), outpatient therapy, and durable medical equipment. source
    Medigap Policies
    Many opt for supplemental policies called Medigap to bridge the coverage gaps in Medicare. These policies vary in coverage and extent. Thoroughly review a policy’s details before purchase. Medicare.gov provides a tool to find a Medigap plan in your area.

    Part B Enrollment
    Recipients of Social Security or Railroad Retirement Board benefits typically receive Medicare Part A and Part B automatically. Those aged 65 who aren’t receiving Social Security or Railroad Retirement Benefits must contact the respective agency to enroll. People delaying Part B enrollment when eligible may face higher premiums due to late enrollment penalties, particularly if they weren’t under a group employer plan at initial eligibility. Those who qualify can avoid this penalty by applying for the Medicare Savings Program.

  • Medicare Part C – Managed Medicare

    Medicare Part C plans, known as Medicare Advantage plans or “Managed Medicare,” function like traditional HMOs or PPOs. These plans involve Medicare paying a fixed monthly sum to a private third-party company providing the plan. The company then offers enrollees care within defined rules.

    Part C plans must adhere to Medicare rules, yet they may vary in out-of-pocket costs, such as deductibles and co-pays, and accessing services. Some plans include Medicare prescription drug coverage (Part D) for an added premium.

    Enrollment in Part C
    Upon enrolling in Medicare, individuals can choose Medicare Advantage (Part C) and/or Part D plans. Every year, changes can be made during “Open Enrollment” between October 15 and December 7. Between January 1 and March 31, one can switch from a Medicare Advantage plan to another or to Original Medicare. Changing Part D plans is also possible within this period.

  • Medicare Part D – Prescription Drug Coverage

    Medicare Part D provides prescription drug coverage through private third-party companies. While regulated by the Centers for Medicare and Medicaid Services (CMS), each plan features distinct lists of covered drugs and pharmacies. Medicare.gov offers a tool to assess plans based on prescription drugs.

    Part D enrollees pay monthly premiums, deductibles, co-payments, and co-insurance as required by their plan. Low-income individuals may qualify for assistance covering these costs. Part D is optional, though late enrollment may lead to penalties.

    Part D Coverage Gap – The Donut Hole
    Most Part D plans have a significant coverage gap or “donut hole” where regular coverage doesn’t apply. Individuals are responsible for a portion of costs. The gap begins at $4,020 in drug costs and ends at $6,350 in total out-of-pocket costs. Beyond this, catastrophic coverage takes effect, reducing costs for the remainder of the year.

    People in the coverage gap pay 25% of drug costs. Even though 25% of “brand-name” drug costs are paid, the full price – including manufacturer discounts – contributes to out-of-pocket spending.

    EPIC and Extra Help – Assistance for Low Income Enrollees
    Low-income New Yorkers might qualify for prescription drug coverage through EPIC or “Extra Help” for Medicare Part D. These programs cover gaps left by regular Part D plans and reduce or eliminate deductibles and co-pays. Full Extra Help recipients have no Part D monthly premium if they choose a qualifying plan.

    Enrollment in Part D
    Upon enrolling in Medicare, individuals can choose Medicare Advantage (Part C) and/or Part D plans. Every year, changes can be made during “Open Enrollment” between October 15 and December 7. Between January 1 and March 31, one can switch from a Medicare Advantage plan to another or to Original Medicare. Changing Part D plans is also possible within this period.

  • Coverage of Home Care by Medicare

    Traditional Medicare Parts A and B do not cover purely “custodial” or “personal” home care, which assists with daily activities rather than addressing medical needs. Long-term home care generally falls under this category. Some Medicare Advantage plans may provide limited coverage for such care.

    Traditional Medicare covers home care for “medical” or “skilled needs”. During periods of “skilled care,” Medicare may cover some “custodial” or “personal” home care in a supportive role.

    Medicare home care services are typically limited in scope and duration. They can aid individuals transitioning home after hospitalization or rehab stays. Additionally, they can provide temporary relief for those awaiting Medicaid approval or paying privately for home care.

  • Exclusions from Medicare Coverage

    Apart from deductibles, coinsurance, and copayments, certain services are not covered by Medicare. Common services not covered by Medicare Parts A & B (some may be covered by Medicare Advantage plans) include:

    • Long-term care – “custodial” or “personal” care, assisting with activities of daily living (ADLs) rather than addressing medical needs. Examples are long-term nursing home care, assisted living, and long-term home care. Medicare provides limited coverage for “medical care” in a skilled nursing facility and some “medical need” home care.
    • Most dental care (including dentures)
    • Eye examinations for prescribing glasses
    • Hearing aids
    • Acupuncture

    The Medicare.gov website offers a tool to check if a test, item, or service is covered.

  • Making Changes to Your Medicare – Open Enrollment

    Changes to Medicare can be made annually during “Open Enrollment” from October 15 to December 7. From January 1 to March 31, individuals can switch from one Medicare Advantage plan to another or return to Original Medicare. Part D (prescription drug) plan enrollment is also possible until March 31. Those with a separate Part D plan alongside a Medicare Advantage plan can’t change the Part D plan.