FAQ - NC Medicare Plans


What is Medicare?

Medicare is a federal health insurance program for people 65 years of age or older and certain people with a disability or end-stage renal disease (permanent kidney failure). It pays for much of your health care, but not all of it. There are some costs that you will have to pay yourself. These are called out-of-pocket costs. Costs that you must pay, like coinsurance, co-payments, and deductibles, are called “gaps” in original Medicare plan coverage.

Who can get Medicare?

Hospital insurance (Part A)

Most people age 65 or older who are citizens or permanent residents of the United States are eligible for free Medicare hospital insurance (Part A). You are eligible at age 65 if:

  • You receive or are eligible to receive Social Security benefits; or
  • You receive or are eligible to receive railroad retirement benefits; or
  • You or your spouse (living or deceased, including divorced spouses) worked long enough in a government job where Medicare taxes were paid; or
  • You are the dependent parent of someone who worked long enough in a government job where Medicare taxes were paid.

If you do not meet these requirements, you may be able to get Medicare hospital insurance by paying a monthly premium. Usually, you can sign up for this hospital insurance only during designated enrollment periods.

NOTE: Even though the full retirement age is no longer 65, you should sign up for Medicare three months before your 65th birthday.

Before age 65, you are eligible for free Medicare hospital insurance if:

  • You have been entitled to Social Security disability benefits for 24 months; or
  • You receive a disability pension from the railroad retirement board and meet certain conditions; or
  • You have Lou Gehrig’s disease (amyotrophic lateral sclerosis); or
  • You worked long enough in a government job where Medicare taxes were paid and you meet the requirements of the Social Security disability program; or
  • You are the child or widow(er) age 50 or older, including a divorced widow(er) of someone who has worked long enough in a government job where Medicare taxes were paid and you meet the requirements of the Social Security disability program.
  • You have permanent kidney failure and you receive maintenance dialysis or a kidney transplant and:
    • You are eligible for or receive monthly benefits under Social Security or the railroad retirement system; or
    • You have worked long enough in a Medicare-covered government job; or
    • You are the child or spouse (including a divorced spouse) of a worker (living or deceased) who has worked long enough under Social Security or in a Medicare-covered government job.

Medical insurance (Part B)

Anyone who is eligible for free Medicare hospital insurance (Part A) can enroll in Medicare medical insurance (Part B) by paying a monthly premium.

If you are not eligible for free hospital insurance, you can buy medical insurance, without having to buy hospital insurance, if you are age 65 or older and you are—

  • A U.S. citizen; or
  • A lawfully admitted noncitizen that has lived in the U.S. for at least five years.

Medicare Advantage plans (Part C)

If you have Medicare Parts A and B, you can join a Medicare Advantage (formerly Medicare + Choice) plan. With one of these plans, you do not need a Medigap policy, because Medicare Advantage plans generally cover many of the same benefits that a Medigap policy would cover, such as extra days in the hospital after you have used the number of days that Medicare covers.

Medicare Advantage plans include:

  • Medicare managed care plans;
  • Medicare health maintenance organization (HMO) plans;
  • Medicare preferred provider organization (PPO) plans;
  • Medicare private fee-for-service plans; and
  • Medicare specialty plans.

If you decide to join a Medicare Advantage plan, you use the health card that you get from your Medicare Advantage plan insurer for your health care. Also, you may have to pay a monthly premium for your Medicare Advantage plan because of the extra benefits it offers.  However, there are typically some Medicare Advantage plans that have no monthly premiums.

People who become newly entitled to Medicare can enroll during their initial enrollment period or during the annual coordinated election period from October 15 – December 7 each year. There also will be special enrollment periods for some situations.

Medicare prescription drug plans (Part D)

Anyone who has Medicare hospital insurance (Part A), medical insurance (Part B) or a Medicare Advantage plan is eligible for prescription drug coverage (Part D). Joining a Medicare prescription drug plan is voluntary, and you pay an additional monthly premium for the coverage. You can wait to enroll in a Medicare Part D plan if you have other prescription drug coverage but, if you don’t have prescription coverage that is, on average, at least as good as Medicare prescription drug coverage, you will pay a penalty if you wait to join later. You will have to pay this penalty for as long as you have Medicare prescription drug coverage.

The initial open enrollment period is three months prior, the month of and 3 months after your benefits to Medicare begins. People who become newly entitled to Medicare should enroll during their initial enrollment period. After the initial enrollment periods, the annual coordinated election period, to enroll or make provider changes will be October 15 – December 7 each year. There also will be special enrollment periods for some situations.

Help for some low-income people

If you cannot afford to pay your Medicare premiums and other medical costs, you may be able to get help from your state. States offer programs for people who are entitled to Medicare and have low income. The programs may pay some or all of Medicare’s premiums and also may pay Medicare deductibles and coinsurance. Our licensed experts can explain this in detail, and make it very easy to understand, please call us and we will help you navigate through Medicare.

What are Part A and Part B of Medicare and what does it cover?

Part A is Hospital insurance- This helps pay for inpatient hospital care, some skilled nursing facility care, hospice care, and some home health care. Part B is Medical insurance- This helps pay for doctors’ services, outpatient hospital care, and some other medical services that Part A doesn’t cover. Part B also helps pay for such covered services and supplies when they are medically necessary. Our licensed experts can explain this in detail, and make it very easy to understand, please call us and we will help you navigate through Medicare.

How do I enroll in Medicare?

You’ll be automatically enrolled in Medicare when you turn 65 if you’re already receiving Social Security benefits, or when you apply for Social Security benefits at age 65. In either case, the Social Security Administration will notify you that you’re being enrolled. Although there’s no cost to enroll in Medicare Part A (Hospital Insurance), you’ll pay a premium to enroll in Medicare Part B (Medical Insurance). If you’ve been automatically enrolled in Part B, you’ll be notified that you have a certain amount of time after your enrollment date to decline coverage. Even if you decide not to enroll in Medicare Part B during the initial enrollment period, you can enroll later during the annual general enrollment period that runs from January 1 to March 31 each year. However, you may pay a slightly higher premium as a result. If you decide to postpone applying for Social Security past your 65th birthday, you can still enroll in Medicare when you turn 65. The Social Security Administration suggests that you call (800) 772-1213 three months before you turn 65 to discuss your options. You can apply by visiting your local Social Security office. If you are unable to visit your local office, you may be able to enroll over the phone

Do I have to be enrolled in Medicare Part A and B to get supplemental insurance?

Yes, you must be enrolled in both Medicare Part A and B to be enrolled in either a Medicare supplement plan or a Medicare Advantage plan.

What is Medicare Advantage (Part C)?

Medicare Advantage, also known as Medicare Part C, is a combination health insurance policy that includes all of the Part A and Part B coverage together. Medicare Advantage plans are administered by private insurance companies and can include coverage for vision care and dental care, along with doctor visits. Medicare enrollment for Medicare Advantage plans is not automatic. You will need to enroll through a private insurance company during the Medicare enrollment period.

Each Medicare Advantage provider has different plans and options and this also functions as a privatized version of the individuals’ Medicare coverage. The Medicare Advantage provider will manage all the programs and the policyholder will have only a single card to carry. Several different types of Medicare Advantage plans are available to choose from such as HMOs (Health Maintenance Organization), PPOs (Preferred Provider Organization) and other types as well. Our licensed experts can explain this in detail, and make it very easy to understand, please call us and we will help you navigate through Medicare.

What is Medicare Part D or the Drug Card?

Starting January 1, 2006, new Medicare Part D drug coverage was available to all Medicare recipients. All Medicare recipients can get this coverage that can help lower drug costs and help protect against higher costs in the future. Medicare Part D drug coverage is a Medicare program run through private insurance companies. You choose the drug plan and pay a monthly premium. Like Medicare part B insurance, if you decide not to enroll in a drug plan when you are first eligible, you will pay a penalty if you choose to join later. If you delay taking and don’t take Medicare part D when you are initially eligible your premium cost will go up at least 1% per month for every month that you wait to join. You will have to pay this penalty as long as you have Medicare drug coverage. If you join by December 31 in any year your coverage will begin January 1 of the next year. There are two ways to get Medicare prescription drug coverage: 1. Join a Medicare Prescription Drug Plan. These plans, often known as “Part D Plans” or “PDPs” add prescription coverage to Medicare Part A and Medicare Part B and Medicare Advantage Plans without Prescription Coverage. They are sponsored by private insurance companies who contract with and are paid by Medicare. Most plans charge an additional premium to Medicare Recipients enrolled in the plan. 2. Join a Medicare Advantage Plan (like an HMO or PPO) or another Medicare health plan that includes prescription drug coverage. These plans replace Medicare Part A and Medicare Part B and are sponsored by private health insurance companies. They also contain prescription drug coverage. Our licensed experts can explain this in detail, and make it very easy to understand, please call us and we will help you navigate through Medicare.

What is a Medicare Supplement verses a Medigap plan?

A Medicare supplement insurance plan or “Medigap” policy is a health insurance policy sold by private insurance companies. They mean the same thing, they are just different terms used. These Medicare supplement plans must follow federal and state laws. These laws protect you. The front of the Medicare supplement insurance plan material must clearly identify it as a “Medicare supplement insurance” plan. You might want to consider buying a Medicare Supplement plan to cover the above described gaps in Original Medicare coverage. Some Medicare supplemental plans also cover benefits that the Original Medicare Plan doesn’t cover, like emergency health care while traveling outside the United States, At Home Recovery Services, and Preventive services that might not otherwise be covered by Medicare. A Medicare Supplement insurance plan may help you save on out of pocket costs. If you buy a Medicare supplemental insurance plan, you will pay a monthly premium to the private Medicare supplement insurance company that sells you the policy. Medicare supplement plans do not have an open enrollment period. This allows you to switch another Medicare supplement plan at any point throughout the year as long as you qualify medically.

Why do I need a Medicare supplement or ``Medigap`` policy?

You may need to supplement Medicare Coverage for one or more of the following reasons:

  • Medicare was never designed to pay all the health care costs of Medicare beneficiaries.
  • Medicare coverage has many gaps, a Medicare supplement policy will help cover these gaps.
  • Medicare deductibles may increase on an annual basis.

How do I enroll into a Medicare supplement policy?

All companies have an application process that each individual client needs to fill out. If you are in your guaranteed issue period then you do not need to answer the health medical questions. After you fill out the application and send it back to us for review, we will sign the application and get it to the carrier for processing. It takes 3-4 weeks to process applications and once processed we will let you know of the status. Each carrier will then send you out a copy of the policy in the mail for you to keep. Our licensed experts can explain this in detail, and make it very easy to understand, please call us and we will help you navigate through Medicare.

When is Medicare’s Initial Enrollment Period?

The Initial Enrollment Period begins 3 months before the month a beneficiary turns 65 and ends 3 months after the month the beneficiary turns 65. If beneficiaries wait until they are 65 or sign up during the last 3 months of the Initial Enrollment Period, their Medicare Part B start date will be delayed.

What are “open enrollment” and “guaranteed issue” in Medicare?

Open enrollment: allows the applicant to be guaranteed a Medicare supplement insurance plan regardless of their current or past health history. Otherwise, the applicant must meet medical underwriting standards to qualify if required by the insurance company.

Guaranteed issue rights: (also called “Medigap protections”) are rights you have in certain situations when insurance companies are required by law to offer you certain Medigap policies even if you have health problems and must cover any pre-existing conditions. In these situations, an insurance company must do the following:

  • Sell you a Medigap policy
  • Cover all your pre-existing health conditions
  • Can’t charge you more for a Medigap policy because of past or present health problems

When is Medicare supplement’s “open enrollment” period?

The 6-month period that begins the first day of the month in which a beneficiary is both age 65 or older and enrolled in Medicare Part B. During this period, an insurance company can’t do any of the following: Refuse to sell you any Medigap policy it sells, Make you wait for coverage to start, or Charge you more for a Medigap policy because of your health problems.

What if I missed my open enrollment period?

There is no open enrollment period if you are over age 65 and have been enrolled in Medicare Part B more than 6 months. You may apply for a Medicare supplement policy, but you will be subject to medical underwriting and a pre-existing condition waiting period or exclusion. If you fail to meet the Medicare supplement policy health standards, the company does not have to insure you. This same situation may arise if you drop your current Medicare supplement policy. There is no guarantee that you can get another policy except in very limited situations (see below). Also if you are under age 65 and receive Medicare because you are disabled, you are not eligible for open enrollment and must meet a company’s medical standards to purchase a Medicare supplement policy.

What are the different situations that one can be in to get “guaranteed issued” for Medicare supplement?

Losing Medicare Advantage coverage-If you’re currently in a Medicare Advantage (Medicare Part C) plan, you can still qualify for Medigap if (1) your insurance Insurer decides to stop offering Medicare policies, or (2) your plan stops providing care or services in your area, or (3) you are moving out of your Medicare Advantage plan’s coverage area. However, you can only get Medigap in such situations IF you transfer to an “original” Medicare plan (Parts A and B) — not into a new Medicare Advantage program.

Losing other supplement program-Many seniors are currently in a Medicare Parts A and B plan, but receive additional coverage from a union health plan or employer-provided group health plan. Those plans act much like Medigap and pay many of the expenses that are not covered by Medicare. If those other plans should end, you can obtain a Medigap policy even outside the mandated Medigap open enrollment period.

Losing Medicare Select-A Medicare Select policy is a type of Medigap option that can offer lower Medigap premiums and fees — as long as you use the plan’s network of hospitals and physicians. If you move out of your Medicare Select plan’s coverage area, you can replace Medicare Select with a standard Medigap plan offered in your state.

End of trial period-Medicare offers seniors the right to certain “trial’ periods of Medicare Advantage (Part C) plans, which are offered by private health insurance providers. For example, if a 65-year-old senior citizen opts for a Medicare Advantage plan instead of an Original Medicare Part A and B program, the first year may be considered a trial period. They can switch to an Original Medicare (Parts A and B) plan any time that first year—and obtain a Medigap plan as well. Similarly, if you drop your Medigap plan to join a Medicare Advantage program (for the very first time), you have one year to switch back to the original Medicare (Parts A and B) program—with Medigap.

Failure of Medigap Insurer-If your Medigap Insurer goes bankrupt or hasn’t followed the rules (or misled you), you may switch to a different Medigap plan offered in your state.

What is 'Medicare assignment' in the Original Medicare Plan and why is it important?

“Medicare assignment” is an agreement between Medicare and doctors, other health care providers, and suppliers of health care equipment and supplies (like wheelchairs, oxygen, and braces). Doctors and suppliers who agree to accept assignment accept the Medicare-approved amount as payment in full for Part B services and supplies. You pay the coinsurance and deductible amounts. In some cases (such as if you have both Medicare and Medicaid), your health care providers and suppliers must accept assignment. If assignment is not accepted, charges are often higher. This means you may pay more. In addition, you may have to pay the entire charge at the time of service. Medicare will then send you its share of the charge. There is a limit on the amount your doctors and providers can bill you. The highest amount of money you can be charged for a covered service by doctors and other health care providers who don’t accept assignment is called the limiting charge. The limit is 15% over Medicare’s approved amount. The limiting charge only applies to certain services and does not apply to supplies or equipment.

Where can I find a list of all physicians that participate in Medicare?

A list of participating physicians in your area can be found in the Participating Physician Directory section in the www.medicare.gov website. Or, your local Medicare Insurance Carrier can assist you with this question. You can find their phone number in the Helpful Contacts section of www.medicare.gov.

Do I have to wait to switch to a different Medicare supplement policy?

No, but the length of time you’ve had your Medicare supplemental plan will affect how your new Medicare Supplement policy covers you for pre-existing conditions. If you’ve had a Medicare Supplement insurance plan for at least six months and you decide to switch, your new Medicare supplemental insurance plan must cover you for all pre-existing conditions. If you’ve had a Medicare supplemental insurance plan for less than six months, the new Medicare supplement policy must give you credit for the time the older policy covered you.

What happens to my Medicare supplement policy if I move?

Because your Medicare supplemental insurance plan is guaranteed renewable, you will still have insurance coverage if you move. If you move to a new state, however, the Medicare supplement insurer may quote you a different premium. If you have a Medicare Select insurance plan, which contain network restrictions, you must change your Medicare insurance coverage. But you have the right to buy Medicare supplemental insurance plans A, B, C, F, K, or L in the state you move to without having to medically qualify.

Can a Medicare supplement policy be cancelled?

No. All Medicare supplement policies are guaranteed renewable, no matter how many claims you file, but a company can cancel if you do not pay premiums or give false information of a material fact on your application. If you want to switch policies, don’t cancel your first Medicare supplement policy until the second one is in place and you have reviewed it and decided to keep it. You have 30 days to return the policy and receive a full refund.