Medicare is a federal health insurance program administered by the Centers for Medicare & Medicaid Services. There are some minor differences from state to state, but the vast majority of Medicare is the same everywhere in the United States, so the coverage New Jersey residents receive will be much like Medicare coverage throughout the nation.
Two groups of people are eligible for Medicare:
Medicare has four parts. At a high level, these parts provide the following coverage:
Part A and Part B are also referred to as Original Medicare. Part C is commonly called Medicare Advantage. It should be noted that dental, hearing, and vision are usually not covered by Original Medicare, and most times you'll need to get coverage by purchasing an additional policy.
Medicare coverage extends to all 50 states, Washington, D.C., the Northern Mariana Islands, American Samoa, Guam, or the U.S. Virgin Islands.
Medicare coverage pays for a variety of tests and services, and sometimes depend on where you live. However, other items and services are covered no matter where you live.
To see a complete list of tests, items, and services covered by Medicare no matter where you live, go here.
Let’s take a closer look at each part of Medicare.
Coverage
Part A is also known as Medicare hospital insurance, and coverage typically includes inpatient hospital care, skilled nursing facility care, hospice, and certain types of eligible home health care. Medically necessary services and equipment (e.g., nursing services, a semi-private room, prescription drugs, etc.) are also generally covered if part of a beneficiary's inpatient treatment.
Coverage also includes hospice care if a beneficiary is diagnosed as terminally ill and has six months or less to live. Doctor/nursing services, hospice aide services, physical/occupational therapy, prescription drugs, and respite care for caregivers are included.
Part A does not cover long-term nursing home or care facility benefits. Coverage only includes facilities where help with personal care such as eating and bathing is not the only assistance a beneficiary receives.
Eligibility
You are automatically enrolled in free Part A coverage at age 65 if you paid Medicare taxes while working for at least 10 years (40 quarters). If your spouse qualifies for Part A benefits without a premium, then you may be eligible for premium-free benefits as well.
You can also qualify for free benefits if you or your spouse receive or you're eligible to receive Social Security benefits or Railroad Retirement benefits. This benefit is available even if the spouse is deceased or divorced from the person seeking coverage.
If you don't meet work requirements, you can still sign up for Part A, but you will need to pay a monthly premium.
If you're under age 65, you can qualify for Medicare Part A benefits if:
Enrollment
If you already get Social Security or Railroad Retirement Board benefits, then most of the time you'll automatically get Part A and Part B coverage starting the first day of the month you turn 65 years old.
If you're under 65 and disabled, you'll automatically get Part A and Part B after receiving disability benefits from Social Security or the Railroad Retirement Board for 24 months.
In both cases, you'll get a "Welcome to Medicare" package with your Medicare card and complete information about how Medicare works.
If you don't meet these requirements, you can sign up for Medicare during your Initial Enrollment Period (IEP). Your IEP is the 7-month period that begins three months before you turn 65 and ends three months after the month you turn 65.
After your IEP ends, you can sign up for Part A and Part B during a Special Enrollment Period, if you qualify. You can also sign up during the Medicare General Enrollment Period (January 1 through March 31 annually), but you may face higher premiums and delayed coverage if you choose this option.
Costs
If you qualify, Part A coverage is free, other than some deductibles for hospital stays.
If you don't qualify for free Part A coverage, you can still enroll and pay a premium under the following requirements:
Premium costs will vary depending on how long you have worked and how close you are to meeting the minimum of 40 Social Security credits.
In most cases, if you enroll and pay for Medicare Part A, you must also enroll and pay a separate premium for Medicare Part B.
Coverage
Part B covers doctor's services, outpatient care, labs and clinics, and preventative services. This bundle of services is often collectively referred to as outpatient care.
Part B also covers ambulance services to the nearest appropriate medical facility, but Medicare only helps pay for ambulance services when using other transportation could put your health at risk. Medicare may also cover emergency air transportation when serious health dangers are present, and you can't be safely transported by ground.
Durable medical supplies for use in your home are also covered under Part B. Some examples of these types of supplies include wheelchairs, hospital beds, walkers, oxygen equipment, CPAP devices, infusion pumps, commode chairs, and so forth.
Part B also covers outpatient mental health services, including visits to psychiatrists, clinical psychologists, clinical social workers, clinical nurse specialists, nurse practitioners, and physician's assistants. Treatment for alcohol and drug abuse is also covered, as well as depression screenings, psychiatric evaluations, psychotherapy, medication management, and other similar services.
Eligibility
If you’re eligible to enroll in Part A at no cost, you are eligible to enroll in Part B by paying a monthly premium.
Suppose you don't qualify for Part A at no cost. In that case, you can qualify for Part B if you're 65 years or older and a U.S. citizen or legal permanent resident who has lived in the United States continuously for five years immediately preceding the month you apply for Part B.
Enrollment
Part B enrollment typically takes place during an IEP when a person also signs up for Part A. You're automatically enrolled in Medicare Part B if you already receive Social Security benefits or the Railroad Retirement Board.
But if you don't enroll in Part B at that time, you can enroll during a General Enrollment Period between January 1 and March 31 each year. One drawback if you sign up during this period is that your Part B coverage will not begin until July 1, and you may have a coverage gap.
Also, if you don't sign up for Part B when you're first eligible, then you could end up paying more for coverage as well as a late enrollment penalty.
Medicare beneficiaries also can review their existing coverage for all Parts and make changes during an Annual Open Enrollment Period from October 15 through December 7.
Costs
You will have to pay a monthly premium for Part B coverage. Premiums are often taken directly out of Social Security or Railroad Retirement benefit checks, so most people don't need to worry about paying a monthly bill.
If your adjusted gross income is above a certain threshold, you may be required to pay a larger premium.
If you initially decide not to enroll in Part B coverage, then the monthly premium will increase by 10% for each 12-month period you're eligible when you finally do enroll. That penalty is permanent, and you’ll pay it for as long as you have Part B coverage.
Also, after you meet your Part B deductible, you'll pay 20% for all approved Medicare services as your cost-sharing portion.
Coverage
Part C is interchangeable with the term Medicare Advantage plans. These policies are optional plans sold by Medicare-approved private insurance companies.
Part C plans offer added benefits above what Part A and Part B offer. This might include vision, dental, or hearing coverage. Most Part C plans also provide prescription drugs services as well.
By law, Medicare Advantage plans must provide at least the same level of coverage as Original Medicare but can do so with differing costs and restrictions. There are several types of coverage offered by HMOs, PPOs, PFFSs, and Special Needs Plans.
Eligibility
If you have Medicare Part A and Part B coverage, you can enroll in a Part C plan. The only qualification is that you must make sure you live in an area where you're eligible to enroll in Part C. Also, even after enrolling in a Part C plan, you must keep paying your Part B premium.
In most cases, people with end-stage renal disease (ESRD) can't join a Medicare Advantage Plan, although there are a few narrow exceptions.
Enrollment
You can enroll in a Part C plan during your Initial Enrollment Period.
You can only enroll in Medicare Advantage plans or make changes to your existing coverage at certain times of the year. Those periods include:
If you no longer want Part C coverage, you can opt out during the Medicare Advantage Disenrollment Period between January 1 and February 14 each year. You can only switch to Medicare Part A and Part B if you opt out, but not a new Medicare Advantage Plan.
Costs
While plan providers agree to follow Medicare's rules regarding care and coverage, they can provide those services differently and use different fee structures for expenses.
Part C costs vary depending on what services are covered and the plan's level of copayments and coinsurance. For example, some beneficiaries may pay more per month for a smaller deductible for services or cheaper copayments for doctor visits.
When shopping for a plan, pay close attention to what is covered, what the costs are, how well the company is reviewed, and if they have a good track record of customer service.
As part of their agreement with Medicare, providers can only change plan costs once a year, beginning on January 1.
It's also worth noting that Medicare Advantage Plans have annual out-of-pocket maximums, but Original Medicare does not. After a Part C maximum amount is reached, there are no charges for covered services.
Coverage
Part D provides enhanced drug coverage to go with the coverage provided with Medicare Part A and Part B. Part D plans are available through private insurance companies that Medicare has approved. Typically, Part D plans offer higher degrees of coverage and a lower limit on out-of-pocket expenses.
Any person eligible for Part A or Part B can purchase a Part D plan, regardless of income or health status.
Eligibility
If you have Medicare Part A and Part B coverage, then you're eligible for Part D.
The other requirement is to live in the service area of the Part D plan you want to enroll in.
Enrollment
You can enroll in Part D through a Medicare-approved private insurance company during your IEP, the Annual Election Period from October 15 to December 7, and immediately following the General Enrollment Period between April 1 to June 30.
You can also enroll at any time you qualify for the Extra Help program.
Costs
Part D costs vary from plan to plan because different providers offer various types of coverage.
With a Part D plan, you'll pay a monthly premium and a yearly deductible. In addition, you'll also have to pay some copayments or coinsurance after meeting your yearly deductible. You may also have some small costs if you're enrolled in Extra Help, but often your costs are zero.
The other thing to know is that if you enroll in Part D late, you'll pay an enrollment penalty.
The good news is that if a person enrolls in a Medicare Advantage Plan, drug coverage is usually included as part of the policy.
You will have a cap on your yearly out-of-pocket expenses, and once you reach this amount, catastrophic coverage kicks in, and you'll pay only a small copayment or coinsurance for the balance of the year.
Because there are so many cost variables for Part D plans, it's essential to shop around for an affordable plan that best meets your needs.
Most people get Medicare Part A for free by working and paying taxes over an extended period.
You earn Social Security Credits by paying Social Security and Medicare payroll taxes while working. You earn one credit for each quarter year you work, and for free Part A Medicare, you must earn 40 credits (10 years of work) to qualify.
You must meet income minimums for each quarter as well. In 2021, that amount is $1,470 per quarter. This amount can change annually, so you may want to verify the minimum if this has the potential to impact you.
You can only earn a maximum of four credits per year, and if you accrue more than 40 credits over your working life, these do not provide you with any added benefits.
You may also qualify for Medicare if you have been a government employee who has paid Medicare payroll taxes while working.
For various reasons, perhaps you didn't enroll in Medicare during your Initial Enrollment Period (IEP). How and when you enroll in Medicare is an important part of the coverage you receive, so you need to be aware that Medicare has several other enrollment opportunities throughout the year for those who meet qualifying conditions.
Your IEP is seven months beginning three months before the month you turn 65 and ending three months after your 65th birthday. You can sign up for coverage during your IEP even if you don't plan on retiring when you turn 65. If you're already getting Social Security or Railroad Retirement benefits, you'll be contacted three months before you turn 65.
You can also apply for Medicare before age 65 if you meet one or more of the following conditions:
Annual Enrollment Period (AEP). This begins every year in mid-October and runs through the first week in December. If you missed your IEP, you could enroll during this special timeframe, but you may have to pay a penalty in some cases if you didn't enroll during your IEP. Any changes to coverage go into effect on January 1 of the following year.
General Annual Open Enrollment Period. People who did not sign up for Part B at the required time can use January 1 to March 31 each year to sign up. If you choose this option, your Part B coverage will start on July 1, and you may have to pay a penalty for late enrollment.
Part B Special Enrollment Period (SEP). You can enroll in Part B without penalty after 65 if you can show you or your spouse had group health coverage from an employer after turning 65. This SEP runs eight months from the time you or your spouse stopped working.
Part D Special Enrollment Period. You can delay enrolling in Part D drug coverage beyond age 65 if you have creditable drug coverage from another provider. Creditable is defined as having prescription drug coverage equal to or exceeding what you can get with Part D.
Annual Disenrollment Period. People enrolled in Medicare Advantage Plans and who want to change to Original Medicare or enroll in Part D coverage can do so between January 1 and February 14. New coverage begins the first day of the month after you make your changes.
Several other Special Enrollment Periods are available in specific circumstances related to Medicare Advantage and Part D plans. Check with Medicare to see if you qualify for one of these SEPs.
Two of the most extensive healthcare programs administered by the federal government are Medicaid and Medicare. Although they sound alike and are sometimes confused with each other, they are distinctly different.
Medicare is primarily for people who are 65 and older or who have qualifying conditions if they're under 65. Medicaid has no age restrictions, is based strictly on need, and provides benefits if a person falls below designated income and asset levels. Most Medicaid services are provided at no cost, with a few exceptions.
Per federal regulations, there are core benefits states are required to provide under Medicaid and optional benefits offered at the discretion of each state.
Medicaid core benefits are like those offered by Medicare. They include inpatient and outpatient hospital services, nursing and home health care services, labs and x-rays, pediatric and family nurse practitioner services, transportation to medical centers, and other related benefits.
Optional Medicaid benefits include prescriptions, physical and occupational therapy, respiratory care, dental and vision services, chiropractic services, private nursing, hospice, psychiatric care for people under 21, and mental health institutional care for people over 65.
In some instances, the answer is yes.
If you meet qualifying circumstances under both programs, you can get assistance from Medicare and Medicaid in New Jersey. People eligible to receive benefits are known as "dual eligible."
The term includes beneficiaries enrolled in Medicare Part A and/or Part B and getting full Medicaid benefits and/or assistance with Medicare premiums or cost-sharing through the Medicare Savings Program.
Medicare pays covered dual-eligible beneficiaries' services first because Medicaid is generally the payer of last resort. Also, Medicaid may cover medical costs Medicare may not cover or only partially covers.
In New Jersey, Medicaid is known as N.J. Family Care and is officially known as a State Health Insurance Assistance Program.
Dual eligible coverage varies by state, so it's best to check with your nearest New Jersey Medicaid office for more detailed coverage information.
Some Medicare beneficiaries in New Jersey may find out that Original Medicare does not cover some of their healthcare costs, including copayments, coinsurance, deductibles, and other similar out-of-pocket expenses.
If this is the case, you may want to consider a Medigap policy. These are also often referred to as Medicare Supplement policies.
Medigap policies are different from Medicare Advantage Part C plans. In fact, Medigap policy bridges the coverage gap to help pay for services not fully covered by Part A, Part B, or at all.
Medicare Part B covers 80% of costs after the Part B deductible is met. This means Medicare beneficiaries are responsible for the remaining 20%. Depending on the policy and coverage, beneficiaries with some Medigap plans would have the cost-sharing covered completely, creating a potentially significant benefit for a policyholder.
One important thing to note is that you can't purchase a Medigap policy if you have a Medicare Part C Plan.
Most states, including New Jersey, offer a variety of standardized Medigap plans to eligible beneficiaries. Each of these plans is designated by a specific letter (A, B, C, D, F, G, K, L, M, and N).
The plans are not standardized, and the monthly premium you'll pay for a Medigap policy depends on the types of benefits in the policy and what individual companies charge for coverage.
If you decide that a Medigap policy is a good option for you, you'll need to do some homework and work with a qualified and experienced agent.
Some companies may offer premium discounts for such things as multiple policies in the same household, automatic premium deductions, and so forth. Also, Medigap policies only cover one person. If you and your spouse both want Medigap coverage, you will have to buy separate policies.
The best time to sign up for a Medigap policy is during your Medigap Open Enrollment Period (OEP). Your OEP is the six-month period that begins the month you turn 65 or older and enrolled in Medicare Part B. During your OEP, you can enroll without the need to submit a medical background or history and without any fear of being denied coverage. However, once your OEP has expired, you can still enroll, but your rates may be higher, and you may be subject to medical underwriting or even denial of coverage based on pre-existing conditions.
If you miss your OEP, you can also buy a Medigap policy when you have a guaranteed issue right. If you’re 65 or older, you have a guaranteed issue right within 63 days of when you lose or end certain kinds of health coverage.
New Jersey has several programs to assist people who need help paying for their Medicare benefits.
The New Jersey Division of Aging Services administers N.J. Save to help low-income seniors and individuals with disabilities save money on Medicare premiums, prescription costs, and other living expenses.
N.J. Save enrolls eligible applicants into the following programs:
The program also screens individuals for other savings and assistance programs. If it looks like they may qualify, their data is forwarded on for enrollment. These programs include:
Individuals who qualify for PAAD and Lifeline Utility Assistance through N.J. Save may also be eligible for:
Medicare separately offers four types of Savings Programs for eligible individuals:
Qualified Medicare Beneficiary (QMB) Program. QMB pays for Part A and Part B premiums and cost-sharing expenses. You must be eligible or currently enrolled in Medicare Part A to qualify for this program.
Specified Low-Income Medicare Beneficiary (SLMB) Program. If you earn slightly more than the QMB program's maximum, you may qualify for this program instead, which helps with Medicare Part B premiums.
Qualifying Individual (Q.I.) Program. If you don't qualify for QMB or the SLMB program, you may consider applying for the Q.I. program. It helps with Part B premiums and automatically qualifies you for the Extra Help program.
Qualified Disabled and Working Individuals (QDWI) Program. This only pays for Medicare Part A premiums.
State Medicaid agencies run these programs, so program qualifications may differ from state to state, but all are based on assets and income.
When you're eligible for a Medicare Savings Program, you’re automatically qualified for participation in the Extra Help program as well.
Extra Help means Medicare pays for your Part D prescription drug plan premium and any yearly deductible, coinsurance, and copayments.
Some people with higher incomes get partial Extra Help, paying reduced premiums, deductibles, and copayments. Those who qualify for partial Extra Help pay no more than 15% of the costs of drugs on a plan's formulary (drug list) until reaching an out-of-pocket limit.
If you don't qualify for Extra Help, you may still be able to seek relief at the state level for drug prices. Many states provide State Pharmacy Assistance Programs (SPAP) to help low-income individuals with a disability or a medical condition pay for prescription drugs. Contact your state's Medicaid office or your State Health Insurance Assistance Program to learn more.
For more information on these programs, visit a local Medicaid office or go to Medicare's website.
To ensure that Medicare beneficiaries receive the best possible care, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) created the Quality Payment Program (QPP) to reward physicians based on the quality of care they provide to patients.
The program streamlined several other existing merit-based payment programs and refocused on providing value instead of paying clinicians based on the number of patients they treat. This fundamental shift rewards high-quality Medicare providers with payment increases while reducing payments to those clinicians who don’t meet performance standards. Reducing paperwork and focusing emphasis on delivering better health outcomes for Medicare patients has lowered program costs overall as well.
The QPP also has a built-in continuous improvement element, meaning it keeps evolving and remains flexible to best meet the needs of a rapidly changing healthcare environment. The result is that Medicare can better leverage the input and expertise of frontline staff to create a partnership that benefits patients, providers, and Medicare administration.
If you need help, contact your local New Jersey County Office on Aging. You can also call the state's Division of Aging and Community Services at 1-800-792-8820.
Medicare information is available online at the Medicare website.
If you're not sure if you're eligible or have general questions about Medicare, including possible premium costs, you can call Medicare's customer service at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week.
You can also call Social Security at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users can call 1-800-325-0778.
Another option is to use the Eligibility and Premium Calculator on the Medicare website to answer those types of questions.
Information is for educational purposes only and should not be construed as an offer of insurance, advice, or recommendation. The information provided is not intended as tax, financial, investment or legal advice. Please consult legal or tax professionals for specific information regarding your individual situation.
Not connected or endorsed by the US Govt or the Federal Medicare Program. Medi-Solutions Insurance Agency, LLC is an independent Life, Accident and Health Insurance Agency, NJ Ref#1642311. Some plans and features may not be available in all states.
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