As your trusted Medicare resource with Licensed Medicare experts, we know that understanding Medicare eligibility and the enrollment process can often overwhelming or confusing. Whether you’re approaching age of 65 or considering retirement, or navigating Medicare eligibility for yourself or a loved one, this guide will help clarify who qualifies for Medicare and how to navigate the enrollment process.

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Who Qualifies for Medicare?

The most common way to qualify for Medicare is by reaching the age of 65. If you or your spouse have worked and paid Medicare taxes for at least 10 years (40 quarters), you’re eligible for premium-free Medicare Part A (hospital insurance). Medicare Part B (medical insurance) is available for a monthly premium based on your adjusted gross income from your tax return income from 2 years prior.

If you’re under 65 but have been receiving Social Security Disability Insurance (SSDI) for at least 24 months, you automatically qualify for Medicare. You’ll receive Medicare Parts A and B, just like someone who qualifies based on age. Based on the health insurance you have access to currently you may or may not accept Part B at that time.

Individuals of any age with End-Stage Renal Disease (ESRD), requiring regular dialysis or a kidney transplant, qualify for Medicare. Coverage usually starts the first month of dialysis if you apply promptly.

If you have ALS, you automatically qualify for Medicare the first month you start receiving SSDI benefits, with no 24-month waiting period.

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How to Apply for Medicare

Already Receiving Social Security: If you’re already receiving Social Security benefits, you’ll be automatically enrolled in Medicare Parts A and B when you turn 65. Your Medicare card will arrive in the mail about three months before your 65th birthday. Based on your specific situation if you are working or covered through your spouse you may keep your company coverage or consider Medicare options at this time. If you choose to keep the company coverage you would need to reject your Part B so that the premium for Part B does NOT come out of your social security check. This decision is an important one and our suggestion is to consult with an experienced Medicare advisor to guide you properly to your best course of action at this stage.

If you’re not receiving Social Security benefits, you will need to be proactive in signing up for Medicare on your own when the time is right. You can do this through the Social Security Administration (SSA) website, by phone by scheduling an appointment, or in person at your local SSA office. Consult a medicare expert to ensure you avoid timing and/or penalty issues. 

The Initial Enrollment Period is a seven-month window that includes the three months before your 65th birthday, the month of your birthday, and the three months after. This is your first opportunity to sign up for Medicare Parts A and B. This ONLY applies to individuals who are self-employed, unemployed or working for a company of less than 20 employees. This is often a very often misunderstood aspect of Medicare.

If you’re still employed (for a company greater than 20 employees) and covered by an employer’s health plan, you can delay enrolling in Part B without penalty. Once your employment ends, you’ll have an eight-month Special Enrollment Period to sign up for Part B before you would incur a penalty. Each person’s situation is different based on the cost of Cobra for you and your family and the quality and details of coverage your company provides.

Missed Initial Enrollment: If you miss your Initial Enrollment Period and don’t qualify for a Special Enrollment Period, you can enroll in Medicare during the General Enrollment Period, which runs from January 1 to March 31 each year. However, a late enrollment penalty may apply.

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Understanding Medicare Parts A and B

Medicare Part A (Hospital Insurance): Covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care.

Medicare Part B (Medical Insurance): Covers doctor visits, outpatient care, preventive services, and medical supplies.

Understanding these components is crucial for selecting the right coverage and avoiding potential penalties. To learn more, click below to read our blog post on Medicare Parts A and B. 

Take Charge of Your Medicare Journey with Emerald Medicare

Navigating Medicare eligibility and enrollment can be overwhelming, but you don’t have to do it alone. Our team of Licensed Medicare experts is here to guide you through every step of the process, ensuring you make informed decisions about your healthcare coverage. Click below to schedule an appointment with one of our expert brokers through Calendly, or contact us via the provided phone number or email.

Contact Us:
Phone: (888) 683-6372 or (845) 358-1220
Email: office@emeraldmedicare.com

As your go-to team of Medicare experts, we’re committed to keeping you informed about the latest developments and trends that could impact your healthcare decisions. With 2025 on the horizon, there are key changes and trends affecting Medicare that you should be aware of. These shifts are likely to influence everything from your premiums to the cost of your care, to the benefits available under different Medicare plans. Let’s explore what you can expect from Medicare in 2025.

Rising Healthcare Costs and the Impact on Medicare

Healthcare costs to both consumers and insurance carriers continue to be a significant concern in the United States, especially for those aged 65 and older. In fact, 50% of all medical costs in the U.S. are related to prediabetic conditions, insulin care, or medications. Additionally, $1 in $5 of the Gross National Product (GNP) in America is spent on healthcare, highlighting the growing financial burden on the system and its users. With healthcare being the top concern for 63% of people aged 65 and above, making the right Medicare decisions is more crucial than ever (per seniorliving.org).

In 2025, we anticipate further adjustments to all Medicare plans to address these rising health care costs. For instance, the Inflation Reduction Act will impact Medicare Advantage benefits, cost-sharing, and Medigap premium prices, particularly affecting Part D premiums and co-pays. These changes are still being worked out and expected to be finalized by October 2024, so staying informed and connected with your Medicare broker will be essential for all Medicare beneficiaries.

Changes to Medicare Advantage (MA) Plans

As you may know, Medicare Advantage (MA) plans have come under scrutiny for deceptive marketing practices, leading to increased oversight from the Centers for Medicare & Medicaid Services (CMS). In 2025, CMS is expected to introduce new regulations aimed at improving service delivery, reducing marketing abuses, and cutting down on the number of unsolicited calls to consumers. These changes are designed to protect enrollees and ensure they receive the coverage and benefits they deserve without being misled.

One significant trend in MA plans for 2025 is the standardization and simplification of ancillary benefits. Beneficiaries can expect changes to over-the-counter benefits, the exploration of in-home benefits, non-emergency transportation, dental benefit enhancements, and even expanded mental health coverage. Additionally, gym membership benefits may be adjusted to include home-based fitness options, reflecting the growing demand for flexibility in how Americans exercise and stay fit.  

The Prescription Drug Cost Cap and New Payment Plans

Another significant change being rolled out for 2025 is the introduction of a $2,000 limit on prescription drug costs for each individual for the calendar year. This cap will provide much-needed relief to many Medicare beneficiaries who struggle with the high cost of medications. Alongside this, new payment plans for expensive medications will be introduced, making it easier for enrollees to manage their healthcare expenses over time. This development is particularly important given the rising costs of prescription drugs and the growing reliance on medications to manage chronic conditions.

Enhancements in Medicare’s Star Ratings and Family Caregiver Support

Medicare plans are rated based on feedback from real policyholders, which covers areas such as customer service and chronic condition management. In 2025, carriers are likely to focus on improving these star ratings by encouraging enrollees to take full advantage of the benefits offered under their plans. This could lead to more proactive communication and support from your plan provider, ensuring you’re getting the most out of your coverage.

Another important change on the horizon is the introduction of training for family caregivers by medical professionals. CMS recognizes the vital role that family caregivers play in the healthcare system and is planning to offer more resources to help them manage their important role in support of their loved ones.

The Role of Artificial Intelligence (AI) in Medicare

Artificial Intelligence (AI) is set to revolutionize healthcare and Medicare services in 2025. AI will enhance efficiency in various tasks, such as Part D reviews, marketing, and virtual assistance. These advancements are expected to streamline some of the administrative aspects of Medicare, making it easier for beneficiaries to find answers to their individual questions about their plans and their medications.

Special Programs and Benefits for Dual-Eligible Individuals

For individuals who are eligible for both Medicare and Medicaid, Dual-Eligible Special Needs Plans (DSNPs) will continue to offer a range of additional benefits in 2025. These plans include support for utilities assistance, extra transportation, healthy foods and wellness items, hearing aids, pet supplies, a personal care team, and more. As these benefits expand, DSNPs will become an increasingly attractive option for those who qualify.

Prepare for the Near Future with Emerald Medicare

As we look ahead to 2025, it’s clear that the landscape of Medicare is evolving in ways that will impact beneficiaries across the board. From changes in healthcare costs and prescription drug coverage to advancements in AI and enhanced support for caregivers, staying informed will be key to making the right decisions.

At Emerald Medicare, we’re here to help you navigate these changes with confidence. Our team of experts is focused on providing you with the education and guidance you need to make the best choices for your healthcare. 

At Emerald Medicare, we know how important it is for you to have a clear understanding of your healthcare options. In this post, we’ll break down Medicare Parts A and B — often referred to as “Original Medicare” — to help you make informed decisions about your health coverage.

What is Medicare Part A?

Part A (Hospital Coverage) covers essential services such as inpatient hospital stays, home health care, and skilled nursing facility care. Together with Medicare Part B, these services form the core of Original Medicare.

Q: “Is Medicare Part A free?”

A: Most people don’t pay for Part A if they have paid Medicare taxes (FICA) while working. However, if you don’t qualify for premium-free Part A, it can be purchased for a monthly premium. The exact amount may vary based on how long you or your spouse worked and paid Medicare taxes.

What is Medicare Part B?

Part B (Medical Coverage) is designed to cover doctor visits, outpatient services, X-rays, lab tests, and preventive screenings. It’s a key component of your healthcare, granting you access to a wide array of medical services.

Q: “Do you need Medicare Part B?”

A: Yes and No; If you have health insurance through a current job or your spouse’s employer plan, you can delay your Medicare Part B enrollment without penalty*. Once the employer coverage ends, you have an eight-month window to sign up for Part B. Further, you MUST be enrolled in Medicare Part B if you want to sign up for a Medicare Advantage and/or MediGap plan. Reviewing the costs associated with your employer coverage is essential when making this decision.

*company providing coverage must be greater than 20 employees.

How Do Parts A and B Work Together?

Together, Medicare Parts A and B provide coverage for both hospital and medical care at 80% coverage. While Part A focuses on inpatient care, Part B covers all outpatient services, making them complementary in providing comprehensive healthcare coverage throughout retirement & beyond the age of 65.

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Key Points to Consider

Enrollment

When you’re eligible, you can enroll in both Medicare Parts A and B through the Social Security Administration (SSA). Enrollment for original Medicare is automatic if you’re already receiving Social Security benefits. However, if you are not collecting Social Security, you’ll need to be proactive and sign up either by going online to SSA.gov, In-Person to your local Social Security office, or by calling Social Security for a phone appointment.

Coverage

Original Medicare covers the essentials, but there are services it doesn’t include, such as prescription drugs (covered via Part D), routine dental or vision care, and/or hearing aids. Understanding these gaps is crucial as you consider additional coverage options like Medigap or Medicare Advantage plans.

Costs

While Part A is typically premium-free, Part B comes with a standard monthly premium which can increase based on your income. When you apply for Part B, your income level is calculated using your tax return from 2 years prior. Additionally, depending on your supplemental coverage, you should expect some out-of-pocket costs, such as deductibles, co-pays and coinsurance. The amount will vary depending on the plan you choose.

Emerald Medicare is your Trusted Medicare Resource.

Making the right decisions about your Medicare coverage can be confusing, timely, and/or stressful. If you have questions about Medicare Parts A and B, or need help navigating your options, our team of Licensed Medicare experts is here to assist throughout retirement & beyond.

Contact Us:
Phone: (888) 683-6372 or (845) 358-1220
Email: office@emeraldmedicare.com

Contact Us:
Phone: (888) 683-6372 or 845-358-1220
Email: office@emeraldmedicare.com

As your knowledgeable, compassionate, and trusted Medicare resource with Licensed Medicare experts, we know that your healthcare needs are unique and can change over time. That’s why it’s essential to review your Medicare plan options annually to ensure your current coverage still meets your health & budgetary needs. Even if your current plan served you well last year, changes in your health, plan benefits, industry changes, or costs could mean that a different plan is now a better fit for you.

Why an Annual Review is Essential

Changes in Health Needs
As the years pass, your healthcare needs may evolve. You or a family member might be dealing with a new health condition, which may require different medications, or the need to see a new doctor. Your current plan may not cover these needs as comprehensively as other plan options. An annual Medicare plan review allows you to adjust your coverage to meet any new health requirements.

Plan Changes
Medicare plans are not static; in fact, most Medicare plans change regularly. Carriers often change their coverage, provider networks, co-pays, deductibles, and/or drug formularies from year to year. For example, your current plan might increase premiums, adjust what services or ancillary benefits it covers, or drop certain healthcare providers from its network. Reviewing your plan annually ensures you’re not caught off guard by these changes and can switch to a plan that better suits your needs if needed.

New Plan Options
Each year, new Medicare plans become available and some are eliminated. A newer plan could offer better coverage or lower costs. For instance, a new Medicare Advantage plan in your area might include or reduce additional benefits like dental or vision coverage. By exploring these new options during the Annual Enrollment Period (October 15th – December 7th), you could find a plan that offers more value and better meets your needs to assure that you have no surprises heading into 2025.

Avoiding Penalties
Certain Medicare plan decision, such as Part B (outpatient medical services) and Part D prescription drug plans, have late enrollment penalties. If you’re not careful, you could end up paying more simply because you missed a deadline you were unaware of. When approaching age 65 or retirement taking the time to access a resource to conduct a thoughtful review of your specific situation helps you stay on top of these important deadlines and avoid these avoidable penalties.

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How to Conduct an Effective Annual Review

1. Evaluate Your Current Coverage

• • • Start by reviewing what your current plan covers. Are there any gaps in coverage, or services you didn’t use? Are there services you’d like to add? No plan offers every service, but making a list of your current healthcare needs and the benefits you are looking for can help you determine which plan(s) best addresses them.

2. Compare Costs

• • • Look at the total costs associated with your plan, including premiums, deductibles, co-pays, and out-of-pocket maximums. Compare these costs with other available plans to determine if you could save money by switching or staying the course with your current Medicare coverage decision.

3. Check Provider Networks

• • • Ensure that your preferred doctors and healthcare providers are still in your plan’s network. If they’re not, you might want to consider switching to a plan that includes them to maintain continuity of care. Medigap plans have no network and include most doctors and facilities that accept Medicare. If you aren’t sure how to check which insurances your doctors accept, call the respective Medical office or seek assistance from your Medicare broker. 

4. Consider Future Needs

• • • Think about any upcoming health changes, procedures, or treatments that might require different coverage. Choose a plan that offers the flexibility to meet your future healthcare needs, such as increased prescription drug coverage, access to a specialist or a specific facility.

Medicare’s Annual Enrollment Period is Around The Corner

Each year on October 1, your ability to review you plan begins and continues until December 7th. An annual Medicare plan review is more than just a good practice—it’s the most important step in ensuring that you’re not overspending and you are properly covered. Don’t wait until it’s too late—start reviewing your Medicare plan with the experts at Emerald Medicare! Our team of Licensed Medicare professionals is here to help you navigate the review process and find the best plan for your budget and your health care needs. 

Contact Us:
Phone: (888) 683-6372 or 845-358-1220
Email: office@emeraldmedicare.com