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Medicare Glossary

Medicare acronyms, terms, and words defined.

Useful Medicare content.

Scroll through our Medicare Glossary to find, define, and clarify the most common Medicare words and terms defined. Get accurate Medicare definitions as well as practical application of the Medicare terms and words used in a sentence to provide you with more context. I want you fully informed as a Medicare client with MedicareSupplementMentor.com.. Use my Medicare Glossary to help you navigate plans and help understand more about your Medicare coverage.

Medicare Glossary A-C

Medicare words and terms defined.

Annual Enrollment Period - AEP

The Annual Enrollment Period is an open window to make changes to your Medicare Advantage Plan (Part C) or Medicare Prescription Drug Plan (Part D). The window runs October 15th – December 7th each Fall. Plans that are updated during this window of time typically become effective January 1st. 

“We will be reviewing your Medicare Prescription Drug Plan this fall during the AEP. The new drug plan will begin on the 1st of January.” 

The AEP is often referred to as the “Open Enrollment Period” as well. I prefer to use more accurate term of Annual Enrollment Period, as it is somewhat misleading. Being that it is not open to move from a Medicare Advantage plan to a Medicare Supplement Plan guaranteed-issue (no health questions asked) after the first year within a Part C Plan, I do not feel it accurately reflects the window as “open” for clients to move freely among all plans. As for Part C to Part C plans or Part D to Part D plans, it is in fact open to all available plans.

Appeal

If you disagree with a coverage or payment decision made by Medicare, your Medicare health plan, or your Medicare Prescription Drug Plan, you can appeal the following: 

  • Your request for a health care service, supply, item, or prescription drug that you think you should be able to get (ie. appeal to get a particular drug covered that isn’t on your plans formulary). 
  • Your request for payment for a health care service, supply, item, or prescription drug you already got (ie. Medicare denied coverage. File an appeal to get the DME equipment covered as your physician has stated it is medically necessary, etc). 
  • Your request to change the amount you must pay for a health care service, supply, item or prescription drug.

You can also appeal if Medicare or your plan stops providing or paying for all or part of a service, supply, item, or prescription drug you think you still need (ie. extend the number of physical therapy appointments Medicare covers with direction of a physician authorizing additional PT therapy appointments are medically necessary).

“I avoided having to file an appeal since my orthopedic surgeon authorized additional physical therapy sessions to help with my recovery after the accident.”

Assignment (Payments)

Assignment refers to an agreement by your doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance. 

“Do you accept Medicare assignment?” Great, I now know that I will not be subject to Part B excess charges.”

Benefit Period

The way that Original Medicare measures your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you’re admitted as an inpatient in a hospital or SNF. The benefit period ends when you haven’t gotten any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods. 

“My Plan G Medicare Supplement covers my inpatient hospital deductible for each benefit period as well as the 20% co-insurance that Original Medicare does not cover.”

Co-insurance

An amount you may be required to pay as your share of the cost for services after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%).

“My co-insurance portion for radiological services is 30% on my Medicare Advantage Plan PPO, after I pay the annual deductible.”

“Tier 4 drugs on my Part D plan charge me a co-insurance of 30% the retail cost of the drug. I hope to find a plan that covers this medication better during this years AEP for the following year.”

 

Co-payment

An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or prescription drug. A copayment is usually a set amount, rather than a percentage. 

“My Medicare Supplement co-payment on Plan N is $20 when I see my dermatologist”

My co-payment for tier 1 generic drugs is only $2 at preferred pharmacies with my Part D plan.”

Coverage Determination for Medicare Prescription Drug Plans

The first decision made by your Medicare drug plan about your drug benefits, including:

  • Whether a particular drug is covered (is it on your formulary?)
  • Whether you have met all the requirements for getting a requested drug (is step therapy required?)
  • How much you’re required to pay for a drug (which tier level does it fall under, if approved?)
  • Whether to make an exception to a plan rule when you request it (Will they cover it even though it is off the formulary– if so, what tier/quantity limit, co-payment or co-insurance costs?, etc)

The drug plan must give you a prompt decision (72 hours for standard requests, 24 hours for expedited requests).  If you disagree with the plan’s coverage determination, the next step is an appeal.

“I requested an expedited coverage determination when I contacted my Part D plan insurance company because I needed a quick decision to be made about my coverage for the medication. They informed me they would cover the drug as a tier 5 for a 33% co-payment amount since its an expensive brand name medication. I’ll need to find another Part D plan that covers this drug better during the AEP this fall.”

Coverage Gap

A period of time in which you pay higher cost sharing for prescription drugs until you spend enough to qualify for catastrophic coverage. The coverage gap (also called the “donut hole”) starts when you and your plan have paid a set dollar amount for prescription drugs during that year. 

“My out-of-pocket expenses for my medications really jumped when I fell into the coverage gap this year. The co-pays in the pharmacy were difficult to afford until I finally made it into the Catastrophic coverage level for the last three months of the year.”

Creditable Coverage (Medigap)

Previous health insurance coverage that can be used to shorten a pre-existing condition waiting period under a Medigap policy. 

“I had creditable coverage from my employer plan before I enrolled into the Medicare Supplement Plan G this Spring. For this reason, I was not subject to the 6 month pre-existing condition clause.”

 

Creditable Coverage (Part D- Medicare Prescription Drug Plans)

Prescription drug coverage (for example, from an employer or union) that’s expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage. 

“Although I first enrolled in Medicare after retiring at the age of 68, I wasn’t subject to the Part D Late Enrollment Penalty because my employer group health plan was considered creditable coverage. I submitted proof of coverage to my Plan D insurance company once I received it from my prior employer’s HR department.”

Medicare Glossary D-I

Medicare words and terms defined.

Deductible

The amount you must pay for health care or prescriptions before Original Medicare, your Medicare Advantage Plan, your Medicare drug plan, or your other insurance begins to pay.

“I love my Plan G coverage. I’m only subject to an annual Part B deductible of $233 (2022). After I pay my deductible, my Plan G Medicare Supplement Plan pick up all Medicare approved medical costs the remainder of the year.”

 

Durable Medical Equipment - DME

Certain durable medical equipment, like a walker, wheelchair, or hospital bed, that’s ordered by your doctor for use in the home. 

“My CPAP machine was covered under DME when it was first billed to Medicare and the remaining 20% was covered by my secondary – Plan G Medicare Supplement Plan.”

 

Excess Charges

If you have Original Medicare, and the amount a doctor or other health care provider is legally permitted to charge is higher than the Medicare-approved amount, the difference is called the excess charge.

“Thankfully, I have Plan G and do not need to worry about excess charges since the plan covers these costs in the even a physician doesn’t accept Medicare assignment and charges excess for her services.”

Extra Help

A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, like premiums, deductibles, and coinsurance.

I applied for “Extra Help with Prescription Drug Plans” this year. They now pay my Part D premium.  My copays are much lower than last year in the same exact plan.”

 

Formulary

A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.

“Medicare.gov’s drug plan finder indicated that all my medications were covered, but 1 medication in my Part D plan’s formulary for 2022. John ran my drug list in October and found a new plan that covered all my medications in their formulary during the this Fall’s AEP.  I’m moving to the new plan the 1st of the year.”

Formulary Exception

A type of Medicare prescription drug coverage determination. 

A formulary exception is a drug plan’s decision to cover a drug that’s not on its drug list or to waive a coverage rule. A tiering exception is a drug plan’s decision to charge a lower amount for a drug that’s on its non-preferred drug tier. You or your prescriber must request an exception, and your doctor or other prescriber must provide a supporting statement explaining the medical reason for the exception.

“My physician prescribed me a new drug. It wasn’t covered on my current Part D plan’s formulary. Thankfully, my physician’s office staff helped we contact the Part D plan to get a formulary exception for the drug to be covered on my plan at a tier 4 level for the remainder of the year. During the AEP this Fall, I’ll run this new prescription along with my other list of medications to be sure they’re all covered next year.”

General Medicare Enrollment Period

If you miss your Initial Enrollment Period, you can sign up during Medicare’s General Enrollment Period (January 1–March 31), and your coverage will start July 1.

“I failed to enroll in Medicare during my Initial Enrollment Period (IEP) and I do not qualify for a SEP. Therefore, I must wait to enroll in Medicare during the General Medicare Enrollment Period. Unfortunately, I’ll likely have penalties for late enrollment for Part B and Part D.”

Guaranteed-issue rights (applicable to Medicare Supplement Plans)

Rights you have in certain situations when insurance companies are required by law to sell or offer you a Medigap policy. In these situations, an insurance company can’t deny you a Medigap policy, or place conditions on a Medigap policy, like exclusions for pre-existing conditions, and can’t charge you more for a Medigap policy because of a past or present health problem.

 “I had guaranteed-issue rights to any Medicare Supplement Plan during my Initial Enrollment Period surrounding my 65th birthday as I started Medicare. For this reason, I was able to skip the health questions and knew my plan application was going to go through for coverage beginning the first of the 65th birthday month.”
“I’m comfortable moving Plan G Medicare Supplement Plans every 2-3 years because I know I have guaranteed-issue rights to the same coverage with a new insurer that is offering lower premiums within 60 days of my birthday in California. John saved me $350 with the same coverage using the California  Birthday Rule!”

Guaranteed-renewable (Medicare Supplement Plans)

An insurance policy that can’t be terminated by the insurance company unless you make untrue statements to the insurance company, commit fraud, or don’t pay your premiums. All Medigap policies issued since 1992 are guaranteed renewable.

“I know Medicare Advantage Plan coverage is subject to changing or cancellation every year. For this reason, I chose to go with a Medicare Supplement Plan since they are all guaranteed-renewable. I know that if I pay my premium, I will never be dropped from the coverage, ever!”

Health Maintenance Organization (HMO)

A type of Medicare Advantage Plan (Part C) available in some areas of the country. In most HMOs, you can only go to doctors, specialists, or hospitals on the plan’s list except in an emergency. Most HMOs also require you to get a referral from your primary care physician.

“No, I do not have Medicare and a Medicare Supplement Plan. I chose to go with a Medicare Advantage Plan (HMO). I carefully reviewed the plans available in my ZIP code to be sure I chose a plan that my physicians were accepted as in-network. I do not want to find new physicians.”

Hospice

A special way of caring for people who are terminally ill. Hospice care involves a team-oriented approach that addresses the medical, physical, social, emotional, and spiritual needs of the patient. Hospice also provides support to the patient’s family or caregiver.

“It’s comforting knowing my Medicare and Medicare Supplement Plan will cover hospice in the event I’m diagnosed with a terminal illness.”

Initial Enrollment Period with Social Security (IEP)

A seven month period surrounding your 65th birthday. Three months before, the month of, and three months after. During your IEP, you have the ability to coordinate your Medicare with Social Security for your Medicare Part A & B effective start dates.  

If you are receiving your Social Security benefit, the IEP will automatically enroll you in Part A & B for the 1st of the month of your 65th birthday. 

If you are delaying your Social Security benefit, the IEP is open to you coordinate your Medicare with Social Security to start Medicare. You will need to proactively enroll yourself into Medicare using the IEP at your local Social Security Office or Online. 

“Since I’m taking my Social Security benefits and turn 65 in 3 months, I’m currently in my IEP and was mailed my Medicare card showing my Medicare effective start dates as the 1st of the month I turn 65. I was able to enroll in a Medicare insurance plan(s) of my choice once I received my card. I chose to enroll in a Medicare Supplement Plan during my Initial Enrollment Period which gave me guaranteed-issue rights to coverage without medical underwriting and pre-existing condition clauses within 6 months of my Part B effective date  I was also able to enroll in a stand-alone Medicare Prescription Drug Plan using my IEP for Part D coverage. This IEP for my Part D plan is also the same seven month period surrounding my 65th birthday.”

If you are working past 65 or covered under a large group employer plan through yourself or a spouse, refer to SEP for you enrollment periods for Part C and Part D plans. Also refer to Medicare Open Enrollment Period for more information on enrolling in a Medicare Supplement after using a SEP to start your Part B after 65. This is typically within 6 months of your Part B effective date, however, it’s best to apply before this 6 month window so your coverage begins on the 1st of the month your Part B begins. 

Contact us for more specific advice on timing your Medicare and Medicare insurance plan enrollment.

Medicare Glossary L-M

Medicare words and terms defined.

Large group health plan

In general, a group health plan that covers employees of either an employer or employee organization that has at least 100 employees.

“Since my employer insures it’s employer insurance through large group health plan and I’m still working past the age of 65, I know that the large group plan remains primary to Medicare. Therefore, I can delay Part B of medicare and use a SEP to start Medicare Part B and my Medicare Supplement Plan guaranteed-issue when the time comes to retire. I will also have creditable coverage and will not be subject to the Part B and Part D late enrollment penalties.”

Medicaid

A joint federal and state program that helps with medical costs for some people with limited income and resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

“Since I have Medicaid (Medi-Cal), I’m considered dual-eligible or Medi-Medi.”

Medical Underwriting

The process that an insurance company uses to decide, based on your medical history, whether to take your application for insurance, whether to add a waiting period for pre-existing conditions (if your state law allows it), and how much to charge you for that insurance.

“I was able to skip medical underwriting using the CA birthday rule, as I have guaranteed-issue rights to a like plan (Plan G to Plan G) within 60 days of my birthday in California. I’m going to shop rates with John in June to see if I can save a few hundred dollars on my Plan G Medicare Supplement premium this year. 

Medically Necessary

Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.

“I was worried Medicare and my Medicare Supplement wouldn’t cover the advanced procedure for my knee replacement. However, since it is considered medically necessary to use the new state of the art technology for the surgery, Medicare and my Medicare Supplement Plan will cover the procedure.”

 

Medicare Advantage Open Enrollment Period (MAOEP)

During the window between January 1 – March 31, Medicare Advantage enrollees can switch to Original Medicare or to a different Medicare Advantage Plan. The ability to switch plans during the MAOEP is limited to one plan change per year. This is different from the AEP, where multiple plan changes can occur. 

“I found that the new MAPD plan I enrolled in during the AEP is not what I expected it to be. Therefore, I’m choosing to take advantage of the Medicare Advantage Open Enrollment Period. This is a one time opportunity I can use to move my Medicare Advantage back to the previous plan I had the year prior. The call center agent misguided me and in February, I found my favorite doctors were not part of my new plans HMO network.”

“I applied for a Medicare Supplement Plan during the Fall AEP. I didn’t think I was guaranteed-issue, but since I’m moving after my 1st year in the Medicare Advantage Plan, I found out I was approved for my Medicare Supplement Plan G coverage through guaranteed-issue. I’ll be using the MAOEP to enroll in a Part D in January since it’s past December 7th, effectively cancelling my current Medicare Advantage Plan January 31st. Thus, reinstating my Original Medicare as primary February 1st. My new Medicare Supplement Plan G and stand-alone Part D plan will all become effective February 1st of the new year as well.”

Medicare Advantage Plan (Part C)

A type of Medicare health plan offered by a private company that contracts with Medicare. Medicare Advantage Plans provide all of your Part A and Part B benefits, with a few exclusions, for example, certain aspects of clinical trials which are covered by Original Medicare even though you’re still in the plan. Medicare Advantage Plans include:
• Health Maintenance Organizations (HMO)
• Preferred Provider Organizations (PPO)
• Private Fee-for-Service Plans 
• Special Needs Plans
• Medicare Medical Savings Account Plans

If you’re enrolled in a Medicare Advantage Plan:
• Most Medicare services are covered through the plan (Not Medicare, as you signed over your Original Medicare to the specific Medicare Advantage plan).
• Most Medicare services aren’t paid for by Original Medicare (Paid by the plan as it’s primary, not Medicare).
• Most Medicare Advantage Plans offer prescription drug coverage (Part D included inside Part C).

“I searched my ZIP code to shop for a Medicare Advantage Plan. I had roughly 10 options. I selected an HMO Medicare Advantage Plan with my preferred medical group that my primary care physician accepts in-network. Also, my Medicare Advantage Plan includes a Part D plan in the “bundled” plan and covers all my medications.”

Medicare-approved amount (aka. negotiated rate)

In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you’re responsible for the difference.

“I’m not responsible for the difference in the Medicare-approved amount that my Original Medicare doesn’t pay because I added a Plan G Medicare Supplement Plan that covers the full 20% after the annual Part B deductible ($233, 2022).”

“Wow, the hospital charged $2,200, but I see that the Medicare-approved amount was much less. The Medicare approved amount was $1000. Medicare paid $800 and my Medicare Supplement Plan picked up the remaining 20% or $200.”

 

Medicare Prescription Drug Plan (Part D)

Optional benefits for prescription drugs available to all people with Medicare for an additional charge. This coverage is offered by insurance companies and other private companies approved by Medicare.

These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare drug plans.

I added a stand-alone Medicare Prescription Drug Plan to my Medicare Supplement Plan to complete my Medicare health plan coverage for the year. 

“I’m not enrolling in a stand-alone Medicare Prescription Drug Plan during AEP because if I do, the new drug plan enrollment will dis-enroll my Medicare Advantage Plan the 1st of the new year. This is because my MAPD Part C plan already includes a Medicare Prescription Drug Plan (Part D) within the plan”.

Medigap (aka. Medicare Supplement Plans)

Medicare Supplement Insurance sold by private insurance companies to fill “gaps” in Original Medicare coverage. 

“I chose to add a Medicare Supplement Plan or Medigap policy to my Original Medicare coverage. I prefer to have access to all Medicare providers as well as predictable out-of-pocket costs for my medical coverage. It may cost more monthly, but its guaranteed renewable and I like not having copays for medical appointments and procedures with Plan G.”

Medigap or Medicare Supplement Plan Open Enrollment Period

A one-time only, 6-month period when federal law allows you to buy any Medigap policy you want that’s sold in your state. It starts in the first month that you’re covered under Part B and you’re age 65 or older. During this period, you can’t be denied a Medigap policy or charged more due to past or present health problems. Some states may have additional open enrollment rights under state law. Technically, insurer’s will allow you to apply using this period three months before the start of your Part B effective date. Why? Well, most clients want their Medicare Supplement Plan to “supplement” Medicare on day 1 and not wait to add the secondary coverage. 

“I enrolled guaranteed-issue into my Medicare Supplement Plan using my Medicare Supplement Plan Open Enrollment Period when I turned 65. On the other hand, my wife used her Medicare Supplement Open Enrollment Period at 68. She had an employer group plan health coverage from 65-68 which allowed her to delay Part B. Once she took Part B by way of a SEP, she had the same Medicare Supplement Open Enrollment Period for her Supplement as well. We were both guaranteed issue and no Part B late enrollment penalties applied to her. 

“We choose to enroll two months prior to the Part B start date using our Medicare Supplement Open Enrollment Period so our coverage would all begin together on the 1st of the month. We had a 6 month window, but I wanted my Medicare Supplement Plan to “Supplement” my Medicare the first day coverage began. 

Medicare Glossary O-P

Medicare words and terms defined.

Original Medicare (aka. Part A & B)

Original Medicare is a fee-for-service health plan that has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance). After you pay a deductible, Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance and deductibles).

I didn’t want to sign over my Original Medicare to a Medicare Advantage Plan. I chose to keep Original Medicare, add a Medicare Supplement Plan, and add a Stand-alone Medicare Prescription Drug Plan.”

Out-of-pocket costs

Health or prescription drug costs that you must pay on your own because they aren’t covered by Medicare or other insurance.

 “John estimated my annual out-of-pocket costs for my Medicare Prescription Drug Plan (Part D) to give me an idea of what I’ll pay at my preferred pharmacy when I pick up my prescriptions.”
 
“The total out-of-pocket medical costs I’m subject to this year in my Medicare Advantage Plan for medical appointments, procedures, hospital stays, etc is $7550 (OOP Max).”

Part A (Original Medicare)

Hospital Insurance – Inpatient care in hospitals, skilled nursing care, hospice care, and home health care. 

“My Part A and Part B were effective the 1st of the month I turned 65. I added a Medicare Supplement Plan to supplement the costs that Original Medicare (Part A & B) does not cover.”

“I’m still working past 65. I currently have “Part A Only” and have delayed my Part B since my employer group health plan is primary to Medicare while I continue working. I will use a SEP to activate Original Medicare Part A & B to be primary coverage the 1st of the month after I leave my employer group plan.”

Part B (Medical Insurance)

Medical Insurance – Physician services, outpatient care, home health care, DME, preventative services. 

“My Part A and Part B were effective the 1st of the month I turned 65. I added a Medicare Supplement Plan to supplement the costs that Original Medicare (Part A & B) does not cover.”

“Since I’m still working past the age of 65, I’m going to forego my IEP surrounding my 65th birthday as I have creditable coverage through my employer group plan that is primary to Medicare. I’ll use an SEP with forms 40B and L564 to activate my Part B, penalty-free, the 1st of the month after I leave my employer group coverage.”

Part B late enrollment penalty

If you didn’t get Part B when you’re first eligible, your monthly premium may go up 10% for each 12-month period you could’ve had Part B, but didn’t sign up. In most cases, you’ll have to pay this penalty each time you pay your premiums, for as long as you have Part B. And, the penalty increases the longer you go without Part B coverage.

Usually, you don’t pay a Part B late enrollment penalty if you meet certain conditions that allow you to sign up for Part B during a Special Enrollment Period. This penalty will not apply to you if you have creditable coverage through an employer group health plan while delaying your Part B. Simply use the SEP forms 40B and L564 to reinstate your Part B on the month you want Medicare to become primary after leaving the employer group health plan. 

“I avoided the Part B late enrollment penalty by submitting forms 40B and L564 to show that I had creditable coverage for the 3 years after I was initially eligible for Medicare at 65. I’m now 68 and retiring from my employer group health plan. I’ve indicated on the 40B to start Medicare on the 1st of the month after I intend to leave my employer group plan. I have no lapse in coverage, and avoided the Part B penalty.”

Part C (Medicare Advantage Plan)

Medicare approved plans offered by private insurance companies offering an alternative to Original Medicare for your health and drug coverage. Most Part C plans include a Part D Prescription Drug Plan. 

“I chose to enroll in a Medicare Advantage Plan (Part C) for my health and drug coverage. In the process of enrolling, I signed my Medicare over to a private insurance Medicare Advantage Plan HMO (Part C) that provides me with a network of physicians/facilities that have agreed to accept the plan. It also includes a Part D Prescription plan.”

Part D (Medicare Prescription Drug Plan)

Helps cover the cost of prescription drugs (including many recommended shots or vaccines). You join a Medicare drug plan in addition to Original Medicare, or you get it by joining a Medicare Advantage Plan with drug coverage. Plans that offer Medicare drug coverage are run by private insurance companies that follow rules set by Medicare.

“I enrolled in a Stand-alone Medicare Prescription Drug Plan (Part D) along with my Medicare Supplement Plan to complete my Medicare health plan for the new year.”

“My Medicare Advantage Plan includes a Medicare Prescription Drug Plan (Part D) as part of my Part C plan through a private insurance company.”

Part D late enrollment penalty

The late enrollment penalty is an amount that’s permanently added to your Medicare drug coverage (Part D) premium. You may owe a late enrollment penalty if at any time after your Initial Enrollment Period is over, there’s a period of 63 or more days in a row when you don’t have Medicare drug coverage or other creditable prescription drug coverage. You’ll generally have to pay the penalty for as long as you have Medicare drug coverage.

Medicare calculates the penalty by multiplying 1% of the “national base beneficiary premium” ($33.37 in 2022) times the number of full, uncovered months you didn’t have Part D or creditable coverage. The monthly premium is rounded to the nearest $.10 and added to your monthly Part D premium.

“I made the mistake of not enrolling in a Part D plan the first year I was enrolled in Medicare. The Part D late enrollment penalty is now applied to my Part D plan premium for the rest of my life as long as I have Part D Prescription Drug coverage.”

“After using an SEP to get my Medicare Part B activated, I enrolled in a Medicare Supplement Plan. I also enrolled in a Stand-alone Medicare Prescription Drug Plan (Part D) to complement my health coverage. The Plan indicated that I may have a Part D late enrollment penalty for the years I worked past my Medicare eligibility at 65. Fortunately, John advised me that I can eliminate the potential penalty by submitting proof of creditable coverage from my ex-employer. I contacted the HR department and was mailed proof that John faxed into my Part D plan to erase the penalty.”

Pre-existing conditions

A health problem you had before the date that new health coverage starts. 

“I was not subject to pre-existing conditions because I moved Medicare Supplement Plans during the California Birthday Rule with guaranteed-issue rights. I lowered my monthly premium while keeping the same coverage and access to physicians.”

Premium

The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage. 

 “I set up my Medicare Prescription Plan premium to be paid monthly through an automatic bank draft once I received my payment coupon book.”

Preventative services

Health care to prevent illness or detect illness at an early stage, when treatment is likely to work best (for example, preventive services include Pap tests, flu shots, and screening mammograms).

“I reviewed the list of preventative services under Medicare.gov. I do my best to take advantage of the screenings each year to be as proactive as I can with my medical care annually.” 

Primary care doctor

The doctor you see first for most health problems. They make sure you get the care you need to keep you healthy. They also may talk with other doctors and health care providers about your care and refer you to them. In many Medicare Advantage Plans, you must see your primary care doctor before you see any other health care provider.

“Since I chose a Medicare Supplement Plan to add to my Original Medicare, I’m able to see specialists directly and do not need referrals from my primary care doctor.“

“My Medicare Advantage Plan requires me to get a referral from my primary care doctor before I’m able to see my orthopedic doctor for a knee injury.”

Prior Authorization

Approval that you must get from a Medicare drug plan before you fill your prescription in order for the prescription to be covered by your plan. Your Medicare drug plan may require prior authorization for certain drugs.

“Even though my formulary lists my pain medication, I need to get prior authorization cleared before the pharmacy will dispense the drug. I contacted my physician’s office and they contacted the plan to push through the prior authorization so I could pick up the medication at my preferred pharmacy.”

Medicare Glossary R-Z

Medicare words and terms defined.

Referral

A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.

“My Medicare Advantage referral was approved for me to visit a physical therapist for treatment before deciding on whether or not surgery is/will be required for my injury.”

“Even though my Medicare Supplement Plan doesn’t require referrals for insurance purposes, the very specialized spine surgeon needs a referral from my current orthopedic doctor before I can consult with her about my surgical options because she only takes the most critical cases in her sugical practice.”

Rehabilitation services

Health care services that help you keep, get back, or improve skills and functioning for daily living that you’ve lost or have been impaired because you were sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

“I was sent to a speech language therapist to help with my speech after having maxillofacial surgery.”

“The physical therapy sessions after my knee replacement helped me recover much sooner than I thought.”

Secondary payer

The insurance policy, plan, or program that pays second on a claim for medical care. This could be Medicare, Medicaid, or other insurance depending on the situation. 

“My Medicare Supplement Plan is the secondary payer to my Original Medicare. It follows Medicare wherever it is accepted and pays what Medicare doesn’t.”

“My Medicare Advantage Plan is primary and doesn’t have a secondary payer because it’s technically not additional coverage to Medicare. Once I signed over my Original Medicare over to the plan to provide me with coverage it became my primary insurance.”

“Since I qualify for $0 share of cost Medi-Cal, I’m considered dual eligible full Medi-Medi. Medicare is the primary payer for my medical expenses and Medi-Cal is the secondary payer. For this reason, I don’t have to add a Medicare Supplement Plan, unless it’s being used as a spend-down to qualify me for $0 share of cost Medi-Medi to get my Part B premium reimbursed monthly.”

Service Area

A geographic area where the plan accepts members. The plan may limit membership based on where people live. For plans that limit which doctors and hospitals you may use, it’s also generally the area where you can get routine (non-emergency) services. The plan may disenroll you if you move out of the plan’s service area.

” I’m not subject to service areas with my Medicare Supplement Plan within the United States.”

“My Medicare Advantage Plan (HMO) has a service area for Placer and Sacramento County. My plan only allows me to see in-network physicians in my service area, except for in emergencies.” 

Skilled nursing facility and/or care (SNF)

A nursing facility with the staff and equipment to give skilled nursing care and, in most cases, skilled rehabilitative services and other related health services.

Skilled nursing care and therapy services provided on a daily basis, in a skilled nursing facility. Examples of skilled nursing facility care include physical therapy or intravenous injections that can only be given by a
physical therapist or a registered nurse.

“I chose to enter a SNF for a few days after my surgery since the physician recommended that I need a higher level of care while my injuries healed from the accident/surgery.”

 

Special Enrollment Period (SEP)

Once your Initial Enrollment Period ends, you may have the chance to sign up for Medicare during a Special Enrollment Period (SEP). You can sign up for Part A and or Part B during an SEP if you have special circumstances that allow you to use the SEP for Part A and/or Part B. 

“I used my SEP to enroll in a new Medicare Supplement Plan since my current Medicare Advantage Plan is being cancelled in my service area next year. I received a letter stating I had the choice of enrolling in a new Medicare Advantage Plan or guaranteed-issue into a Medicare Supplement Plan. I’m tired of wondering if my plan is going to change every year. Therefore, I chose to take this opportunity to move to a Medicare Supplement Plan. I know the Medicare Supplement Plan is more expensive, however, it will give me more predictable out of pocket costs as well as more access to physicians. Also, Medicare Supplement Plans are guaranteed-renewable, so I know it will never be forced to find a new plan as long as I pay my premium each month.” 

“I will be using my SEP to enroll in Medicare at age 67. I had employer group coverage that allowed me to delay my Part B of Medicare for the last two years. I’ll be working with John to submit forms 40B and L564 to successfully start my Medicare (Part A & B) as my primary coverage, penalty-free, the 1st of the month after I retire from the my group employer plan.”

Step Therapy

A coverage rule used by some Medicare Prescription Drug Plans that requires you to try one or more similar, lower cost drugs to treat your condition before the plan will cover the prescribed drug.

“Even though my Medicare Prescription Drug planned covers my drug, it is still subject to step therapy. This means I’ll need to try a lower cost generic if available, or get my physician to submit reasoning for the newer drug as I’ve already taken the generic and/or he/she believes I need the brand name drug for my condition.”

Tiers

Groups of drugs that have a different cost for each group. Generally, a drug in a lower tier will cost you less than a drug in a higher tier.

“My medication list includes three drugs in tier 1 and one in tier 3 as it is a brand name drug. Each year the tiers can change for my medication list. Therefore, I always review my Part D plan during the AEP to find the best possible plan for the next calendar year.”

Urgent Care

Care that you get outside of your Medicare health plan’s service area for a sudden illness or injury that needs medical care right away but isn’t life threatening. If it’s not safe to wait until you get home to get care from a plan doctor, the health plan must pay for the care.

“Im not concerned with which urgent care facility I can see when traveling as my Medicare and Medicare Supplement Plan cover me anywhere in the United States with Medicare approved providers. My Medicare and Supplement plan will pick up the applicable costs just as it would if I were home.”

“I should research urgent care facilities near my home that my Medicare Advantage Plan takes in network in case it’s late a night and I need medical care, but it’s not an emergency. If I’m traveling, I’ll likely need to go to an emergency room if I’m very sick since I’m out the service area of my HMO plan.”

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Welcome to MedicareSupplementMentor.com!

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Our Compensation

How are we compenated as Independent brokers?

Our agency works independently of each insurance company we represent to provide objective, unbiased options from a variety of insurance companies.  We do not receive a salary or any other form of payment other than what we make from the plans our clients choose to enroll in through our insurance agency. We are compensated for new clients who choose to work with us as well as current clients who maintain a plan through us. The commission we receive is paid directly by the insurance company for your enrollment. You do not pay us, ever. 

Premiums are exactly the same as going direct.

Medicare insurance products have different payment structures (ie. Medicare Supplement Plans, Medicare Advantage Plans, and Medicare Prescription Drug Plans). Our clients never pay us for any of the services or advice we offer. Medicare insurance plans are priced 100% the same as going direct. It’s a win-win for us and our clients. Monthly plan premiums are exactly the same as going direct to an insurance company’s call center. When you work with us, you get to work directly with the broker as opposed to an employee of the insurance company in a call center. 

Medicare Supplement Plan (Medigap) Compensation

When a client chooses us to help facilitate their enrollment into a Medicare Supplement Plan, we receive a monthly commission based upon a percentage of the monthly premium. You are not charged more than the companies premium for our service. The insurance company pays us a commission for the product you choose. Our clients never pay us for any of the services we offer. We are paid on a monthly or annual period depending on the insurance companies payout structure. 

When it comes to Medicare Supplements, our goal is to keep you in a product with competitive rates. Medicare Supplement Plans are standardized plans, therefore, there’s no reason to pay more for the same exact thing, right? We want you to be confident with any recommendation we make. Transparency is the key to our success. We know every insurance company is seeking your business during this transition to Medicare. When your rates increase, we are not paid on the new “increased amount”. We are paid on the initial premium. Therefore, it is in both our best interest to review your rates each year or every other year to find a new plan that provides you with better rates. We want our clients to be satisfied with the products we offer and the service we provide for our compensation.

Medicare Advantage Plan (Part C) Compensation

Just like Medicare Supplement Plans, we are paid directly from the insurance company for facilitating your enrollment with a Medicare Advantage Plan. Our clients never pay a cent more than going direct to the company’s call center. We are paid is fixed by the Medicare Advantage product and state it is issued through (CA). To be clear, we are paid the fixed amount regardless of the premium you pay for the Medicare Advantage Plan. We receive the same commission on the $0 premium plan as the $100+ plans. We will help you breakdown each plan option to find the best value for all plans available to you. You can simply choose the plan that works best for you. We are then compensated by the insurer of the plan you choose once your enrollment is complete.

The amount we are paid for helping you enroll in the plan of your choice is the same amount whether it is a new plan or a plan we recommend you consider moving to. I like to clarify this so our clients know that if we make a recommendation for a new MAPD plan, it has nothing to do with how we are compensated. We are compensated for helping you maintain your plan and answer questions about your coverage. We are able to offer independent advice because we can provide you will multiple plans from multiple companies. If you ever have a question about a new plan available in your area, or something you’ve seen on television,  please contact us.  We will help you review the plan to see if it’s something that would benefit changing to during the AEP for the following year. 

Medicare Prescription Drug Plan (Part D) Compensation

Similar to the Medicare Advantage Plans, we are paid a fixed amount from the insurance company. This commission we receive is not based on the premium you pay for the Medicare Prescription Drug Plan. We are compensated exactly the same for a $10 a month plan as a $100+ a month prescription drug plan. Monthly premiums our clients pay are exactly the same as premiums for those who enroll directly through a call center. Yes, 100% the same. We receive a commission for helping you initially enroll in the plan. We are also compensated each year you choose to stay in the plan.

When we recommend to move your plan during AEP (each Fall), it is likely because the plan you’re in has changed or it is not going to cover your prescription list as well for the following year. Medicare Prescription Drug Plans are the plan type that change most often year to year. You’ll likely be making updates to your drug coverage every year or every couple years to keep up with annual changes. We help our clients review Part D plans every fall. If you have more questions about how Medicare Prescription Drug Plans work or how we are compensated for providing them to you, please contact us. We would are more than happy to review your current plan and answer any questions you may have.

Transparency is Key.

5 Step Enrollment Guide Introduction

An Educational Approach to Medicare

Can I get a spousal benefit through Social Security and my spouse's quarters to qualify for Medicare?

Yes, to qualify for Medicare, you need to have paid into Social Security for 10 years or 40 quarters, or you can qualify under your spouse’s record of quarters paid to Social Security. Many times, in this scenario the spouse is/will be taking Social Security as well as Medicare through the other spouse. 

The important difference between taking Social Security and taking Medicare through a spouse, is that you must be 65 to qualify for the Medicare portion of benefits through your spouse. I only note this because taking Social Security through a spouse can take place before turning 65. In this situation, the timing of the Medicare benefit for the younger spouse can be mistaken as active when one spouse is over 65 and the other is under 65, yet taking Social Security benefits through the older Medicare eligible spouse. This isn’t a common mistake, but just a reminder. 

Typically, the younger spouse may start taking a portion of the older spouse’s Social Security benefit (allowing their benefit to grow to a certain point) At a later time, they may choose to elect to start their own Social Security benefit separately from their spouse. Timing the Social Security benefit and Medicare are separate enrollments, but many times this can overlap and seem complicated when enrolling in Medicare and changing Social Security benefits at the same time. 

If you have been taking benefits through a spouse (delaying your own benefit) and decide to elect to start your own Social Security benefit at a later date (ie. your SS benefit has been building on the side for you as you have been delaying it), remember to update Medicare and your Medicare insurance plans because it’s likely your Medicare ID# will be updated under your own benefit (you’ll get a new Medicare card). Medicare coverage should not be affected. Rather, just a new Medicare ID# to run your own medical billing through the same product you’re currently covered under. 

For more Social Security planning guidance, please refer to the Social Security 101 tab at the top of the home page or contact my office for one on one advice with John to talk through when its best for you to take your Social Security benefit. 

Are you working past 65, delaying your Social Security benefit, and enrolling in Medicare at a later date?

This is the most complicated election for timing your Medicare start dates, yet it is very common. I’ll walk you through each step to thoroughly cover exactly what you need to do to get Medicare started on time, without penalties, and without any hassles. I’ll assume a few things as we go through this step by step so you can put yourself in this scenario even if your situation is slightly different. 

This Medicare enrollment scenario assumes you are working past the age of 65, delaying your Social Security benefit, and covered through your employer sponsored plan with more than 20 employees or you are older than 65 and covered through your spouse’s employer sponsored plan with more that 20 employees. 

Note: Im very specific with the employer plan being more than 20 employees because if you or your spouse’s employer plan is more than 20 employees, then the employer group plan is primary to Medicare the month you turn 65 and after the age of 65 while you are working. This means that even though you are over the age of 65, you were able to skip enrollment into Part B (and technically Part A) of Medicare since it is not primary coverage (employer plan remains primary). Therefore, enrollment into Part B can be delayed in this scenario without penalty until transitioning to full Medicare A & B the 1st of the month following retirement/leaving the employer group plan. Part A may have been activated at 65 if you enrolled online for “Part A Only” and delayed Part B. Technically whether you enrolled in “Part A Only” or not with more than 20 employees in your group plan, “Part A Only” is just “sitting on the sidelines” until you elect to start Part B (they then both become primary once activated via your SEP).  

If your employer group plans is less than 20 employees, Medicare will be primary and the employer group plan would then act as the supplemental coverage to Medicare. If under 20 employees, you’ll be best off not delaying your Part B of Medicare. You’ll need to proactively enroll in Part B 3 months before turning 65 using IEP even though you are working. I recommend you try to negotiate with your employer to pay your Part B premium as well as the group plan coverage acting as your supplemental in this scenario. Many times the company may offer to pay for the Part B premium, the Medicare Supplement and your Part D plan while working. It is much cheaper for the employer if you to go off their group plan, so many times, they are happy to reimburse the Medicare Part B premium and Medicare insurance products for you each month.  

If you have more questions, call my office so I can go through this with you. It’s tricky, but I’m very familiar with timing these scenarios for my clients.  

Back to the scenario…. you are over 65, working, delaying Social Security, and wishing to enroll at some future date for Medicare to begin the day you leave your or your spouse’s employer group plan that is larger than 20 employees. Let’s assume, you’re 68 years old and wishing to retire in the month of September for a seamless transition to Medicare for October, 1 2022. In this scenario, your birthday is irrelevant when it comes to enrolling in Medicare with Social Security. Since you are outside the Initial Enrollment Period (IEP) (the 7 months surrounding your 65th birthday), you’ll need a different election tool to activate your Medicare properly. You’ll be using whats called, a Special Election Period or SEP. Since you have been covered on an employer group plan prior to the month leading to your 65th birthday, you’ve had what is called “credible coverage”. This credible coverage is going to allow you to enroll into Medicare on any retirement date in the future if you remain covered under that employer group plan while employed with the company. For this example, we are using 10/01/2022 as the preferred Medicare start date after retiring in September so I can be specific with dates for this illustration. 

In this specific scenario you would need to print forms on SSA.gov or print from the Resources Tab under Helpful Medicare Forms and Documents on this site. These forms are SSA form L564 and form 40B. 

40B is a form that you’ll use to “say” that you want to elect to start your Medicare Part B on “X” date. In this example, we are targeting 10/01/2022 for the start date. Print and fill out form 40B indicating your intended Part B start date of 10/01/2022. 

Now, to SSA form L564. This form is what activates the use of form 40B. L564 is a form that your employer administrator will fill out showing you’ve had credible coverage under their group plan from date “X” to date “Y” — signed by the benefits administrator in your company. You can get this form signed up to 8 months prior to your intended Medicare start date- 10/01/2022. 3-4 months prior to your start date is sufficient in my opinion. 

To continue the example, let’s say you filled out the 40B in June/July and had your employer sign off on your credible coverage on the L564 and returned the form to you. You can submit both forms to the Social Security office in person for your 10/01/2022 start date. If you’re working with me on this, I’ll be happy to guide you and fax the documents to the local Social Security office with your permission to get a hard copy receipt of SEP enrollment for 10/01/2022.  

Let’s assume for ease of the this example that you are still delaying your Social Security benefit. You’re Medicare is set for 10/01/2022. You’ll now receive a quarterly Part B billing statement for the Part B premium. Remember, Part A is “premium free” since you paid into the system for more than 10 years. If Part A was activated as “Part A Only” at 65 online it is still “sitting on the sidelines”. Once L564 and 40B go through both Part A and Part B will be activated to be primary on 10/01/2022, once the group employer ends the last day of September. No penalties!

Medicare is now primary and you can work with John to get quotes, pricing, and enroll yourself in the plan of your choice. You will have exactly the same guarantee issue rights as someone who went through the process when turning 65 (no health questions asked). You are not subject to late enrollment penalties for Part B or Part D because of the credible coverage you had through the employer group plan or your spouse’s employer plan. L564 took care of the proof for the Part B penalty, but you may need to show proof of “credible coverage” to the FIRST enrollment into a Part D plan you enroll into whether it be a standalone Part D or Part D included in a Medicare Advantage plan. After this initial Part D enrollment, you should not need to resubmit proof.

If you enroll in Medicare insurance products with my office, we will help you get this organized and submit it with your application before they even ask- avoiding any confusion as to whether you had credible coverage or not. Best to give them the proof ahead of time than deal with it at a later time. 

Once you elect to start your Social Security benefit at a later time (ie. 68-70 in this example), the Part B premium will then be withdrawn automatically each month prior to the monthly draft (your monthly Social Security benefit amount minus the Part B premium = monthly Social Security benefit draft into your account). The standard Part B premium for 2022 is again, $170.10 (more if subject to IRMAA).  

This is one example- please call if you want me to review your specific enrollment scenario so we can pin point the exact months you needs to complete each step to get it all coordinated correctly without penalties. 

Mentor One Insight

Mike is 68 (outside his IEP at 65), he is still working and delaying his Social Security. He is covered through a large employer plan (over 20 employees) so he can delay his Medicare Part B and use his group plan as his primary coverage while he works past 65. He has credible coverage through his employer plan for Part B and Part D. He can retire any month he wants and can elect to have Medicare begin without penalty on the 1st of the month he chooses. He wants to start July 1 – 07/01/2022. He is retiring June 5th -06/05/2022 and therefore, has coverage through 06/30/2022 with his employer plan (check with your benefits to be sure you’re covered through the end of the month- take advantage of this if you can). 

In March/April (3-4 months prior to his desired start date of July 1 – 07/01/2022), Mike printed off the forms 40B and L564 and reviewed the timing of his Medicare with John over the phone to pin point his exact dates. Since he settled on July 1 for his Medicare start date based on leaving his employer at 68 years old on June 5th. He filled out form 40B that indicated a 07/01/2022 Medicare Part B start date (Part A will become active on 07/01/2022 as well). Mike now contacts his employer benefits division to get a representative to sign off on his credible coverage with form L564 to allow him to activate his form 40B. He submits both forms to Social Security in the month of March or early April (depending on when his employer gets the L564 back to him). Mike gets confirmation of Part B effective 07/01/2022.  Part A may have an earlier date and it will always show the earlier date if elected “Part A Only”, however, Part A will become effective 07/01/2022 because the primary insurer (employer) drops 06/30/2022. Both Part A and Part B are coordinated and effective 07/01/2022.

He is now set for his Medicare start date of 07/01/2022 without penalty for his Medicare coverage at 68 years old. Mike meets with John to review Medicare insurance plans, pricing, and enrolls in the plan of his choice. Additional credible coverage proof is sent to the Part D plan of his choice– the Part D penalty is now not applicable to him. He is now fully covered without a lapse in his coverage. His group plan ends June 30th and his Medicare as well as his Medicare insurance product(s) all start July 1 without a lapse in coverage. 

Are you working until 65, delaying your Social Security, and plan to enroll in Medicare at 65?

This scenario is similar to the one above, but in this situation, you are currently working and covered under your employer group plan until the last day of the month you leave your group plan (or spouse’s) and retire. You are planning to retire the month prior to your 65th birthday and looking to time your Medicare start date the day after your employer health plan benefits end (last day of the month). Maybe you chose to work up to this date because you know the cost of insurance plans in your early 60’s are extremely expensive as an individual and you are timing your retirement to coincide with Medicare your 65th birthday IEP Medicare start date. 

In this scenario, you are delaying your Social Security benefit. Therefore, you will need to proactively enroll into Medicare (Part A & B) for coverage to start the 1st of the month you turn 65. It is best to do this 1-3 months before your 65th birthday month (The Part B Initial Enrollment Period starts 3 months before your 65th birthday). Most clients apply in the 1-3 month window prior to their birthday (plan ahead if possible). You can enroll online or in person with the Social Security office (pending appointment availability). We are available to help you through the enrollment process if you have questions at this stage in the process. Once enrolled online or in-person, always print a receipt of your enrollment date, write down and/or print the confirmation number from the Social Security. 

Since you are delaying your Social Security benefit, there is no monthly Social Security benefit check for the Part B premium to be withdrawn from, right? For this reason, you’ll be receiving a quarterly Part B bill. You will need to continue paying this bill to keep you Medicare Part B active until you elect to start your Social Security benefit and it’s automatically withdrawn. You will have the option to pay through a monthly checking account auto draft or monthly credit card. You’ll need to wait until you receive the quarterly bill to set up these other payment options. The standard Part B premium for 2022 is $170.10 (more if subject to IRMAA). Part A is again, “premium free” if you have fulfilled the minimum requirement of 10 years (40 quarters).

Once you elect to start your Social Security benefit at a later time (ie. 66-70), the Part B premium will then be withdrawn automatically each month (your monthly Social Security benefit amount minus the Part B premium = monthly Social Security benefit draft into your checking acct.) 

I chose to show this example because many times the SEP forms for Medicare enrollment for someone leaving an employer group plan AFTER the age of 65 can be mistakenly used in conjunction with IEP or in place of IEP (Initial Enrollment Period) 3 months prior to turning 65. 

IEP will take precedent over the SEP forms in this situation. To be clear, you do not want to use the SEP (leaving an employer group plan) enrollment unless you are outside the IEP period surrounding your 65th birthday. With that being said, for this example, he/she is enrolling prior to turning 65, yet still leaving an employer group plan. So, use the standard IEP enrollment period and proactively enroll directly with Social Security in-person or online for your Medicare (Part A & B) to begin on the 1st of your 65th birthday month. See SEP situation in the next example if you are curious how that works when enrolling in Medicare AFTER turning 65 and leaving an employer group plan outside your IEP. 

Mentor One Insight

Diane is approaching her 65th birthday –August 19th, 2022. Diane has been anticipating her retirement date since last year at 64, but after viewing the cost of medical insurance through the employer COBRA option or going on her own with an individual plan costing her approx. $1000 a month, this wasn’t an option for her. She decided to work another year with her current employer and plans to retire in July- the month before she turns 65. Since she is currently covered under her employer plan, she knows that if she retires the month prior to turning 65 (on the 10th of July and  her 65th bday is August 19th), her Medicare coverage starts 08/01/2022. If she leaves the employer plan on the 10th of July, she will have coverage through the end of the month through the employer plan. She will have no lapse in coverage. 

The day the employer plans ends, is the same day her Medicare activates as her primary coverage (08/01/2022). Diane is delaying her Social Security and plans to take it at a later date (ie.66-70). She is focused on Medicare timing at this time and can elect to start her Social Security at any point she sees fit in the future. Electing to start her Social Security benefit will not have an effect on her Medicare. It will only effect how her Medicare Part B premium is paid to Social Security (quarterly if delaying/monthly withdraw if taking the benefit). 

Three months before Diane’s 65th birthday month of August, Diane should proactively enroll herself into Medicare during her IEP (Initial Enrollment Period). Again, she is proactively enrolling in Medicare in-person or online because she has chosen to delay her Social Security benefit at this time. Once she has met with Social Security or confirmed her effective date/start date by enrolling in Medicare online, she is set to start her Medicare coverage – effective 08/01/2022.  

Now that Diane completed the first enrollment of coordinating her Medicare properly, she can comfortably continue reviewing the second enrollment process of reviewing Medicare plan paths and the insurance products to find the plan that best suits her coverage needs. After reviewing Medicare Basics 101 and the following steps of the process (5 Steps), Diane can now confidently contact John in May, June, or July to confirm her understanding of insurance products on her Medicare plan path as well as ask for quotes, pricing, and enrollment paperwork to start the enrollment process for the insurance products. Diane’s Medicare and Medicare insurance product(s) will all start 08/01/2022. Diane timed her retirement perfectly from leaving an employer group plan and transitioning to Medicare with no lapse in coverage. 

Are you delaying your Social Security benefit and plan to enroll in Medicare when you turn 65?

You will need to proactively enroll into Medicare (Part A & B) for coverage to start the 1st of the month you turn 65. It is best to do this 3 months before your 65th birthday month (The Part B Initial Enrollment Period starts 3 months before your 65th birthday). Most clients apply in this 1-3 month window prior to their birthday (plan ahead if possible).You are able to enroll up to the day prior to your 65th birthday month (ie. March, 31st– for an April 1 start date when 65th birthday is in April). If you apply the month of or just weeks prior to your 65th birthday month, you may not have your card in hand, but you will be covered- effective as of the 1st of your 65th birthday month.  You can enroll online or in person with the Social Security office (pending appointment availability). We are available to help you through the enrollment process if you have questions. Always print a receipt of your enrollment date, write down and/or print the confirmation number from the Social Security website if enrolling online. 

Since you are delaying your Social Security benefit, there is no monthly Social Security benefit for the Part B premium to be drafted from, right? With no Social Security benefit for you to withdraw your Part B, you will be receiving a direct bill in the mail. This bill will likely be quarterly, which you’ll need to continue paying to keep you Medicare active until you elect to start taking your Social Security benefit. The Part B premium will then be automatically withdrawn. 

Referring back to the quarterly Part B bill, you will have the option to pay through a monthly checking account, auto draft, or monthly credit card on the quarterly statements if you choose. You’ll need to wait until you receive the quarterly bill to set up these alternative payment options. The standard Part B premium for 2022 is 170.10 (more if subject to IRMAA). And as with all Medicare beneficiaries that worked for 10 years or 40 quarters and paid into Social Security, Part A is again, “premium free” to you.  

Once you elect to start your Social Security benefit at a later time since you are delaying it at this time, the Part B premium will then be automatically withdrawn each month (your monthly Social Security benefit amount minus the Part B premium = monthly Social Security draft into your account). Once this is set up, you should never have to update it. 

Mentor One Insight

Mark is currently retired. He works part time as a consultant, but continues to be covered through his spouse’s employer group health plan until he turns 65. He turns 65 on April 7th of 2022, so he wants his Medicare to start on the 1st of his 65th birthday month- 04/01/2022. Mark has savings and other forms of income through investments as well as his spouse’s income which is allowing him to delay his Social Security benefit to a later date. He has not decided exactly when he’ll take his benefit (he’s planning on a date between 66 and 70). For now, he is focused on only starting Medicare. Let’s assume it is early January, 2022 in this example. 

Mark will need to proactively enroll in Medicare for his Medicare to activate 04/01/2022. His Initial Enrollment Period for Part B (IEP) begins on January 1 of 2022 (3 months prior to his 65th birthday month). He can call Social Security to schedule an in-person appointment or can go online to SSA.gov to proactively enroll in Medicare prior to his desired April 1 start date. Mark and his wife show less income on their IRMAA than $182,000 so he will be paying the standard $170.10 per month for his Part B premium. He also fulfills the requirement for Part A after working for 45+ years. Therefore, Mark’s Part A is “premium free”. Since he has chosen to delay his Social Security benefit, there is not a monthly Social Security benefit to withdraw the $170.10 Part B premium. He will be mailed a Part B bill for $510.30 (quarterly). He can elect to pay this through his credit card or checking account auto draft as soon as he receives the quarterly statement and coordinates the payment option he prefers. Mark will likely receive this quarterly bill along with his Medicare card 2-4 weeks after coordinating his Medicare with Social Security for his 04/01/2022 start date.

Now that Mark has completed the first enrollment into Medicare (Part A & B) effective 04/01/2022, he can now move to the second enrollment and start reviewing Medicare Basics 101 to begin researching the “Parts” and Medicare plan paths and Medicare insurance products. Mark has a good idea of which “Plan Path” he prefers for his Medicare coverage. Mark scheduled an appointment in late January/early February to review his plan with John and to start the paperwork for completing applications for insurance products to start along with his Medicare on 04/01/2022. 

Are you actively taking your Social Security benefit and plan to enroll in Medicare when you turn 65?

You will be automatically enrolled in Medicare (Part A and B) qualifying by paying into Social Security for 10 years or 40 quarters. Your card will be mailed to you and it will indicate your Medicare coverage to begin on the 1st day of your 65th birthday month (ie. Birthday, March 21st– Medicare starts March 1, 2022). The card will typically be sent 3-4 months prior to your 65th birthday month. Assuming you’ve paid into Social Security for 40 quarters (or you qualify through your spouse), Part A is premium free to you (you were taxed!) Medicare Part B has a separate premium. The standard premium for 2022 is $170.10 (subject to change annually). The Part B premium will be automatically deducted from your Social Security benefit since you’ve already elected to start your Social Security benefit prior to your Medicare start date (you have a benefit amount established to deduct the $170.10 from monthly). 

If you happen to set up your Medicare at the same time you elected to start your Social Security benefit (simultaneously at 65), the Part B premium may be deducted as an automatic monthly draft (if set up in time for Social Security billing), or it may be billed to you as a quarterly statement until the payment deduction is processed. Review your Social Security benefits statement to confirm the Part B premium draft ($170.10 or more if subject to IRMAA).  Call your local Social Security office to confirm payment information or to coordinate the transition of the Part B premium payment. Once you’ve completed this enrollment, you can transition to planning out your second enrollment of choosing your Medicare insurance product(s) for that path.

Mentor One Insight

Roberta has been retired for a couple years and has been covered with an individual health plan until she is Medicare eligible. She is planning to transition to Medicare the month of her 65th birthday (when she is first eligible). She has already elected to start her Social Security benefit early at 62. Her birthday is February, 18 and wants to be sure her Medicare starts on the 1st of February (first possible day for her Medicare to begin). Let’s assume it’s the first week of November, 2021 in this example (3 months before her 65th birthday month).

Roberta will be automatically enrolled in Medicare since she is actively taking her Social Security benefit. She will get her Medicare card approximately 2–3 months prior to February. Since her Social Security benefit is already active, her Part B premium will be automatically deducted from her check each month starting in February of 2022. Her Part B premium will be the standard $170.10 and her Part A is “premium free” since she worked well over the 10 years to qualify. Her Part A and Part B effective dates on her Medicare card will both be 02/01/2022. She does not need to worry about the Part B Initial Enrollment Period (3 months before, the month of 65th bday, and 3 months after) for Medicare enrollment. Remember, Social Security automatically enrolled her using Roberta’s IEP and mailed her card directly to her. Roberta then can move on to the next step of enrollment into a Medicare insurance product of her choice. 

Roberta reviewed Medicare Basics 101 under the navigation bar and continued making her way through the 5 Step Medicare Enrollment Guide to find the Medicare plan path and insurance product that will give her the coverage that suits her healthcare needs. Roberta filled out the Help/Quote Request Form on the website in late November/early December. She now has an appointment scheduled to discuss plans and enroll into Medicare insurance products with John to get everything set up for her 02/01/2022 start date. 

Side-by-side comparison of Medicare Advantage Plans
(Medicare.gov - 95747, Placer, CA)

This screenshot was taken from Medicare.gov for educational purposes. The image above shows 3 of the 18 plans available in Placer County, California (95747) in 2022. These three plans were chosen to illustrate how to use the Medicare.gov plan finder as well as show Medicare beneficiaries how they can search for plans using Medicare.gov for side-by-side comparisons in groups of 3. 

The description of premium, deductibles, and OOP Max is intended to be used as educational examples of how the plans are presented by Medicare.gov. No sales material is provided on this site for Medicare Advantage Plans. Please contact my insurance agency directly, medicare.gov, or the insurance company for more plan details and/or to enroll a Medicare Advantage Plan. 

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Ask a Question.

Questions? We have answers.

Medicare Supplement vs. Medicare Advantage Plans?

At this point, you should have a decent grasp of Medicare Basics 101 and your path to a successful Medicare Enrollment with Social Security. Hopefully, you are planning ahead of your Medicare start date, as its best to give yourself plenty of time to get organized. At this point in the process, you may or may not have confirmation of your Medicare Part A & Part B effective dates. If you do, great. If your Medicare card is on its way, you should have confirmation of dates (online or in-person with SS office), which is just as good. If you’re still in the process of getting the enrollment process started (or planning it out), you’re still on the right track! 

Choosing between these two plan types will be the DECIDING FACTOR which will dictate how your Medicare will function. Try not to think about the insurance carriers yet– once you have a plan type in mind, we can then dig deeper to shop which carriers are offering what plans to find the best value for you. 

Choose your Plan Path:

Medicare (Part A & B) + Medicare Supplement + Part D Prescription Drug Plan

Medicare Advantage Plan w/ Part D Prescription Drug Plan Included (MAPD)

Keep in mind– as long as we get you enrolled in a Medicare Supplement + Part D Rx plan or a Medicare Advantage plan w/ a Part D Rx plan before your Medicare start date, either style of a Medicare insurance plan will be effective the 1st of the month you’re eligible to begin Yes, even if you were to enroll in a plan the day before your start date, although I don’t recommend waiting until the last minute. I only say this so if you’re being told to enroll months ahead by another agent/broker pressuring you, they’re full of it! 

Which Medicare plan type/design do you prefer? If you’ve made your decision, but still want to confirm with me over the phone to make sure you prefer that plan for the right reasons, I can do that for you. If you’ve gone through the plan types and are still unsure, and would like me to guide you through it step by step while you follow on your computer, then let’s do that. Contact my office to schedule a phone appointment and I’ll review anything you have questions about. In fact, talking briefly over the phone typically allows me to clarify questions in matter of minutes rather than both of us writing lengthly emails back and forth. A brief chat will also give you the opportunity to put a voice to your guide. You can then decide if you would like me to help assist you with plan selection as your Medicare insurance broker. I look forward to helping you through the insurance plan selection process.

CMS L564

For printable version-- see Medicare Forms & Documents

CMS- 40B

For printable version-- see Medicare Forms & Documents

CMS- 2022 Medicare Supplement Chart

Are you over 65, delaying your SS benefit, and starting Medicare after you retire?

4th month after turning 65 to any future date while covered under employer group plan.

Using a SEP to activate Medicare Start Date

Covered under an employer group plan after the age of 65. Using Form 40B and L564 to activate Medicare to begin any month you select.

4th month after turning 65 to any future date while covered under employer group plan.

1-8 months prior to desired Medicare start date

Submitting 40B & L564

You’ve signed off on 40B indicating your desired start date (1st of the month). Employer has signed off indicating you’ve had credible employer coverage on form L564. Submit both forms to Social Security to activate your Medicare on the future date-  1st of the month you chose within 8 months of submitting forms.

1-8 months prior to desired Medicare start date

1-3 months before Medicare start date-- after confirmation of Medicare start date with Social Security (SEP)

Enroll in Medicare Insurance Products(s) with Mentor One

Set appointment with John, confirm understanding of your preferred Medicare plans type, review Medicare plan quote, enroll in Medicare insurance product(s) of your choice by phone, in-person, or virtually. 

1-3 months before Medicare start date-- after confirmation of Medicare start date with Social Security (SEP)

Date of choice you indicated Medicare to start and your Medicare insurance product(s) to start.

You’re Covered!

Congratulations! You are covered and may use your Medicare and Medicare insurance product(s) as needed (no penalties applicable with “credible coverage”).

Date of choice you indicated Medicare to start and your Medicare insurance product(s) to start.

Working, delaying your Social Security benefit, and starting Medicare at age 65 (ie. August birthday)

May 1, 2022 - July 31, 2022 (3 months before 65th bday month).

Initial Enrollment Period (IEP) Medicare (Part A & B)

Working, yet retiring prior to 65th bday month. Delaying your Social Security benefit. You’ll be proactively enrolling yourself in-person or online with Social Security to have your Medicare begin on the 1st of your birthday month.

May 1, 2022 - July 31, 2022 (3 months before 65th bday month).

May 1, 2022 - July 31, 2022 (any day before August, 1).

Enroll in Medicare Insurance Product(s) with Mentor One

Set appointment with John, confirm understanding of your preferred Medicare plan type, review Medicare plan quote, enroll in Medicare insurance product(s) of your choice by phone, in-person, or virtually. 

May 1, 2022 - July 31, 2022 (any day before August, 1).

August 1, 2022

Medicare & Medicare Insurance Product(s) Start Date

Medicare (Part A & B) and your Medicare insurance product(s) start on the 1st of your 65th birthday month- 08/01/2022

August 1, 2022

August 1, 2022 - Future

You’re Covered!

Congratulations! You are covered and may use your Medicare card and Medicare insurance product(s) as needed. 

August 1, 2022 - Future

Delaying your SS benefit & starting Medicare at 65
(ie. April Bday)

January 1, 2022 - March 31, 2022 (3 months before 65th bday month).

Intial Enrollment Period (IEP) Medicare (Part A & B)

Since you are delaying your Social Security benefit, you’ll be proactively enrolling yourself in-person or online with Social Security to have your Medicare to begin on the 1st of your 65th birthday month.

January 1, 2022 - March 31, 2022 (3 months before 65th bday month).

January 1, 2022 - March 31, 2022 (any day before April, 1).

Enroll in Medicare Insurance Product(s) with Mentor One

Set appointment with John, confirm understanding of your preferred Medicare plan type, review Medicare plan quote, enroll in Medicare insurance product(s) of your choice by phone, in-person, or virtually. 

January 1, 2022 - March 31, 2022 (any day before April, 1).

April 1, 2022

Medicare & Medicare Insurance Product(s) Start Date

Medicare and your Medicare insurance product(s) start 04/01/2022. 

April 1, 2022

April 1, 2022 - Future

You’re Covered!

Congratulations! You are covered and may use your Medicare card and Medicare insurance cards as needed. 

April 1, 2022 - Future

Medicare Basics 101

Part A, Part B, Part C, Part D– Medicare Supplement plans & Medicare Advantage plans….Who came up with this system!? Well, it’s what we have to work with, so let’s break this down in stages to get a basic understanding of what each “Part” represents.  For starters, NO, you can’t have all 4 parts. As to why they choose to label them (A-D) as if they all fit together still puzzles me as well.  

Start by reviewing each category under Medicare Basics 101. Use this pop up to refer back to as needed:

Medicare Plan Map View how "Parts" interact with each Medicare plan path (two paths)

Original Medicare (Part A & B) The foundation of Medicare. Keep (w/ Medicare Supplement) or Sign Over (w/ Medicare Advantage).

Medicare Supplement Plans (Medigap) View the structure & functionality of the plan. (Keep Original Medicare Add Medicare Supplement).

Medicare Advantage Plans (Part C) View the structure & functionality of the plan. Sign Over to its own "Medicare Plan".

Medicare Prescription Plans (Part D) View the structure and functionality of the plan - Add (w/ Medicare Supplement) or Included (w/ Medicare Advantage).

Medicare Enrollment Planning Overview

First things first! Let’s take you through the enrollment process of activating your Part A & B of Medicare with Social Security. Start here with the Medicare Enrollment Planning section. In this section, you’ll be discovering when you’re able to enroll in Medicare and whether it will be automatic or you’ll need to be proactive with Social Security. You will also be able to view Timeline buttons under each enrollment scenario to reinforce the concepts (ie. IEP -3 months before your 65th birthday month, etc.).

Under this Medicare Enrollment Planning section, I’ve broken down the most likely Medicare Enrollment Scenarios, so you can read through each and find the one that best applies to your situation. The timing will depend on whether you have already started or delayed your Social Security benefit. Are you actively receiving a SS benefit, delaying the benefit, maybe undecided and still working? Every Medicare beneficiary’s goal is to activate their Medicare properly on the day they intend to take benefits, however, each person’s path may differ. Here is an outline of the enrollment scenarios:

- Have you taken your Social Security benefit and plan to enroll in Medicare when you turn 65?

- Are you delaying your Social Security benefit and plan to enroll in Medicare when you turn 65?

- Are you working until 65 or later, and delaying your Social Security benefit and enrolling in Medicare at age 65?

- Are you working past 65, delaying your Social Security benefit and moving to Medicare at later retirement date (leaving a group employer health plan upon retirement)?

- Can I get a spousal benefit through Social Security and my spouse's quarters to qualify for Medicare?

After this initial step of finding your Medicare enrollment path with Social Security, you’ll be ready to confirm your start date with Social Security and/or organize yourself so you’re ready for when the time comes to enroll (depends on how early you’re starting the planning process). After this first step, start the process of reviewing the “Parts” of Medicare and the “Plan Types” being offered to you under Medicare Basics 101.

Medicare Checklist for medicare enrollment.

John V. Crump

Broker | President

Welcome,

I would like to take the opportunity to share with you a little more about myself, John Crump, broker and mentor for MedicareSupplementMentor.com. First and foremost, I believe it’s important that you meet the person delivering the content that may influence your enrollment and/or coverage decision(s). I’ve built this site to help you navigate Medicare and Medicare insurance plans in a pressure free environment.

Us my Medicare Video Library, Map, Checklist, and 5 Step Enrollment Guide to process everything you need to know about “all things Medicare”. Here is a brief outline of what my site will help you with as you weigh your Medicare enrollment options and decide with whom you want to set up your Medicare insurance coverage:

- Coordinating Medicare with Social Security- Medicare Enrollment Planning

- Clearly define and explain to the "Parts" of Medicare- Medicare Basics 101

- Breakdown the Medicare plan paths & Medicare "Plan Types" - Compare Medicare Plans

- Objective Medicare plan quoting & Medicare insurance plan enrollment - Contact John

- Medicare & Medicare insurance product education from a broker's perspective.

As an independent insurance broker, I will be transparent with you. I am in the insurance business of brokering Medicare Supplement Plans for retirees. I make my living off of helping new clients enroll into Medicare insurance plans. My mission is change the high pressure sales environment most retirees are subject to surrounding their transition to Medicare with call centers. MedicareSupplementMentor.com was designed to change the way in which Medicare beneficiaries have access to accurate and trustworthy sources of information. You deserve to have access to information that is clear and direct. The accessible and comprehensive design will allow you to review the Medicare plan material at your own pace without an any agent’s “enroll now” sales pressure. If you found the material on my site useful, I do ask that you give me an opportunity to help you enroll in the Medicare Supplement Plan, Medicare Prescription Drug Plan , or Medicare Advantage Plan of your choice. 

Please take your time reviewing the layout and design of the site’s content. It’s all been constructed with you in mind. Take advantage on the “pop up” informative material, “maps”, and “buttons” which are all accessible throughout the site. Look for my Mentor One Insight, which will provide you with more details on each Medicare topic by applying hypothetical scenarios and examples throughout the site. 

I look forward to guiding you through the maze of Medicare plans when you’re ready.  

Thank you,

John V. Crump

AARP UnitedHealthcare

Aetna

Anthem Blue Cross

Blue Shield of California

Cigna

Authorized to Offer

Continental Life

Combined

Coventry

Health Net

Humana

IAC

Mutual of Omaha

National Guardian Life

Transamerica

Wellcare 

Actively taking Social Security & starting Medicare at 65
(ie. February birthday)

November, 1 2021 - January, 31, 2022 (3 months before 65th bday month)

Initial Enrollment Period (IEP) Medicare Part (A & B)

You’ll have automatic Medicare enrollment since your Social Security benefit is active. Medicare will begin on the first of the month you turn 65.

November, 1 2021 - January, 31, 2022 (3 months before 65th bday month)

November 1, 2021 -January 31, 2022 (any day prior to February, 1).

Enroll in Medicare Insurance Product(s) with Mentor One

Set appointment, confirm understanding of preferred Medicare plan type, review Medicare plan quote, enroll in Medicare insurance product of your choice by phone, in-person, or virtually.  

November 1, 2021 -January 31, 2022 (any day prior to February, 1).

February 1, 2022

Medicare & Medicare Insurance Product(s) Start Date

Medicare and your insurance product(s) start 02/01/2022.

 

February 1, 2022

February 1, 2022 -Future

You’re Covered!

Congratulations! You are covered and are ready to use your Medicare card and Medicare insurance cards as needed.

February 1, 2022 -Future

Medicare Plan Map

Medicare Map - choose your Medicare Plan path.

Medicare Planning Made Simple Booklet

Mailed directly to your mailbox.