General Information

What is Medicare?

Medicare is a health insurance program for people 65 years of age and older, some disabled people under 65 years of age, and people with end-Stage Renal Disease (permanent kidney failure treated with dialysis or a transplant).

Medicare has two parts. Part A is hospital insurance. Most people do not have to pay for Part A. Part B is medical insurance. Most people pay monthly for Part B. Click here for Medicare Premiums for Part A & Part B. (This information is provided by the Center of Medicare & Medicaid Studies.)

Will a beneficiary get Medicare coverage?

Everyone eligible for Social Security Disability Insurance (SSDI) benefits is also eligible for Medicare after a 24-month qualifying period. The first 24 months of disability benefit entitlement is the waiting period for Medicare coverage. During this qualifying period for Medicare, the beneficiary may be eligible for health insurance through a former employer. The employer should be contacted for information about health insurance coverage.

How months are counted?

SSA counts one month for each month of disability benefit entitlement.

When do previous periods of disability count?

Months in previous periods of disability may be counted towards the 24-month Medicare qualifying period if the new disability begins:

  • Within 60 months after the termination month of the workers` receiving disability benefits; or
  • Within 84 months after the termination of disabled widows` or widowers` benefits or childhood disability benefits; or
  • At any time if the current disabling impairment is the same as, or directly related to, the impairment which was the basis for the previous period of disability benefit entitlement.

What happens to Medicare coverage if a beneficiary works?

A beneficiary may receive at least 93 months of hospital and medical insurance after the trial work period as long as she/he still has a disabling impairment. This provision allows health insurance to continue when a beneficiary goes to work and engages in substantial gainful activity. The beneficiary does not pay a premium for hospital insurance. Although cash benefits may cease, the beneficiary has the assurance of continued health insurance.

After premium-free Medicare coverage ends due to work, beneficiaries can purchase Medicare hospital and medical insurance if they continue to have a disability at the end of the 93-month period.

Click here for an Overview of the Extension of Medicare Coverage Provision (as provided by the Ticket to Work and Work Incentives Act of 1999.)

Who is eligible to buy Medicare coverage?

Beneficiaries are eligible to buy Medicare coverage if:

  • They are not 65
  • Have a disabling impairment
  • Their Medicare stopped due to work

What type of Medicare can a beneficiary buy?

A beneficiary can buy Premium Hospital Insurance (Part A) at the same monthly cost which uninsured eligible retired beneficiaries pay ($441.00 per month for 2013 or $243.00 per month if the beneficiary has earned 30 quarters of coverage); and

A beneficiary can buy Premium Supplemental Medical Insurance (Part B) at the same monthly cost which uninsured eligible retired beneficiaries pay ($104.90 per month for 2013); or

A beneficiary can buy Hospital Insurance separately without Supplemental Medical insurance. A beneficiary can buy Supplemental Medical Insurance only if they buy Hospital Insurance.

When can a beneficiary enroll?

During their initial enrollment period (the month they are notified about the end of their premium-free health insurance and the following seven months);

During the annual general enrollment period (January 1 through March 31 of each year); or

During a special enrollment period if they are covered under an employer group health plan.

Some beneficiaries with low incomes and limited resources may be eligible for State assistance with these expenses. Please refer to Qualified Disabled Working Individual for more information.


Medicare for Working Beneficiaries with Disabilities

Question: How long will I get to keep Medicare if I go to work?

Answer: As long as your disabling condition still meets our rules, you can keep your Medicare coverage for at least 8 ½ years after you return to work. (The 8 ½ years includes your nine month trial work period.)

Question: I have Medicare hospital Insurance (Part A) and medical insurance (Part B) coverage. Will I get to keep both parts?

Answer: Yes, as long as your disabling condition still meets our rules. Your Medicare hospital insurance (Part A) coverage is premium-free. Your Medicare medical insurance (Part B) coverage will also continue. You or a third party (if applicable) will continue to pay for Part B. If your Social Security Disability Insurance cash benefits stop due to your work, you or a third party (if applicable) will be billed every 3 months for your medical insurance premiums. If you are receiving cash benefits, we will continue to deduct your medical insurance premiums from your check.

Question: I have Medicare (Part A) but I did not take Part B coverage when it was first offered to me. Can I get Part B now?

Answer: Yes. If you did not sign up for Part B, you can only sign up for it during a general enrollment period (January 1st through March 31st of each year) or a special enrollment period.

The special enrollment period is available if you have been covered under a group health plan based on your own or a family member's current employment status since the month you were first eligible for Part B.

You can sign up for Part B during any month you are covered under the group health plan based on current employment status, or during the 8-month period that begins the first full month after the employment or the group health plan coverage ends, whichever comes first.

Question: When I return to work and get medical coverage through my employer, will this change my Medicare? Do I need to notify anyone?

Answer: Medicare may be the "secondary payer" when you have health care coverage through your work. See the information under "Coordination of Medicare and Other Coverage for Working Beneficiaries with Disabilities" about when Medicare is a "secondary payer or primary payer". Notify your Medicare contractor or the Coordination of Benefits Contractor at 1-800-999-1118 right away. Prompt reporting may prevent an error in payment for your health care services.

Question: After my Trial Work Period, how long will I have Medicare coverage?

Answer: You will get at least 7 years and 9 months of continued Medicare coverage, as long as your disabling condition still meets our rules.

Promptly report any changes in your work activity. This way you can be paid correctly, and we can tell you how long your Medicare coverage will continue after you return to work.

Question: I plan to continue working. Will I be able to purchase Medicare after my premium-free Medicare Part A (hospital insurance) coverage ends?

Answer: Yes. As long as you still have a disabling condition, you can purchase Medicare Part A (hospital insurance). If you purchase Part A, you may purchase medical insurance (Part B). You cannot purchase Part B in this situation, unless you also purchase Part A.

Question: Do I need to apply for premium Medicare Part A (hospital insurance)? If so, when?

Answer: Yes. Once your premium free Medicare Part A coverage ends, you will get a notice that will tell you when you can file an application to purchase Medicare coverage.

Question: How much are the premiums if I decide to purchase Medicare Part A?

Answer:

Part A (Hospital Insurance) premium for 2013

  • $243.00 per month if you or a spouse has at least 30 quarters of Medicare covered employment. (Note: If an individual works in covered employment during the 8 ½ year premium-free Medicare period, 38 quarters of coverage would be earned.)

  • $441.00 per month if you have less than 30 quarters of Medicare covered employment).

Part B (Medical Insurance) premium for 2013

  • $104.90 per month.

There is a program that may help you with your Medicare Part A premiums if you decide to purchase Part A after your extended coverage terminates. To be eligible for this help, you must be:

  • Under age 65.
  • Continue to have a disabling impairment.
  • Sign up for Premium Hospital Insurance (Part A).
  • Have limited income.
  • Have resources worth less than $4,000 for an individual and $6,000 for a couple, not counting the home where you live, usually one car, and certain insurance.
  • Not already be eligible for Medicaid.

To find out more about this program, contact your county, local or State Social Services or medical assistance office. Ask about the Medicare buy-in program for Qualified Disabled and Working Individuals.

Question: Where can I find publications on Medicare?

Answer: You can view, print, or order publications online or by calling 1-800-MEDICARE (1-800-633-4227). The fastest way to get a publication is to use our search tool and then view and print it. If you order online or through 1-800-MEDICARE, you will receive your order within 3 weeks. The link to search publications is at: http://www.medicare.gov/Publications/home.asp

Question: If I have additional question on my Medicare coverage, who do I call?

Answer: 1-800-MEDICARE (1-800-633-4227) or TTY/TDD: 1-877-486-2048 for the hearing and speech impaired)

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Coordination of Medicare and Other Coverage for Working Beneficiaries with Disabilities

Question: I am under age 65, disabled, working and have both Medicare and group health coverage. Who pays first?

Answer: It depends. If your employer has less than 100 employees, Medicare is the primary payer if:

  • you are under age 65, and
  • have Medicare because of a disability.

If the employer has 100 employees or more, the health plan is called a large group health plan. If you are covered by a large group health plan because of your current employment or the current employment of a family member, Medicare is the secondary payer (see example below).

Sometimes employers with fewer than 100 employees join other employers in a multi-employer plan. If at least one employer in the multi-employer plan has 100 employees or more, then Medicare is the secondary payer for disabled Medicare beneficiaries enrolled in the plan, including those covered by small employers. Some large group health plans let others join the plan, such as a self-employed person, a business associate of an employer, or a family member of one of these people. A large group health plan cannot treat any of its plan members differently because they are disabled and have Medicare. A large group health plan must offer the same benefits to plan members and their spouses that are over 65 and disabled as are offered to employees and their spouses under 65.

Example: Mary works full-time for GHI Company, which has 120 employees. She has large group health plan coverage for herself and her husband. Her husband has Medicare because of a disability. Therefore, Mary's group health plan coverage pays first for Mary's husband, and Medicare is his secondary payer.

Question: If I have additional question on my Medicare coverage, who do I call?

Answer: 1-800-MEDICARE (1-800-633-4227) or TTY/TDD: 1-877-486-2048 for the hearing and speech impaired)

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Medicare and Group Health Coverage for People with
End-Stage Renal Disease (ESRD) (Permanent Kidney Failure)

Question: I have ESRD and group health coverage. Who pays first?

Answer: If you are eligible to enroll in Medicare because of End-Stage Renal Disease (permanent kidney failure), your group health plan will pay first on your hospital and medical bills for 30 months, whether or not you are enrolled in Medicare and have a Medicare card. During this time, Medicare is the secondary payer. The group health plan pays first during this period no matter how many employees work for your employer, or whether you or a family member are currently employed. At the end of the 30 months, Medicare becomes the primary payer. This rule applies to all people with ESRD, whether you have your own group health coverage or you are covered as a family member.

Example: Bill has Medicare coverage because of permanent kidney failure. He also has group health plan coverage through the company he works for. His group health coverage will be his primary payer for the first 30 months after Bill becomes eligible for Medicare. After 30 months, Medicare becomes the primary payer.

Question: Can a group health plan deny me coverage if I have permanent kidney failure?

Answer: No. Group health plans cannot deny you coverage, reduce your coverage, or charge you a higher premium because you have ESRD and Medicare. Group health plans cannot treat any of their plan members who have ESRD differently because they have Medicare.

Question: If I have additional question on my Medicare coverage, who do I call?

Answer: 1-800-MEDICARE (1-800-633-4227) or TTY/TDD: 1-877-486-2048 for the hearing and speech impaired)

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Medigap Policies for People Under Age 65
With a Disability or End-Stage Renal Disease

A Medigap policy is a health insurance policy sold by private insurance companies to help you pay the medical costs the Original Medicare Plan does not cover.

Question: If I have Medicare and I want to enroll in mine or my spouse's employer group health plan, can I stop my Medigap policy?

Answer: The Ticket to Work and Work Incentive Improvement Act of 1999 gives you the right to suspend a Medigap policy. If you are under 65, have Medicare, and have a Medigap policy, you have the right to suspend your Medigap policy. This lets you suspend your Medigap policy benefits and premiums, without penalty, while you are enrolled in your or your spouse's employer group health plan.

If, for any reason, you lose your employer group health plan coverage, you can get your Medigap policy back. You must notify your Medigap insurance company that you want your Medigap policy back within 90 days of losing your employer group health plan coverage.

Your Medigap benefits and premiums will start again on the day your employer group health plan coverage stopped. The Medigap policy must have the same benefits and premiums it would have had if you had never suspended your coverage. Your Medigap insurance company can't refuse to cover care for any pre-existing conditions you have. So, if you are disabled and working, you can enjoy the benefits of your employer's insurance without giving up your Medigap policy.

Question: If I have additional question on my Medicare coverage, who do I call?

Answer: 1-800-MEDICARE (1-800-633-4227) or TTY/TDD: 1-877-486-2048 for the hearing and speech impaired)

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Medicare and Veteran's Benefits

Question: I have Medicare and Veteran's benefits. Who pays first?

Answer: If you have or can get both Medicare and Veterans benefits, you can get treatment under either program. When you get health care, you must choose which benefits you are going to use. You must make this choice each time you see a doctor or get health care, like in a hospital. Medicare cannot pay for the same service that was covered by Veterans benefits, and your Veterans benefits cannot pay for the same service that was covered by Medicare. You do not have to go to a Department of Veterans Affairs (VA) hospital or to a doctor who works with the VA for Medicare to pay for the service. However, to get services paid by VA, you must go to a VA facility or have the VA authorize services in a non-VA facility.

Question: Are there any situations when both Medicare and VA can pay?

Answer: Yes. If the VA authorizes services in a non-VA hospital, but doesn't pay for all of the services you get during your hospital stay, then Medicare may pay for the Medicare-covered part of the services that the VA does not pay for.

Example: John, a veteran, goes to a non-VA hospital for a service that is authorized by the VA. While at the non-VA hospital, John gets other non-VA authorized services that the VA refuses to pay for. Some of these services are Medicare-covered services. Medicare may pay for some of the non-VA authorized services that John received. John will have to pay for services that are not covered by Medicare or the VA.

Question: Can Medicare help pay my VA co-payment?

Answer: Sometimes. The VA charges a co-payment to some veterans. The co-payment is your share of the cost of your treatment, and is based on income. Medicare may be able to pay all or part of your co-payment if you are billed for VA-authorized care by a doctor or hospital that is not part of the VA.

Question: I have a VA fee basis ID card. Who pays first?

Answer: The VA gives fee basis ID cards to certain veterans. You may be given a fee basis card if:

  • You have a service connected disability;
  • You will need medical services for an extended period of time; or
  • There are no VA hospitals in your area.

If you have a fee basis ID card, you may choose any doctor that is listed on your card to treat you for the condition. If the doctor accepts you as a patient and bills the VA for services, the doctor must accept the VA's payment as payment in full. The doctor may not bill either you or Medicare for any charges. If your doctor doesn't accept the fee basis ID card, you will need to file a claim with the VA yourself. The VA will pay the approved amount to either you or your doctor.

Question: Where can I get more information?

Answer: You can get more information on Veterans' benefits by calling your local VA office, or the national VA information number 1-800-827-1000. Or, you can use a computer to look on the Internet at www.va.gov. If you do not have a computer, your local library or senior center may be able to help you get this information using their computer.

Question: If I have additional question on my Medicare coverage, who do I call?

Answer: 1-800-MEDICARE (1-800-633-4227) or TTY/TDD: 1-877-486-2048 for the hearing and speech impaired)

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Medicare and COBRA (The Consolidated Omnibus Budget Reconciliation Act of 1985)

Question: What is COBRA?

Answer: COBRA is a law that requires employers with 20 or more employees to let employees and their dependents keep their group health coverage for a time after they leave their group health plan under certain conditions. This is called continuation coverage. You may have this right if you lose your job or have your working hours reduced, or if you are covered under your spouse's plan and your spouse dies or you get divorced. COBRA generally lets you and your dependents stay in your group health plan for 18 months (or up to 29 or 36 months in some cases), but you may have to pay both your share and the employer's share of the premium. Some state's laws require employers with less than 20 employees to let you keep your group health coverage for a time, but you should check with your State Department of Insurance to make sure. In most situations that give you COBRA rights, other than a divorce, you should get a notice from your benefits administrator. If you don't get a notice, or if you get divorced, you should call your benefits administrator as soon as possible.

Question: What happens if I have COBRA and enroll in Medicare?

Answer: If you already have group health coverage under COBRA when you enroll in Medicare, your COBRA may end.

The length of time your spouse may get coverage under COBRA may change when you enroll in Medicare. For more information about group health coverage under COBRA, call your State Department of Insurance.

Question: What happens if I am in Medicare and choose to get COBRA coverage?

Answer: If you elect COBRA coverage after you enroll in Medicare, you can keep your COBRA continuation coverage. If you have only Medicare Part A when your group health plan coverage based on current employment ends; you can enroll in Medicare Part B during a Special Enrollment Period without having to pay a Part B premium penalty. You need to enroll in Part B either at the same time you enroll in Part A or during a Special Enrollment Period after your group health plan coverage based on current employment ends. However, if you have Medicare Part A only, sign-up for COBRA coverage, and wait until the COBRA coverage ends to enroll in Medicare Part B; you will have to pay a Part B premium penalty. You do not get a Part B special enrollment period when COBRA coverage ends. State law may give you the right to continue your coverage under COBRA beyond the point COBRA coverage would ordinarily end. Your rights will depend on what is allowed under the state law.

Remember, enrolling in Medicare Part B will also trigger your Medigap open enrollment period. To make sure you understand about this, you should call
1-800-MEDICARE (1-800-633-4227, TTY/TDD:
1-877-486-2048 for the hearing and speech impaired) and ask for your free copy of the Guide to Health Insurance for People with Medicare.

Question: Who pays first, Medicare or my COBRA continuation coverage?

Answer: If you are age 65 or older and have Medicare and COBRA continuation coverage, Medicare pays first. If you or a family member has Medicare based on a disability and COBRA coverage, Medicare is the primary payer. However, if you or a family member has Medicare based on ESRD, the COBRA coverage is the primary payer and Medicare is the secondary payer for the first 30 months.

Question: If I have additional question on my Medicare coverage, who do I call?

Answer: 1-800-MEDICARE (1-800-633-4227) or TTY/TDD: 1-877-486-2048 for the hearing and speech impaired)

For more information about Medicare go to: http://www.medicare.gov