As much as we appreciate the support it brings, we know Medicare can be somewhat confusing. To make things a little easier to understand, we’ve broken down our most frequently asked Medicare questions here. If you have questions about how Medicare works, how to get enrolled, or need to know who qualifies for Medicare, keep reading below.
What is Medicare?
Medicare is a health insurance program for Americans 65+ years old. It was created by the federal government and continues to be maintained at the federal level.
Medicare is also offered to qualified young people with disabilities and people with End-Stage Renal Disease (ESRD).
Medicare is divided into multiple tiers of coverage, or parts. The most common parts are:
- Medicare Part A: Hospital Insurance
Provides coverage should you need to visit a hospital. This covers inpatient stays, care required in a nursing facility, hospice and some level of home health care. - Medicare Part B: Medical Insurance
Covers qualified doctors’ visits, outpatient treatment, medical supplies and preventative care. This can be declined. - Medicare Part C: Medicare Advantage Plans
Offered by private companies to contract out Medicare Part A & B. - Medicare Part D: Prescription Drug Coverage
Prescription coverage added to your Medicare package.
What are the three phases of Medicare Part D: Prescription Drug Coverage?
Phase 1: Deductible Phase
In this phase, Medicare patients must pay a certain amount out of pocket before the prescription drug plan will kick in. This amount will vary by plan.
Phase 2: Initial Coverage Phase
After you’ve reached your deductible, you will start paying the plan’s cost share for covered medications.
Phase 3: The Donut Hole, Coverage Gap Phase
This is the phase where you start to see the true cost for your prescriptions. You are responsible to pay up to $2,000/year for medication(s) and you could be responsible for a large amount of this cost depending on your plan. This is not an option for most patients, especially ones who are on fixed incomes. This is why we urge you to contact us at 1-877-386-0206 ext 1 or apply for assistance online.
What exactly is the Medicare donut hole?
The Medicare donut hole referred to the gap in coverage from Medicare Part D plans but is not valid effective January 1, 2025. Under the new laws, after you have met your deductible, you have a maximum $2,000 out of pocket maximum spend for the year. That could leave you with high out of pocket medication costs. Speak with one of our staff and we can show you how to save money for your medication(s).
Phase 1: Deductible Phase
In this phase, Medicare patients must pay a certain amount out of pocket before the prescription drug plan will kick in. This amount will vary by plan.
Phase 2: Initial Coverage Phase
After you’ve reached your deductible, you will start paying the plan’s cost share for covered medications.
Phase 3: The Donut Hole, Coverage Gap Phase
This is the phase where you start to see the true cost for your prescriptions. Unless you want to wait until January 1st when your plan resets, the only way to get out of this phase is for you to spend an additional $1,700 out of pocket on medications in the current year.
This is not an option for most patients, especially ones who are on fixed incomes. This is why we urge you to contact us at 1-877-386-0206 ext 1 or apply for assistance online.
Phase 4: Catastrophic Phase
You get a bit of a break in this phase since you have spent so much out of pocket during the year. In the catastrophic phase, you pay whichever amount is greater: either 5% of the covered drug cost or $2.65 for generics and $6.60 for brand name drugs.
How can Simplefill help?
Let Simplefill, ease the burden of high copays or the much dreaded donut hole. If you’re currently paying more than $100 out-of-pocket for your prescription needs, contact the Simplefill team. Apply Today and start getting help.
How do I apply for Medicare?
You can apply for Medicare online at socialsecurity.gov. You can start the application process when you are 64 years and 9 months old—this is because you can apply either three months before or three months after your 65th birthday. This time is generally referred to as Medicare Open Enrollment.
How does Medicare work?
For Original Medicare, which is the default option when you sign up for Medicare, you can see any doctors or hospitals that accept Medicare, or new Medicare patients.
When you apply to Medicare, you select which plans you would like to enroll in. Enrolling in Part A costs nothing, but from there you can pick and choose which other parts to add to your Medicare coverage.
However, there is an out-of-pocket cost for Medicare Part B, which varies by which plan you choose. In most cases, you pay a deductible before Medicare pays out its share of your healthcare costs.
Who qualifies for Medicare?
In general, U.S. Citizens qualify for Medicare at age 65 if they meet all three of the following conditions:
- US. citizen or legal resident;
- And have lived in the United States for at least five years;
- And have worked a minimum of 10 years in Medicare-covered employment
Prior to turning 65, you’ll likely have received information in the mail from Medicare about your coverage options.
If you are a U.S. citizen or legal resident aged 65+ but don’t meet the above requirements, you can enroll in “voluntary enrollment.” This means you’ll need to pay monthly premiums for both Medicare Part A and Medicare Part B.
If you’re younger than 65, your eligibility requirements are a little different. You can qualify for Medicare if you either have End-Stage Renal Disease (ESRD) or you’ve received Social Security Disability Income (SSDI) payments for 24 months. You can also qualify for Medicare if you’re in the first month of receiving disability payments for ALS.