The Basics of Medicare

Medicare is the federal government program that provides health care coverage (health insurance) if you are 65+, under 65 and receiving Social Security Disability Insurance (SSDI) for a certain amount of time, or under 65 and with End-Stage Renal Disease (ESRD).

Once you have become Medicare-eligible and enroll, you can choose to get your Medicare benefits from Original Medicare, the traditional fee-for-service program offered directly through the federal government, or from a Medicare Advantage Plan, a type of private insurance offered by companies that contract with Medicare (the federal government). Original Medicare includes:

• Part A (Inpatient/hospital coverage)
• Part B (Outpatient/medical coverage)

If you want Medicare prescription drug coverage (Part D) with Original Medicare, in most cases you will need to actively choose and join a stand-alone Medicare private drug plan (PDP).

You still have Medicare if you enroll in a Medicare Advantage Plan. This means that you will still owe a monthly Part B premium (and your Part A premium, if you have one). Each Medicare Advantage Plan must provide all Part A and Part B services covered by Original Medicare, but can do so with different rules, costs, and restrictions that can affect how and when you receive care. Medicare Advantage Plans can also provide Part D coverage.

Note: if you have health coverage from a union or current or former employer when you become eligible for Medicare, you may automatically be enrolled in a Medicare Advantage Plan that they sponsor. You have the choice to stay with this plan, switch to Original Medicare, or enroll in a different Medicare Advantage Plan, but you should speak with your employer/union before making any change.

Medicare Vs. Medicaid

Medicare and Medicaid are two separate, government-run programs. They are operated and funded by different parts of the government and primarily serve different groups.

• Medicare is a federal program that provides health coverage if you are 65+ or under 65 and have a disability, no matter your income.
• Medicaid is a state and federal program that provides health coverage if you have a very low income.
• If you are eligible for both Medicare and Medicaid (dually eligible), you can have both. They will work together to provide you with health coverage and lower your costs.

Also know that while Medicare and Medicaid are both health insurance programs administered by the government, there are differences in covered services and cost-sharing. Make sure to call 1-800-MEDICARE or contact your local Medicaid office to learn more about Medicare and Medicaid costs and coverage, especially if you are a dual-eligible.

The “Welcome to Medicare” Preventive Visit

Medicare Part B (Medical Insurance) offers its new enrollees the “Welcome to Medicare” preventive visit. This service is tailored to help those newly enrolled in Medicare Part B take proactive steps to maintain their health. It involves a comprehensive assessment and education on preventive strategies, rather than a physical exam, and serves as a detailed evaluation with your healthcare provider.¹

This preventive visit is fully covered under Medicare Part B. Eligible beneficiaries can use this service once during the first year of their Part B enrollment.

During the “Welcome to Medicare” preventive visit, your healthcare provider will:

• Review Medical and Social History: Your provider will examine your medical history and any social factors that may influence your health.
• Provide Information on Preventive Services: You’ll receive details on preventive services, including necessary screenings and recommended immunizations, such as flu and pneumococcal vaccines.
• Conduct a Risk Assessment: Your provider will evaluate your risk factors for substance use disorders, such as alcohol and tobacco use, and depression. Referrals for further treatment will be made if necessary.
• Make Referrals for Additional Care: Referrals for additional medical care will be provided if needed.
• Calculate Body Mass Index (BMI): Your BMI will be calculated during the health assessment.
• Perform a Vision Test: A basic vision test will be conducted.
• Discuss Advance Directives: Your provider will offer to discuss creating advance directives, legal documents that outline your wishes for future medical treatment if you’re unable to make decisions.
• Provide a Written Preventive Plan: You’ll receive a written plan detailing the screenings, vaccines, and other preventive services you need.

When arranging your appointment, inform the doctor’s office that you want the “Welcome to Medicare” preventive visit. Bring along your medical records, immunization history, family health history, and a list of any medications or supplements you take.

For beneficiaries whose providers accept assignment, there is no charge for the visit, and the Part B deductible does not apply. However, if additional tests or services not covered under this preventive benefit are performed during the visit, you may incur costs. It’s essential to discuss any recommended additional services with your provider and verify what Medicare will cover to avoid unexpected expenses.

The “Welcome to Medicare” preventive visit is an essential step in managing your health as a new Medicare beneficiary. It offers an excellent chance to evaluate your current health status and prepare for a healthier future.

Medicare’s Annual “Wellness” Visit

Medicare Part B offers coverage for an annual “Wellness” visit, a crucial preventive measure for beneficiaries designed to create or update a personalized health plan. This visit is not a physical exam; instead, it provides an opportunity to develop a strategy for preventing disease and disability based on your current health status and risk factors.²

During the “Wellness” visit, you will complete a “Health Risk Assessment” questionnaire to help you and your healthcare provider develop a customized prevention plan. The visit typically includes:

• Routine measurements like height, weight, and blood pressure
• Health advice and a review of your medical and family history
• An evaluation of your current medications
• Personalized health advice and advanced care considerations
• A schedule for appropriate preventive screenings
• An optional “Social Determinants of Health Risk Assessment” to identify social needs impacting treatment

Additionally, a cognitive assessment is performed to detect signs of dementia and other mental decline. If cognitive impairment is suspected, Medicare covers a separate, more thorough evaluation. For those with opioid prescriptions, a risk assessment for opioid use disorder and an evaluation of pain management strategies are also conducted, with referrals provided if necessary. Risks related to substance use disorders, including alcohol and tobacco use, are assessed, and treatment referrals are made if needed.

To be eligible for the annual “Wellness” visit, it must be scheduled at least 12 months after your Part B enrollment or your “Welcome to Medicare” preventive visit. The “Welcome to Medicare” visit is not required for eligibility.

There are no charges for the “Wellness” visit if your healthcare provider accepts assignment. The Part B deductible does not apply. However, coinsurance and the Part B deductible may apply if additional tests or services are performed that Medicare does not cover under this preventive benefit. For services not covered by Medicare, such as a routine physical exam, you may be responsible for the full cost.

The “Wellness” visit is available once every 12 months. It’s recommended to discuss the costs of any tests, items, or services with your healthcare provider, especially if they suggest services that Medicare may not cover or that are offered more frequently than allowed. Specific costs depend on various factors, including additional insurance, your doctor’s charges, whether your doctor accepts assignment, the type of facility, and the location of the service.

Medicare’s annual “Wellness” visit is a proactive approach to maintaining health and preventing disease. By understanding what the visit includes and how it is covered, beneficiaries can make informed healthcare decisions and manage any potential out-of-pocket costs effectively.

Questions to Ask About Medicare

If you are new to Medicare, there are several questions you should consider while approaching or within your Initial Enrollment Period (IEP) or a Special Enrollment Period (SEP). Use this guide to consider your options when preparing to enroll in Medicare or after you have already enrolled.

What are the basics?

Medicare is a complex program and can sometimes be confusing. The best place to start when you are new to Medicare is by familiarizing yourself with the differences between it and the health insurance you have now. Learn what makes a person Medicare-eligible, the different parts of Medicare insurance and what those parts cover, times to enroll in Medicare, and how putting off enrollment can result in penalties. These initial steps will help smooth the transition from your current insurance to Medicare once you are eligible.

What are your coverage options?

Everyone has different health care needs, meaning the coverage that is right for your friends or family may not be right for you. Will you enroll in Original Medicare or would you prefer a Medicare Advantage Plan that may limit your provider networks or have different costs but that offers additional coverage? If you have current employer insurance, you may decide not to enroll in Medicare until you have retired. If you are already retired, you might find that Original Medicare plus retiree insurance works better for you than Original Medicare plus a Medigap (or vice versa). Find out the full range of your coverage options.

Should you enroll in Part D?

Medicare’s prescription drug benefit (Part D) is the part of Medicare that provides outpatient drug coverage. Part D is provided only through private insurance companies that have contracts with the federal government—it is never provided directly by the government (unlike Original Medicare).

If you want to get Part D coverage, you have to choose and enroll in a private Medicare prescription drug plan (PDP) or a Medicare Advantage Plan with drug coverage (MAPD). Enrollment is optional (though recommended to avoid incurring future penalties) and only allowed during approved enrollment periods. Typically, you should sign up for Part D when you first become eligible to enroll in Medicare.

Whether you should sign up for a Medicare Part D plan depends on your circumstances. You may have creditable drug coverage from employer or retiree insurance. If so, you don’t need to enroll in a prescription drug plan until you lose this coverage. Also, some people already enrolled in certain low-income assistance programs may be automatically enrolled in a Medicare drug plan and receive additional financial assistance paying for their medicines.

Are you eligible for programs that help lower Medicare costs?

There are several programs for people with low incomes that help pay for Medicare-related costs, such as premiums and copays. Some of these programs are federal while others are state-specific. Find out whether you meet the eligibility requirements and take full advantage.

What resources exist to help you navigate Medicare?

Medicare is a complex and beneficial program, and a variety of trusted sources can help you navigate your rights and options. A few are listed here:

• 1-800-MEDICARE
• Social Security Administration (https://www.ssa.gov/)
• State Health Insurance Assistance Program (SHIP) (https://www.shiptacenter.org/)
• Medicare Rights Center (https://www.medicarerights.org/)