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Understanding Medicare: How the Health Insurance Information, Counseling and Assistance Program Can Help

Medicare is a federal health insurance program for people 65 and over, certain people with disabilities under 65, and those with End Stage Renal Disease (ESRD).  For some people, understanding the specific details of Medicare comes easily.  However, some communities may not know how to access Medicare, such as those with limited English proficiency, and immigrants who came to the U.S. later in life.  The eligibility and enrollment guidelines are confusing, and the costs can be high, particularly for lower income individuals, which is why it’s important to know about cost-saving programs.

The New York City Department for the Aging’s Health Insurance Information, Counseling and Assistance Program (HIICAP) is an excellent resource for questions about Medicare.  HIICAP counselors provide free and objective Medicare information.  HIICAP can also help you learn about programs that may be able to help you with lowering your Medicare costs, such as the Medicare Savings Program and Extra Help. To reach a HIICAP counselor in NYC, call 311 and ask for HIICAP.  Before reaching out, you may find it helpful to review the basics of Medicare.

Medicare consists of three main parts –

  • Part A covers inpatient hospital stays and care in a skilled nursing.  People who have a work history and at least 40 quarters of coverage with the Social Security Administration receive premium-free Part A, so they don’t pay anything to have the benefit.  If you or your spouse don’t have the 40 quarters of coverage, you can buy Part A, though it is expensive; lower income individuals may qualify for a program that can pay for the Part A premium.
  • Part B covers physician services, which includes doctors’ visits, therapy, lab tests, x-rays and outpatient surgery.  You don’t need a work history to qualify for Part B, but you need to be a U.S. citizen, or a Legal Permanent Resident for 5 years.  Medicare Part B has a monthly premium, $135.50 per month in 2019.  The Medicare Savings Program can help pay the premium for lower income individuals.
  • Part D is prescription drug coverage.  Each Part D plan has its own premium and cost sharing requirements.  Extra Help is a program which can help lower Part D costs for people with limited income and resources.

There are many companies that offer Medicare products. Even with all of the advertisements that you have seen, there are really only two choices for getting your Medicare benefits – either withOriginal Medicare, or a Medicare Advantage plan.  Original Medicare offers maximum provider choice, but has significant cost-sharing, so you may want to explore some type of secondary coverage to protect you from high medical costs.  Examples include Medicaid (for people with limited income and resources) Medigap (a supplemental insurance policy that works with Medicare), or retiree/union coverage from a former employer.   In Original Medicare, if you want drug coverage, you would buy a separate Part D plan that only covers drugs.  In a Medicare Advantage plan, you are choosing to get all of your Medicare benefits (A + B+ D, if you want drug coverage) from a private company and you can be restricted to a provider network.  You can often get a Medicare advantage plan for zero premium, which makes it attractive to many people.  However, it is important to understand how much you will have to pay when you go to the doctor or access other health services.  Whether you are in Original Medicare or a Medicare Advantage plan, you will be responsible for the monthly Part B premium.

The Social Security Administration handles enrollment in Medicare Parts A and B.  If you are collecting Social Security benefits as you approach Medicare eligibility, you will automatically be enrolled in Medicare.  If you are not collecting Social Security prior to turning 65, and you want Medicare to start at 65, you need to reach out to SSA in the 7 months surrounding your 65th birthday month (the 3 months before your birthday, the month of your birthday, and the 3 months following your birthday).  Unless you or your spouse are working, and have health insurance through that active employer, you will want to consider enrolling in Medicare when first eligible. Otherwise, you can be subject to a late enrollment penalty and a delay in Medicare enrollment.

HIICAP is a helpful resource if you live in New York City. Outside NYC you can locate your local State Health Insurance Assistance Program (SHIP) at www.shiptacenter.org.  You can also call 1-800-MEDICARE, the federal Medicare program.

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