FAQ's

Medicare FAQ's

Medicare is a health insurance program for people who are 65 or older. Some younger people can also get Medicare if they have disabilities, permanent kidney failure, or amyotrophic lateral sclerosis (ALS). Medicare helps with health care costs, but it doesn’t cover everything, especially most long-term care expenses.

Original Medicare has two main parts:

  • Part A (Hospital): This covers hospital stays, some time in a skilled nursing facility after a hospital stay, and some home health and hospice care.
  • Part B (Medical): This helps pay for doctor visits and many other medical services and supplies that Part A doesn’t cover.

There are also additional parts of Medicare:

  • Part C (Medicare Advantage): Known as Medicare Advantage, these plans are offered by private companies and approved by Medicare. They help cover medical costs not paid for by Original Medicare.
  • Part D (Prescriptions): This provides prescription drug coverage to help with the cost of medications.

If you’re already getting Social Security benefits, you don’t need to sign up for Medicare. The Social Security Administration (SSA) will automatically enroll you in Original Medicare (Part A and Part B) when you’re eligible. They will send you information about this 3-4 months before you become eligible, and this will include your Medicare card.

Part B requires a monthly premium, so you can choose to decline it. If you decide to sign up for Part B later, your coverage might start later, and you could face a late enrollment penalty that lasts as long as you have Part B. Residents of Puerto Rico or foreign countries won’t automatically receive Part B and must choose this benefit separately.

If you’re not getting Social Security benefitsand aren’t ready to apply for them yet, you should sign up for Medicare three months before your 65th birthday. You can apply online or schedule an appointment by calling SSA at 1-800-772-1213 (TTY 1-800-325-0778), Monday through Friday, from 8:00 a.m. to 7:00 p.m.

Medicare Part B premiums depend on your income and can change every year. To find the current rates, visit the Medicare Cost site.

Each year, Social Security sends a letter to people receiving Social Security benefits (and those who pay higher premiums due to their income) with their exact Part B premium amount.

For more details, visit Medicare.gov or contact us through the Contact page at the top of our website.

If you have Medicare Part A but didn’t sign up for Medicare Part B during your Initial Enrollment Period (IEP), you can still enroll during the General Enrollment Period (GEP) or might qualify for a Special Enrollment Period (SEP).

The General Enrollment Period runs from January 1 to March 31, with coverage starting the month after you enroll. You may face a late enrollment penalty for not signing up when you were first eligible.

If you have group health coverage through an employer or your spouse, you might qualify for a Special Enrollment Period (SEP). During an SEP, you can apply online at Apply for Medicare Part B Online during a Special Enrollment Period.

You can also fax or mail your completed Application for Enrollment in Medicare Part B (CMS-40B) and the Request for Employment Information (CMS-L564) forms, along with proof of employment, to your local Social Security office. If you have questions, contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778) or use the Contact page at the top of our website.

When filling out forms CMS-40B and CMS-L564:

  • In the CMS-40B form or online application, write “I want Part B coverage to begin (MM/YY)” in the remarks section.
  • If your employer can’t complete Section B, fill it out as best as you can without their signature.
  • Also include one of these forms of secondary evidence:
    • Income tax returns showing health insurance premiums paid.
    • W-2s showing pre-tax medical contributions.
    • Pay stubs showing health insurance premium deductions.
    • Health insurance cards with policy effective dates.
    • Explanations of benefits paid by the group health plan.
    • Statements or receipts showing payment of health insurance premiums.

In most cases, if you don’t sign up for Medicare when you’re first eligible, you may have to pay a higher monthly premium.

More information on Medicare late enrollment penalties:

If you have health insurance through a group health plan from your own or your spouse’s current job, you might not need to sign up for Medicare Part B when you turn 65. You could qualify for a Special Enrollment Period, which lets you delay signing up for Part B without a late enrollment penalty.

Keep in mind that this doesn’t apply to coverage from COBRA (Consolidated Omnibus Budget Reconciliation Act), retiree health coverage, VA (Veterans Affairs) health coverage, or individual health plans (like those from the Health Insurance Marketplace).

It’s a good idea to speak with an insurance agent who can compare your current coverage with Medicare to help you find the best option for your needs.

Individual and Family Health Insurance FAQ's

A health insurance marketplace, or exchange, is a platform where you can compare and buy health insurance plans. It shows options from different insurance companies, helping you find a plan that fits your needs and budget.

The health insurance marketplace is mainly for individuals and families who don’t have health insurance through their job or other government programs. It helps people find affordable health insurance options, even if they have pre-existing conditions.

The marketplace offers several types of health insurance plans:

  • HMO (Health Maintenance Organization): Requires you to choose a primary care doctor and get referrals to see specialists. It doesn’t cover out-of-network care except in emergencies.
  • PPO (Preferred Provider Organization): Gives you more flexibility in choosing doctors and specialists. It has lower costs for in-network care but higher costs if you go out of network. No referrals are needed, and it often includes travel coverage.
  • EPO (Exclusive Provider Organization): Similar to PPOs but usually doesn’t cover out-of-network care except in emergencies.
  • POS (Point of Service): Combines features of HMOs and PPOs. You choose a primary care doctor and can decide whether to use in-network or out-of-network providers, with different costs for each.
  • HDHP (High Deductible Health Plan): Has lower monthly premiums but higher deductibles. It’s often paired with a Health Savings Account (HSA) to help cover costs.
  • Catastrophic Plans: For young adults and those with low incomes, these plans offer low premiums and high deductibles, designed for worst-case scenarios.

You can apply for health insurance during the open enrollment period, which runs from November 1st to January 15th. If you qualify for a Special Enrollment Period (SEP) due to life events like losing other coverage, getting married, or having a baby, you can apply up to 60 days before or after these events. Applications are usually submitted online through the official marketplace website or with the help of an insurance agent.

During a valid enrollment period you’re able to enroll in, renew, or change your plan.

Open Enrollment (One annual period for everyone)

  • November 1: Open Enrollment starts — first day you can enroll in, renew, or change health plans through the Marketplace. Coverage can start as soon as January 1.
  • December 15: Last day to enroll in or change plans for coverage to start January 1.
  • January 1: Coverage starts for those who enroll in or change plans by December 15 and pay their first premium.
  • January 15: Open Enrollment ends — last day to enroll in or change Marketplace health plans for the year. After this date, you can enroll in or change plans only if you qualify for a Special Enrollment Period.
  • February 1: Coverage starts for those who enroll in or change plans December 16 through January 15 and pay their first premium.
Special Enrollment Periods (Individuals who have a qualifying life event at anytime throughout the year)
Changes in household
You may qualify for a Special Enrollment Period if in the past 60 days you or anyone in your household:
  • Got married. Pick a plan by the last day of the month and your coverage can start the first day of the next month.
  • Had a baby, adopted a child, or places a child for foster care. Your coverage can start the day of the event – even if you enroll in the plan up to 60 days afterward.
  • Got divorced or legally separated and lost health insurance. Divorce or legal separation without losing coverage doesn’t qualify you for a Special Enrollment Period.
  • Died. You’ll qualify for a Special Enrollment Period if someone on your Marketplace plan dies which causes you to lose your current health plan.

Changes in residence

You may qualify for a Special Enrollment Period if you move to:

  • New home in a new ZIP code or county
  • The U.S from a foreign country or United States territory

Or, move to or from:

  • Place you attend school (if you’re a student)
  • Place you both live and work (if you’re a seasonal worker)
  • Shelter or other transitional housing

Moving only for medical treatment or staying somewhere for vacation doesn’t qualify you for a Special Enrollment Period.

You must prove you had qualifying health coverage for one or more days during the 60 days before you move. You don’t need to provide proof if you’re moving from a foreign country or United States territory.

Loss of health coverage

You may qualify for a Special Enrollment Period if you or anyone in your household lost qualifying coverage in the past 60 days OR expects to lose coverage in the next 60 days.

Job-based coverage

You may qualify for a Special Enrollment Period if you lose health coverage through your employer or the employer of a family member, including if you lose health coverage through a parent or guardian because you’re no longer a dependent.

Notice: Voluntarily dropping coverage you have as a dependent doesn’t qualify you for a Special Enrollment Period unless you had a decrease in household income or a change in your previous coverage that made you eligible for savings on a Marketplace plan.

Individual health coverage

You may qualify for a Special Enrollment Period if you lose individual health coverage, including if:

  • Your individual plan or your marketplace plan is discontinued (no longer exists).
  • You lose eligibility for a student health plan.
  • You lose eligibility for a plan because you no longer live in the plan’s service area.
  • Your individual or group health coverage year is ending in the middle of the year and you chose not to renew it.
  • Your household income decreased, and now you qualify for savings on a Marketplace plan.

Notice: You won’t qualify for a Special Enrollment Period if you lost coverage because you didn’t provide required documentation.

Medicaid or the Children’s Health Insurance Program (CHIP) coverage (or were denied Medicaid/CHIP)

You may qualify for a Special Enrollment Period if you lost Medicaid or CHIP since March 31, 2023.

You may also qualify if you lose or were denied Medicaid or CHIP coverage because:

  • You’re no longer eligible, like if you had a change in household income that makes you ineligible for Medicaid.
  • Your child ages off CHIP.
  • You applied for Medicaid/CHIP or Marketplace coverage during Open Enrollment or with a different Special Enrollment Period and were told you might be eligible for Medicaid/CHIP. But, when your state agency told you that you weren’t eligible, Open Enrollment or your Special Enrollment Period had already ended.

Eligibility for Medicare

You may qualify for a Special Enrollment Period if you lose premium-free Medicare Part A.

You don’t qualify for a Special Enrollment Period if you lose:

  • Medicare Part A because you didn’t pay your Medicare premium.
  • Medicare Parts B or D only.

Coverage through a family member

You may qualify for a Special Enrollment Period if you lose qualifying health coverage if you had a parent, spouse, or other family member. This might happen if you lose health coverage because:

  • You turn 26 (or the maximum dependent age allowed in your state) and can no longer be on a parent’s plan.
  • A family member loses health coverage for their dependents.
  • A divorce or legal seperation.
  • The death of a family member.
  • You’re no longer a dependent.

You won’t qualify for a Special Enrollment Period if you chose to drop the coverage you have as a dependent, unless you also had a decrease in household income or a change in your previous coverage that makes you qualify for savings on a Marketplace plan.

An employer offers to help with the cost of coverage

You may qualify for a Special Enrollment Period if you (or anyone in your household) were offered an individual coverage HRA or a Qualified Small Employer Health Reimbursement Arrangement (QSEHRA) in the past 60 days OR expects to in the next 60 days.

Your employer may refer to an individual coverage HRA by a different name, “ICHRA.”

If you qualify to enroll in Marketplace coverage through this Special Enrollment Period, contact us to complete your enrollment.

More qualifying changes

Other situations that may qualify you for a Special Enrollment Period:

  • Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder
  • Becoming a U.S citizen
  • Leaving incarceration
  • Starting or ending service as an AmeriCorps State and National, VISTA or NCCC member

Notice:

You may have to submit documents. When you apply, you must attest that the information you provide on the application is true, including the facts that qualify you for a Special Enrollment Period. You may have to submit documents that confirm your life event.

Enrollment Periods for Health Insurance

You can sign up, renew, or change your health plan during certain times of the year.

Open Enrollment (One period each year for everyone)

  • November 1: Open Enrollment starts. You can sign up, renew, or change your health plan. Coverage can begin as soon as January 1.
  • December 15: Last day to sign up or make changes for coverage starting January 1.
  • January 1: Coverage starts for those who signed up or made changes by December 15 and paid their first premium.
  • January 15: Open Enrollment ends. Last day to sign up or make changes for the year. After this, you can only change plans if you qualify for a Special Enrollment Period.
  • February 1: Coverage starts for those who signed up or made changes between December 16 and January 15 and paid their first premium.

Special Enrollment Periods (For people with certain life events)

You can change your plan outside of Open Enrollment if you have a qualifying life event, such as:

Changes in Household

  • Marriage: Get married and pick a plan by the last day of the month, and your coverage can start the first day of the next month.
  • Birth/Adoption: If you have a baby, adopt, or place a child in foster care, coverage can start the day of the event, even if you sign up within 60 days after.
  • Divorce or Separation: If you get divorced or legally separated and lose health insurance, you qualify for a Special Enrollment Period. If you don’t lose coverage, you don’t qualify.
  • Death: If someone on your Marketplace plan dies and you lose your health plan because of it, you qualify for a Special Enrollment Period.

Changes in Residence

You may qualify if you move to:

  • A new home in a different ZIP code or county.
  • The U.S. from another country or U.S. territory.
  • A new place for school, work (if you’re a seasonal worker), or to/from a shelter or transitional housing.

Loss of Health Coverage

You may qualify if you or someone in your household lost health coverage in the past 60 days or expects to lose it in the next 60 days, such as:

  • Job-based coverage: If you lose health coverage through your job or a family member’s job, including losing coverage through a parent or guardian.
  • Individual health coverage: If your individual or Marketplace plan is discontinued, or if you lose eligibility for a student plan or a plan because you no longer live in its service area.
  • Medicaid or CHIP: If you lost Medicaid or CHIP coverage since March 31, 2023, or were denied coverage, you may qualify.

Eligibility for Medicare

You may qualify if you lose premium-free Medicare Part A but not if you lose it because you didn’t pay your premium or lost only Medicare Parts B or D.

Coverage through a Family Member

You may qualify if you lose coverage from a parent, spouse, or other family member, such as:

  • Turning 26 (or the maximum age allowed in your state) and can no longer be on a parent’s plan.
  • A family member loses health coverage for dependents.
  • A divorce or legal separation.
  • The death of a family member.
  • You’re no longer a dependent.

Employer Offers Help with Coverage Costs

You may qualify if you or someone in your household is offered help with coverage costs through an individual coverage HRA or a Qualified Small Employer Health Reimbursement Arrangement (QSEHRA) in the past 60 days or expects to in the next 60 days.

More Qualifying Changes

Other situations that may qualify you for a Special Enrollment Period:

  • Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder.
  • Becoming a U.S. citizen.
  • Leaving incarceration.
  • Starting or ending service as an AmeriCorps State and National, VISTA, or NCCC member.

Notice:
You may need to submit documents to prove your life event. When applying, you must confirm that the information you provide is true and may have to submit documents to confirm your life event.

Depending on how much money you make and the size of your family, you might get help (called Premium Tax Credits) to lower your monthly insurance payments. Some people can also get extra help to lower other costs like deductibles and copayments.

You can call us, and we’ll give you a personalized quote to see if you can save money on premiums or out-of-pocket costs. To get your quote, you’ll need to give us details about your income and household size. Based on this, the marketplace will decide if you qualify for subsidies or other financial help.

You can usually change your health insurance plan during the annual open enrollment period. Outside of this time, you can only make changes if you qualify for a Special Enrollment Period because of certain life events.

When choosing a plan, think about these factors:

  • Premium costs
  • Deductibles and out-of-pocket costs
  • Network of doctors and hospitals
  • Prescription drug coverage
  • Coverage for services you might need (like maternity care or mental health services)
  • Customer service

We’re certified to sell marketplace plans and can offer personalized help. Feel free to give us a call at (813) 469-8797.

Give us a call! We’d be happy to explore plans, compare options, and start the application process with you. If you need help, our team is here to guide you every step of the way.