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Turning 65, are you eligible for Medicare/Medicare? What exactly are the eligibility requirements? Are there conditions for applying for Medicare/Medicare in the US? And what about the plans – HMO, PPO, Plan G, Plan F – it's all so confusing! Let's briefly understand the following...

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Introduction to Medicare

Beginner's Q&A

Medicare, often referred to in the Chinese-speaking community as the "Red, Blue, and White Card," is a federal health insurance program in the United States. Eligibility criteria for applicants include:

U.S. citizens or permanent residents (Green Card holders) aged 65 or older.
Permanent residents who have lived in the U.S. continuously for at least 5 years.
Individuals eligible for Social Security benefits (i.e., those who have worked for at least 10 years and accumulated 40 work credits).
Individuals who have met government disability requirements and have been receiving benefits for at least 2 years (e.g., younger individuals with disabilities or those with End-Stage Renal Disease (ESRD) requiring permanent dialysis or a kidney transplant).

Eligible applicants can apply for Original Medicare through the federal government (https://www.ssa.gov) to receive foundational health coverage. Please note that Original Medicare only covers Part A and Part B; Part C and Part D require separate enrollment. Additionally, beneficiaries may choose to purchase a Medicare Supplement (Medigap) plan to cover out-of-pocket costs not paid by Original Medicare.

(Note: If you are 65 or older but do not meet the work history requirements for premium-free Part A, you can still purchase it from the federal government—refer to the cost links below. We highly recommend consulting with us first to explore tailored solutions before making a final decision.)

The Four Core Parts of Medicare

Part A (Hospital Insurance): Covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and certain home health care services. Generally, you receive premium-free Part A if you have worked for at least 10 years (40 quarters) and paid Medicare taxes during your employment.
Part B (Medical Insurance): Covers certain doctors' services, outpatient care, medical supplies, and preventive healthcare services.
Part C (Medicare Advantage): Offered by private insurance companies approved by Medicare, this plan provides a bundled alternative to Original Medicare. It includes all Part A and Part B benefits and often offers additional coverage. Most Part C plans include prescription drug coverage (Part D) as well as extra benefits like dental, hearing, vision, and fitness programs.
Part D (Prescription Drug Coverage): Offered by private insurance companies, this optional coverage helps pay for prescription medications. Each provider offering a Part D plan determines its own formulary (list of covered drugs) and the associated costs.

(Informational Video: This video explains the introduction to Medicare. Each Medicare service—Parts A, B, C, D, and additional options—is explained in full detail.) Source: Medicare Made Clear. (2019, September 17). Medicare Basics Parts A, B, C, D [Video]. YouTube. https://www.youtube.com/watch?v=ZV6MXJC9j-w

Enrollment & Supplemental Plans

Application Process:

Parts A & B: Applicants must apply directly through the federal government three months prior to turning 65. Upon approval, the federal Medicare card will be issued.
Parts C & D: Applicants can enlist the assistance of a licensed insurance agent to seamlessly complete the enrollment process.

Medicare Supplement (Medigap) Insurance: Beneficiaries can choose to purchase a Medigap (or Supplement) policy to address the financial limitations of Original Medicare. These plans are designed to fill the "gaps" in Original Medicare, covering out-of-pocket costs such as deductibles, copayments, coinsurance, and emergency medical care abroad. Before purchasing a Medigap policy, applicants must be enrolled in both Medicare Parts A and B. Please note that Medigap policies do not include prescription drug coverage; a separate Part D plan must be purchased.

Frequently Asked Questions (Q&A)

1. What are the standard costs for Medicare? Please refer to: https://www.medicare.gov/basics/costs/medicare-costs

2. What are the Medicare IRMAA and Part D premium standards? Please refer to: https://www.medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-coverage/monthly-premium-for-drug-plans

3. What is the Medicare Star Rating system, and how is it measured? Medicare uses a Star Rating system to measure the performance of Medicare Advantage and Part D plans, evaluating aspects such as quality of care and customer service. Ratings range from 1 to 5 stars, with 5 being the highest and 1 being the lowest.

4. What is a Medicare HMO, and what is the difference between an HMO and a PPO? While there are multiple types of Medicare Advantage plans, Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) plans are the most common:

HMO Plans: Beneficiaries are generally required to use healthcare providers, doctors, and hospitals within the plan's network, except in emergencies. Some HMO Point-of-Service (HMO-POS) plans allow for out-of-network care, usually at a higher cost. HMOs also typically require beneficiaries to select a Primary Care Physician (PCP).
PPO Plans: These plans offer in-network and out-of-network coverage. Beneficiaries are not required to use in-network providers or get referrals to see specialists, though utilizing out-of-network providers incurs higher out-of-pocket costs. Both HMO and PPO plans typically include prescription drug coverage through a Medicare Advantage Prescription Drug (MAPD) plan.

5. What is the difference between Medicare Advantage and Medicare Supplement? While they sound similar and are both offered by private insurers, their frameworks are entirely different:

Medicare Advantage (Part C): Contracts directly with Medicare and is funded by the federal government. These "bundled" plans act as an alternative to Original Medicare, combining Parts A and B, and usually including Part D.
Medicare Supplement (Medigap): Does not contract with Medicare. It is an optional policy that covers the out-of-pocket costs (like copayments and coinsurance) that Original Medicare does not pay. You retain Original Medicare as your primary insurance.

6. How do I enroll in Medicare? You can enroll in Medicare Part A and/or Part B through the following methods:

Online: Visit www.SocialSecurity.gov.
By Phone: Call the Social Security Administration at 1-800-772-1213 (TTY: 1-800-325-0778), Monday through Friday, 7:00 AM to 7:00 PM.
In Person: Visit your local Social Security office.
Railroad Workers: If you worked for a railroad, enroll by contacting the Railroad Retirement Board (RRB) at 1-877-772-5772 (TTY: 1-312-751-4701), Monday through Friday, 9:00 AM to 3:30 PM.

Sources:

Medicare.gov: The Official U.S. Government Site for Medicare (https://www.medicare.gov/). Managed by the U.S. Centers for Medicare & Medicaid Services (CMS), this federal website helps provide information and answers to your Medicare questions.
CMS.gov: Centers for Medicare & Medicaid Services (https://www.cms.gov/). Managed by CMS to provide the public with policy and operational information about Medicare and Medicaid.

If you have any other questions or concerns, please feel free to contact us by phone at (909) 913-0123 or fill out the Contact Us form on our website.