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Five Medicare Rules

The Five Medicare Rules In Developing A Health Plan.

Article By : Patrick Mansfield | U.S. Gov Connect
Five Medicare plans

Medicare has been instrumental in maintaining the health of American Citizens over the age of 65 since 1964. Like many government agencies, Medicare is highly complex, with some rules that help to ensure its viability. However, these same rules can be confusing for enrollees in the program. Here are five basic rules to keep in mind that will ensure that you maximize the major benefits of the program:

1 Medicare Has An Initial Enrollment Period to Keep in Mind.

When you first become eligible for Medicare, you have a 7-month window to enroll in the program without incurring any penalty for lateness. The period is from 3 months before the month of your 65th birthday, the month of your birthday, and three months after your 65th birthday month. You must be 65 years old, and you or your spouse must have worked for at least ten years in Medicare-covered employment. You may sign up for Part A of Medicare and delay signing up for Part B if you are still employed. Individuals who choose Original Medicare can also sign up for a Part D prescription drug coverage during this period. If you do not enroll during the Initial Period, you can still enroll during the General Enrollment Period that runs from January 1 to March 31 each year. 

2 You May Be Penalized for Late Applications to Medicare.

If you fail to apply for Medicare within the designated period, you will be subject to a penalty amount. However, those who have insurance coverage through employment or spouse’s employment may delay enrolling in Part B coverage of Medicare. In this case, you will have eight months to sign up for the additional coverage after your other insurance coverage ends, without incurring a penalty. 

3 Medicare Advantage Offers Additional Benefits Over Original Medicare.

Many seniors find that Medical Advantage plans, also called Medicare Part C, offer more benefits for their needs. These plans often provide lower out-of-pocket costs, lower co-payments, and deductibles, coverage for prescription drugs, vision care or dental coverage. Medicare Advantage plans can be a good way to minimize costs for medical care throughout the year. However, they require staying within a specific network of physicians and other providers of medical services. 

4 Medicare also allows enrollees to change their coverage at certain specified times.

Medicare Open Enrollment Period, October 15 to December 7 – This period allows you to make changes to your Medicare plan. For example, you can change from Original Medicare to a Medicare Advantage Plan, change from a Medicare Advantage plan to Original Medicare or change from one type of Medicare Advantage Plan to another Medicare Advantage Plan. 

 *Medicare Advantage Disenrollment Period, January 1 to February 14 – During this period, you can change your coverage from a Medicare Advantage plan to Original Medicare, if you find your medical needs are better served by the change.

5 You Can Dispute Refusals of Coverage

If you feel Medicare has denied coverage for treatment, you can utilize a process of disputing their decision. This process involves five avenues of recourse:
  • You can request a redetermination of coverage from the company handling the Medicare claim.
  • You can enlist the help of a qualified independent contractor to reconsider the Medicare decision. 
  • You can require a hearing before an administrative law judge
  • You can also require a review of the cases from a Medicare Appeals Council
  • You can file a suit in federal court for a judicial review of the decision
Navigating your way through the Medicare system takes a bit of time and practice, but the effort can help you to gain the right coverage for your healthcare needs. 
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