Jeffrey Wade
Medicare is the federal health insurance program for US citizens aged 65 and over. If you are under 65, you may still be eligible for Medicare if you have a disability, End-Stage Renal Disease (ESRD), ALS (Lou Gehrig's Disease), or permanent kidney failure. To sign up for Medicare Part A (insurance for hospitalization, home or skilled nursing, and hospice) and Part B (medical insurance), you must fill out an application form. You can also apply for Part A only, or Part B only if you already have Part A. In some cases, you may need to file a claim to get reimbursed for a vaccine or prescription covered by Medicare. This is done by downloading and filling out the Patient Request for Medical Payment form (CMS-1490S), along with an itemized bill and a letter explaining your claim.
| Characteristics | Values |
|---|---|
| Medicare Enrollment | Sign up for Medicare Part A and Part B through Social Security |
| Sign up for Medicare online, by phone, or by mail | |
| If you are 65 or older, you can enroll in Parts A and B, or Part A only | |
| If you are under 65, you may be eligible for Medicare if you have a disability, End-Stage Renal Disease (ESRD), or ALS | |
| Medicare Part A covers hospitalization, home or skilled nursing, and hospice | |
| Medicare Part B covers medical insurance | |
| Medicare Part C (Medicare Advantage Plans) is a private insurance option that covers hospital and medical costs | |
| Medicare Part D covers prescription medications | |
| Filing a Claim | File a claim if you want to be reimbursed for a covered expense |
| File an appeal if you disagree with a decision by Medicare or your Medicare plan | |
| Submit the completed claim form, itemized bill, and supporting documents to the Medicare Administrative Contractor | |
| Medicare claims must be filed within 12 months of the date the services were provided | |
| Medicare Savings Programs | Qualified Medicare Beneficiary (QMB) |
| Specified Low-Income Medicare Beneficiary (SLMB) | |
| Qualifying Individual (QI) | |
| Qualified Disabled & Working Individual (QDWI) |
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What You'll Learn
Medicare Part A and Part B enrolment
Medicare Part A and Part B Enrollment:
First, it's important to understand the difference between Medicare Part A and Part B. Part A covers hospital stays, care in a skilled nursing facility, hospice care, and some home health care services. On the other hand, Part B covers outpatient care, doctor visits, preventive services, and some home health care that Part A doesn't cover.
Now, to enrol in Medicare Part A and Part B, you need to follow these steps:
- Visit the Social Security Administration (SSA) website or your local SSA office: You can enrol in Medicare Parts A and B online, by visiting the SSA website (ssa.gov). Alternatively, you can enrol in person by visiting your local SSA office.
- Complete the enrolment application: Provide your personal information, such as your name, date of birth, and Social Security number. You will also need to provide information about your current health insurance coverage and any other health care plans you may have.
- Provide proof of eligibility: To enrol in Medicare Part A and Part B, you must meet the eligibility requirements, including being a US citizen or a permanent legal resident for a certain period. Ensure you have the necessary documentation to prove your eligibility, such as a birth certificate, passport, or permanent resident card.
- Choose your coverage options: Decide whether you want to enrol in Medicare Part A, Part B, or both during the enrolment process. If you are already receiving Social Security benefits, you may be automatically enrolled in Part A, and you need to opt out if you don't want it. Ensure you select Part B coverage if you want it.
- Review and submit your application: Review all the information you have provided for accuracy and completeness. Then, submit your enrolment application to the SSA through the chosen channel.
Remember to consider the specific Medicare enrolment periods. The initial enrolment period is usually a seven-month window around the month you turn 65. However, there are also special enrolment periods if you miss the initial period, so be sure to check the eligibility requirements.
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Medicare claims
Medicare is the federal health insurance program for people aged 65 and over. If you are under 65, you may be eligible for Medicare if you have a disability, End-Stage Renal Disease (ESRD), or ALS (Lou Gehrig's Disease).
There are several ways to enrol in Medicare, depending on your situation. For instance, if you are receiving Social Security retirement benefits between the age of 62 and up to 4 months before turning 65, you will be automatically enrolled in Medicare Part A and Part B when you turn 65.
Now, Medicare claims must be filed no later than 12 months (or 1 full calendar year) after the date the services were provided. If a claim isn't filed within this time, Medicare won't pay its share. For instance, if you see your doctor on March 22, 2019, your doctor must have filed the Medicare claim for that visit by March 22, 2020.
If you have Original Medicare, the law requires your doctor, provider, or supplier to file Medicare claims for covered services and supplies you receive. If you have a separate Medicare drug plan (Part D), the pharmacy will file a claim directly with your plan. If you have a Medicare Advantage (Part C) plan, with or without drug coverage, and use in-network doctors, suppliers, and pharmacies, they will usually submit a claim directly to your plan.
You can also file your own claim. To do so, you can download and fill out a form called the Patient Request for Medical Payment form (CMS-1490S). This form is also available in Spanish. You will generally need to submit the completed claim form, an itemized bill from your doctor or healthcare provider, a letter explaining why you are submitting the claim, and any supporting documents related to your claim (like notes from your doctor). If you have Original Medicare, you will need to mail your claim form, itemized bill, and supporting documents to the address for your state, which is listed on the Medicare Administrative Contractor Address Table within the claim form.
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Medicare appeals
If you disagree with a coverage or payment decision by Original Medicare, your Medicare Advantage or other Medicare health plan, or your Medicare drug plan, you can file an appeal. There are several scenarios in which you may want to file an appeal. For example, if Medicare or your plan refuses to cover a health care service, supply, item, or drug that you believe should be covered, you can file an appeal. Similarly, if Medicare or your plan refuses to pay for a health care service, supply, item, or drug that you have already received, or if they change the amount you are required to pay, you can appeal these decisions.
Before starting an appeal, you can ask your provider or supplier for any information that may strengthen your case. If you are enrolled in a Medicare Advantage plan, another health plan, or a drug plan, you should check your plan materials or contact your plan for details about your appeal rights. Your plan must inform you in writing of how to appeal, and you can usually find their contact information on your plan membership card.
The appeals process varies based on the type of coverage you have, but there are generally five levels of appeals. If you disagree with the decision made at one level, you can usually proceed to the next level. To get a judicial review in federal district court, the value of your case must meet a minimum dollar amount. For 2025, this minimum amount is $1900, and you may be able to combine claims to reach this amount.
You can also contact Medicare for assistance with appeals. You can talk or live chat with a representative 24 hours a day, 7 days a week (except some federal holidays) by calling 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. Additionally, you can appoint a trusted family member or friend as your representative to help with your appeal.
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Medicare prescription medications
Medicare is the federal health insurance program for people aged 65 and over. If you are under 65, you may be eligible for Medicare if you have a disability, End-Stage Renal Disease (ESRD), or ALS (Lou Gehrig's Disease).
There are four parts to Medicare: Part A, Part B, Part C, and Part D. Medicare Part D specifically covers prescription medications.
Part B (Medical Insurance) covers a limited number of outpatient prescription drugs under certain conditions. Part B covers drugs that are typically administered by a doctor or medical professional, such as in a hospital or outpatient setting. This includes drugs used with durable medical equipment (DME), like an infusion pump or nebulizer, as long as the drug is reasonable and necessary. Part B also covers some antigens, HIV prevention drugs, injectable osteoporosis drugs, and erythropoiesis-stimulating agents for patients with ESRD or certain other conditions.
In most cases, after meeting the Part B deductible, you pay up to 20% of the Medicare-approved amount for covered Part B prescription drugs. Your coinsurance amount may vary depending on the price of your prescription drug. It's important to note that Part B does not cover "self-administered drugs" in a hospital outpatient setting.
Medicare Part D offers prescription drug coverage, but it is a separate plan that you can join only if you have Part A and/or Part B. If you join a Medicare Advantage Plan (Part C) or other Medicare health plan with drug coverage, you will typically get your Part D coverage through that plan.
If you had to pay out of pocket for a prescription that was covered by Medicare but hasn't been added to your plan's formulary yet, you may need to file a claim to get reimbursed. You can download and fill out the Patient Request for Medical Payment form (CMS-1490S) and submit it along with any supporting documentation. Remember to file your claim within 12 months of the date the services were provided to ensure Medicare pays its share.
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Cancelling Medicare coverage
If you are considering cancelling your Medicare coverage, it is important to be aware of the potential risks and costs. You may be responsible for all healthcare costs moving forward if you cancel your plan without a replacement. Additionally, you may have to pay a late enrollment penalty if you decide to sign up for Medicare again during a future open or special enrollment period.
Cancelling Original Medicare (Parts A and B)
If you pay a monthly premium for Medicare Part A, you can cancel it at any time by submitting CMS Form 1763 to your local Social Security office. You can download this form from the Medicare website or obtain a paper copy from your local Social Security office. Make sure to fill out the form completely and include all required information, such as the full name of the person filling out the form and the signatures of two witnesses.
On the other hand, you can choose to drop Part B at any time. If you have recently been enrolled in Original Medicare, you must follow the instructions included in your welcome packet to opt out of coverage. This usually involves mailing back your Medicare card. If you fail to return the card, you will be responsible for paying the monthly premium for Part B.
Cancelling Medicare Advantage (Part C) and Prescription Drug (Part D) Plans
You can only cancel Part C and Part D plans during an open or special enrollment period. The annual open enrollment period for all Medicare plans lasts from October 15 to December 7. To initiate the cancellation process, contact your plan provider directly. You can usually find their contact information on your plan card or their website. They will guide you through the process, which typically involves submitting a written request or completing a disenrollment form.
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Frequently asked questions
You can sign up for Medicare Part A and Part B through Social Security. If you are 65 or older, you can enroll online for Parts A and B, or Part A only. You can delay Part B if you are already covered through an employer group health plan. If you are under 65, you may be eligible for Medicare if you have a disability, End-Stage Renal Disease (ESRD), permanent kidney failure, or ALS (Lou Gehrig's Disease).
Medicare Part A is insurance for hospitalization, home or skilled nursing, and hospice. Medicare Part B is medical insurance. Medicare Part C (Medicare Advantage Plans) is a private insurance option that covers hospital and medical costs. Medicare Part D covers prescription medications.
You can download and fill out the Patient Request for Medical Payment form (CMS-1490S). Follow the instructions on the form for the type of claim you're filing. Generally, you'll need to submit the completed claim form, an itemized bill from your healthcare provider, and a letter explaining why you're submitting the claim.
If you disagree with a decision by Medicare or your Medicare plan, you can file an appeal. You can download your Medicare claims data and share it with someone you trust to help you. You can also contact Medicare for help by calling 1-800-MEDICARE (1-800-633-4227) or chatting with them online.
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