Medicare Enrollment Criteria

Are You New to Medicare?

INITIAL ENROLLMENT PERIOD

The Initial Enrollment Period for Medicare is any of the following:

  • Three months before your 65th birthday
  • The month of your 65th birthday
  • Three months after your 65th birthday

  • If you are not receiving a Social Security benefit due to age or disability, you will need to contact Social Security to enroll in Medicare. To enroll, visit the Social Security Administration website, call 1-800-722-1213, or go in person to your local Social Security office (currently closed due to COVID-19).
  • If you are a younger person receiving a Social Security Disability (SSDI) check, you will automatically receive your Medicare card about three months before the 25th month of receiving the SSDI check.
  • If you elected to receive your Social Benefit retirement benefit prior to age 65, you will automatically receive your Medicare card about three months before your 65th birthday.

For more information, watch the ABCs of Medicare video designed for persons new to Medicare.

If you or your spouse (or family, if under age 65 and on SSDI) continued to work beyond your Initial Enrollment Period for a large employer (20 or more employees if 65 or older, or 100 employees if under age 65) and the employed person has decided to retire, you may sign up for Medicare Part B any time while the employed person is working, or for eight consecutive months after the group health coverage/employment has ended.

Due to COVID-19, the Social Security Administration has created a new online service. Part of the process will be to complete CMS-40B and CMS-L564 forms by paper or online. If the employer is unable to sign the CMS-L564 form to provide the evidence of group health coverage, you may complete the form and provide evidence of group health coverage and dates of employment. The online option requires your digital signature and a valid email address. Contact Social Security for more information at 1-800-772-1213.

Transitioning to Medicare presentations are currently held on a rotating basis virtually to educate new Medicare Beneficiaries about their benefit. Register by sending an email to medicareinformation@baltimorecountymd.gov or by calling the State Health Insurance Assistance Program (SHIP) at 410-887-2059.

MEDICARE PART A

Medicare Part A helps pay for hospital stays, skilled nursing facilities, home health care, hospice care and other services.

ELIGIBILITY

  • You can enroll in Medicare Part A at age 65.
  • If you have worked at least 10 years under Medicare- or Social Security-covered employment, the Part A benefit will be "free" because you paid toward Part A while you worked. If you have never worked but your spouse has worked 40 quarters (10 years), you can apply for Medicare A by using your spouse’s work record.
  • If you elected to receive your Social Security retirement benefit before you turned age 65, you will automatically be enrolled in Medicare A and B. Your card will arrive about three months prior to your 65th birthday. Likewise, you will automatically receive your Medicare card several months before you reach the 25th month of receiving your Social Security disability benefit.
  • If you are not receiving a Social Security benefit, you will need to enroll in Medicare through Social Security.

ACTIVE EMPLOYMENT

  • If either you or your spouse is actively working and the employer is providing group health coverage, you may proceed to sign up for just Part A. If you have worked 10 years and paid the FICA tax, Part A will be premium-free and will serve as a secondary insurance to your group health insurance.
    • Note: If your employer has fewer than 20 employees, check with the benefits administrator. You may be required to sign up for Medicare A and B, and Medicare will be the primary insurance. Similarly, if you have a Social Security Disability benefit and the employer has fewer than 100 employees, you may be required to sign up for Medicare, in which case the Medicare will be the primary insurance.
  • Do not sign up for Part A if your employer coverage is through a Health Savings Account (HSA). You cannot contribute to an HSA and receive Medicare. (If you are entitled to premium-free Part A, there is no penalty for delaying Part A enrollment.)

MEDICARE PART B

Medicare Part B pays for doctors and other medical services such as physical therapy, occupational therapy, lab service, home health care, outpatient hospital visits and blood.

ELIGIBILITY

  • If you are already receiving benefits from Social Security, you will be automatically enrolled in Medicare A and B starting the first day of the month in which you turn 65 or the 25th month you receive your Social Security Disability check.
  • If you are not receiving a Social Security check, contact Social Security three months before you reach age 65 to enroll in Medicare A and B. Although you have a seven-month window (three months before, the month of, and three months after your 65th birthday) to sign-up for Medicare A and B, it is best to sign up early to avoid a delay in the start of your benefits.
  • If you did not take Part B when you were first eligible for Medicare at age 65, you may sign up during a General Enrollment Period. This period runs from January 1 through March 31 of each year. Due to the Part B penalty, the cost of your Medicare Part B may go up 10 percent for each 12-month period that you could have had Part B but did not take it. Your Part B coverage would become effective the following July and you will have to pay the extra 10 percent for the rest of your life.

ACTIVE EMPLOYMENT

  • The only time you may delay Part B enrollment without a penalty is if you or your spouse is actively employed and the employer has 20 or more employees (100 employees are younger than 65) and is providing group health insurance. You may sign up for Part B at any time while you are working and have the group health coverage. You may also sign up for Part B during a Special Part B Enrollment period, which lasts eight months from the time the employer coverage ended.
  • You will need to contact the Social Security office or download forms CMS-40B and CMS-L564. Once the forms have been completed, they may be sent to SSA via certified mail or faxed to 1-833-914-2016. The CMS-L564 form will enable your employer to certify that you have had group health coverage since age 65 or the 25th month of receiving your Social Security Disability benefit. Due to COVID-19, if your are unable to obtain your employer's signature for the form CMS-L564, you may apply online. You will need to upload documentation as evidence that you have had group health insurance.
  • If you elect not to receive Part B because you or your spouse is actively working and have group health insurance through an employer, you can complete the reverse side of the Medicare card and return it to SSA.

MEDICARE PART D

Prescription drug coverage, called Medicare Part D, is available to everyone with Medicare. Insurance companies and other private companies approved by Medicare offer the drug plans. Drug plans will vary in monthly premiums, the type of drugs covered, deductibles, copays and pharmacies accepting the plan.

ELIGIBILITY

  • You (the beneficiary) should sign up during the seven-month Initial Enrollment Period that begins three months before the month in which you turn age 65 and ends three months after turning age 65.
  • If you do not take Part D when you are first eligible for Medicare at age 65 and you did not have credible coverage during the interim, the cost of Medicare Part D may go up approximately $0.33 for each month you should have had the coverage and you will have to pay the penalty for the rest of your life.

ANNUAL PLAN CHANGES

It is important to annually review the list of drugs you take and review the plans every year because the Part D plans are permitted to change their formulary lists, premiums, deductibles, tier structures and pharmacy contracts every year. Therefore, you may change plans during the open enrollment period from October 15 through December 7 every year.

Medicare Prescription Drug Plans vary by the following:

  • Coverage: Medicare prescription drug plans cover generic and brand name drugs. Each plan can choose which specific drugs they cover in each drug category.
  • Cost: Monthly premiums and your share of the cost (copayment) of your prescription vary depending on which plan you choose.
  • Restrictions: The plan may limit prescription quantities (how many pills you can get at a time), require prior authorization (before the plan will pay for your prescriptions, your doctor must show the plan that the drug is medically necessary for it to be covered) or require step therapy (the plan may require a lower cost drug to be tried before the plan will pay for the prescribed drug).
  • Convenience: Consider whether you local pharmacy accepts the plan or whether the plan has a mail-order option.

SUPPLEMENTING MEDICARE

Medicare is the Federal health insurance program for people over age 65 or people under age 65 who qualify because of a disability. It is not designed to cover all of the cost of medical care. Deductibles, copayments and medical services not covered by Medicare can be expensive.

Most Medicare beneficiaries select one of three options to assist with the gaps (only Medicare-approved services are covered).

Purchase a Medigap insurance policy as a supplement to Medicare:

  • A Medigap policy supplements the Original Medicare Plan to help pay for the “gaps” like copayments, coinsurance, and deductibles that the Original Medicare Plan does not cover.
  • The policies are standardized (A to N), with each type of policy offering the same basic benefits no matter which insurance company sells it. The only difference between policies is the cost. A policy covers only one person, so a couple must each buy separate policies. Private insurance companies sell these policies.
  • The Medicare Supplement open enrollment period lasts for six months, beginning on the first day of the month in which you were eligible for Medicare and enrolled in Medicare Part B. During this period, an insurance company:
    • Must sell you a plan
    • Cannot make you wait for coverage to start
    • Cannot charge more for a Medigap policy because of health problems
  • View the names of Medigap Policies approved to be sold in Maryland and their yearly costs. To obtain a hard copy of the Medicare Supplement Pricing Booklet call the Maryland Insurance Administration at 410-468-2244.

Medigap changes as of January 1, 2020:

  • Those who are newly eligible for Medicare as of 2020 (means an individual who before January 1, 2020 is neither 65 nor has Part A):
    • Must pay Part B deductible, which is $240 for 2024, therefore:
      • Plans C, F and High Deductible F will not be sold to them
      • Can purchase a High Deductible G
  • Those who are not newly eligible for Medicare as of January 1, 2020:
    • Will be able to keep their Plans C, F or High Deductible F plans as long as the premiums are paid on time
    • May purchase Plans C, F or High Deductible F if offered by any companies
    • May purchase a High Deductible G
    • Note: Both High F and High G have a $2,800 deductible for 2024 that must be met before the plans will provide full Plan F or G coverage of the Medicare approved costs. With the High G, the first $240 of Part B expenses must be paid out of pocket and then Medicare begins to cover 80 percent of the Part B costs. With the High F, Medicare begins to pay 80 percent of the Part B Medicare-approved costs immediately.
  • Those who are newly eligible for Medicare under the age of 65:
    • Will be able to buy Plan A (all companies in Maryland must sell to those under age 65) and Plan D if sold to individuals age 65 or older
    • Premiums will be higher than for those age 65 or older
    • Medigap Open Enrollment period lasts for 6 months from the Part B start date and will occur again at the 65th birthday

Join a Medicare Advantage plan (substitute for Original Medicare). See a list of current plans in the back of your "Medicare and You" book.

There are currently four types of Medicare Advantage Plans offered in Baltimore County. The greatest advantage these plans have over using Original Medicare is their out-of-pocket limits. As of January 1, 2021, these plans will have to accept individuals with End State Renal Disease.

  1. Medicare Health Maintenance Organizations (HMO) cover all Part A and B services and may provide extra services. People who join a Medicare HMO plan may be asked to choose a primary care doctor they see first for most health problems. They usually need a referral to see a specialist (such as a cardiologist) or to get certain services. People who are considering joining a Medicare HMO and want to keep seeing their current doctor should find out if their doctor is in the plan’s network. The plan includes prescription coverage. Kaiser, Cigna, Johns Hopkins and CareFirst have HMOs serving Baltimore County.
  2. Medicare Preferred Provider Organization (PPO) cover all Part A and B services and may provide extra services. People who join a Medicare PPO plan can go to network doctors, other health providers and hospitals, but they can also go out-of-network for covered services, usually at a higher cost. Typically, they do not need to choose a primary care doctor and in most cases do not need a referral to see a specialist. The plan includes prescription coverage. Johns Hopkins has two PPOs in Baltimore County.
  3. Medicare Special Needs Plans (SNP) membership is limited to certain groups of people, such as those with certain chronic illness such as diabetes, or have Medical Assistance and Qualified Medicare Beneficiary (QMB), or are living in a nursing home. Medicare SNPs are Medicare Advantage plans designed to provide focused-care management, special expertise of the plan’s providers and benefits tailored to enrollee conditions. These plans provide case management, care monitoring, and health education and monitoring tools, if needed, to provide specialized care. The plans include prescription coverage. Cigna Achieve is a SNP for Diabetics. Cigna Total Care and CareFirst Blue Cross Blue Shield Dual are SNP HMOs serving those on Medical Assistance or QMB.

The other type of plan is Programs of All-Inclusive Care for the Elderly (PACE), which combines medical, social and long-term care services for frail, elderly people to remain in the community. You must be on Medicare and Medical Assistance, and be geographically confined to the eastern edge of Baltimore City.

Continue health insurance coverage through an employer retirement plan such as the Federal Employee Health Benefits Program (FEHBP), State and Local government Retiree Health Plans and private companies Retiree Health Plans.

MEDICARE SAVINGS PROGRAMS

If a person is income-eligible, they can apply for Medicare Beneficiary Savings Programs through Medicaid, the Qualified Medicare Beneficiary Program (QMB) or the Specified Low Income Medicare Beneficiary (SLMB) Program, which provide financial assistance to people with low income and limited assets. 

PRESCRIPTION DRUG PLAN SAVINGS PROGRAMS

If a person is income-eligible, they can apply for prescription drug plan savings through the Maryland Senior Prescription Drug Assistance Program (MD SPDAP) or Social Security Administration Extra Help and Low Income Subsidy (LIS), which provide financial assistance to people with low income and limited assets.