Turning 65 can be daunting in more ways than one. For many North Carolinians, the weeks before their birthday are accompanied by a deluge of advertisements and mailings for various Medicare plans.
The onslaught of new information and lingo can be daunting, as well as making decisions about which plan to choose.
Over 2.2 million North Carolinians are enrolled in the federal program that covers most people over the age of 65. It also covers some people younger than 65 who have disabilities or certain conditions.
Everybody's situation is different when it comes to Medicare, said Rhonda Narron, southeastern regional manager with the Seniors Health Insurance Information Program, or SHIIP.
“It's never one size fits all. That's why it's so confusing for people,” Narron said.
Anyone can visit a local SHIIP counselor for free, unbiased information about the various Medicare options available. But for a general primer, NC Health News compiled the following information about Medicare from several SHIIP counselors and government resources.
You can call SHIIP toll-free at 1-855-408-1212, Monday through Friday from 8 a.m. to 5 p.m.
Or you can search the SHIIP website to find a counselor in your county.
SHIIP counselors advise everyone to reassess their prescription drug plan each year during the open enrollment period from Oct. 15 to Dec. 7.
What is Medicare?
Medicare is made up of several parts denoted by letters. Original Medicare includes Parts A and B, and you can also join a separate Medicare Part D plan to get drug coverage as well as Medigap, a supplemental plan.
Medicare Advantage plans, or Medicare-approved plans from a private company, usually “bundle” Parts A, B and D and often offer extra benefits like dental, vision and hearing coverage, which Original Medicare does not offer.
The first thing to know? Medicare isn’t free, said Jeanne Chamberlin, coordinator for SHIIP at the Orange County Department on Aging.
While Part A generally has a zero-dollar premium for most people, the standard monthly premium for Part B in 2025 is $185 a month. On top of that, many people pay an additional premium for their Part D, or prescription drug, plan.
During the open enrollment period (again, that’s between Oct. 15 to Dec. 7) , anyone with Medicare coverage can change their Part D plan, as well as switch to a Medicare Advantage plan if they choose. If someone is already enrolled in a Medicare Advantage plan, they can switch to a different one during this time window.
Pharmacy benefits
Plans can change the list of prescriptions they cover each year. They can also change premium prices and covered pharmacies, making it harder for patients to go to their preferred pharmacy.
That’s why it’s important to read the details of the annual change of notice letter that insurers send to beneficiaries each year and see if there’s a better option, said Narron.
Three months before turning 65…
People can sign up for Medicare starting three months before turning 65, during their birthday month, and for three months after. If they fail to sign up during this seven-month period — called the initial enrollment period — they may face lifetime penalties if they don’t fall under a few exceptions.
“Timining is everything with Medicare,” Narron said.
That’s why she recommends preparing for the process earlier, even at age 64. She recalled one woman who called her last year asking for help with Medicare. The woman was turning 65 the next week, so Narron had to bring her up to speed as quickly as possible.
“I spent an hour and a half on the phone with her, and I could almost hear her head spinning during our conversation,” she said.
When someone signs up for Medicare for the first time, they go through Social Security either online, via telephone or an in-person appointment. Once that’s done, they will receive their Medicare card and number.
At that point, Narron said, they’re only enrolled in Parts A and B.
Medigap
Once they have their Medicare number, they can go to a local SHIIP counselor for help signing up for a Part D plan that works for them.
This is also a good time to sign up for a supplemental plan to help cover their health care costs, often known as a Medigap plan.
Why sign up for a Medigap plan? If you need an expensive outpatient health care service, Medicare only covers 80 percent of the cost after you’ve paid your deductible. You’re left on the hook for the other 20 percent. That’s where Medigap plans come in.
Created in the 1980s, Medigap insurance will cover the out-of-pocket costs associated with Original Medicare, like copayments, deductibles and coinsurance. It doesn’t sound like much, but if you end up, say, needing chemotherapy infusions for cancer, the bill can easily add up to tens of thousands of dollars or more, potentially leaving you on the hook for a lot. A typical Medigap plan will cost between $100 and $300 a month for most people and there are different types denoted by letters.
Here’s the thing that brokers won’t tell you: all of them are the same. That’s because of a law Congress passed in the early 1990s. So, you can look for your best price on a Medigap plan with confidence.
Again, according to the federal Medicare website: The premium amount is the only difference between policies with the same plan letter sold by different companies.
The federal Medicare website has a way to search for policies that cover your area.
Here’s the catch: There’s only a six-month window to sign up for a supplemental plan after the Part B insurance becomes effective — after that, it can be much more difficult — and more expensive — to buy a Medigap plan.
Even someone who doesn’t have any prescriptions should still sign up for a Part D plan with a low monthly premium at first, Chamberlin said. That way, if they do need prescription drug coverage down the line, it’s already set up. If someone waits until later to sign up for the Part D plan, they also may be fined a late enrollment penalty for the rest of their life.
What if I or my spouse will keep working after 65?
Many people work past age 65, said Narron, and as long as they’re covered under an employer group health plan that meets certain qualifications, they can delay enrolling in Medicare Part B without any penalties. That’s also the case if they’re covered under their spouse’s employer group health plan and their spouse is actively working full-time.
For those working past age 65, it’s best to consult with the employer’s human resources department to confirm that the employer plan is considered “creditable coverage” and that you won’t be penalized for delaying enrollment in Medicare, Narron said.
Chamberlin recommended still signing up for Part A as soon as you turn 65 (as long as you don’t have a health savings account, something offered by many employers). This part of Medicare has zero-dollar premiums and can help pay for any leftover hospital costs after the employer health insurance pays their portion.
Once you decide to stop working, you can then sign up for the rest of Medicare.
But if your employer has less than 20 employees, that health insurance doesn’t count — you must sign up for Medicare as soon as you’re eligible, even if you continue to work.
Chamberlin recalled one man she counseled who was a lawyer, and his firm had fewer than 20 employees. At age 70, he came to SHIIP to sign up for Medicare. She had to tell him that since he hadn’t signed up at age 65, he would receive a 10 percent penalty for every year he was late — in his case, five years.
For a $185 monthly premium, that’s an extra $92.50 each month for the rest of his life, she said.
“All because nobody told him, and he didn't know,” she said.
COBRA, short for the Consolidated Omnibus Budget Reconciliation Act, is a federal law that allows the temporary extension of health coverage for workers under certain circumstances. But policies for people covered under this provision also don’t count as creditable coverage to Medicare. Neither does a state-run health insurance marketplace plan, nor do plans sold through the federal government-run Health Insurance Marketplace.
Some special cases
What if I’m a North Carolina state retiree?
State employees are still required to sign up for Medicare Parts A and B when they turn 65. From there, the state has three retiree plan options: two are Medicare Advantage plans and one is a 70/30 PPO plan, or preferred provider organization. You can call the State Health Plan Eligibility and Enrollment Support Center for further questions at 855-859-0966.
What if I’m eligible for Medicaid?
Some people who earn less than a certain amount and who are enrolled in Medicare are also eligible for Medicaid. Medicare pays for covered services, then Medicaid can pick up much of the rest. There are Medicare Advantage plans specifically designed for these “dual” eligibles, Chamberlin said. These beneficiaries don’t usually pay any copays for covered services and may receive allowances that can go toward expenses like groceries or transportation.
What if I started receiving Social Security benefits before age 65?
Most people can start drawing their Social Security benefits at age 62, so if you have already done so, you will be automatically enrolled in Medicare at age 65. The same goes for you if you received Social Security benefits earlier because of a disability.
Choosing between Medicare Advantage and Original Medicare
For most people, Medicare has two avenues: Original Medicare with a supplement and drug plan, or a Medicare Advantage plan.
Chamberlin said the choice depends on a beneficiary’s finances and how they use health care services. Choosing Original Medicare with a supplement plan will likely cost more each month for the beneficiary, but they will usually pay less for health care services.
Medicare Advantage beneficiaries will likely pay much lower premiums each month, but will likely be on the hook for higher out-of-pocket costs when using any health care services.
Some people would rather know what their budget is and be assured they won’t have a big medical bill if they get sick, Chamberlin said. Others would rather save that money with the hope they won’t get very sick.
“It’s about what lets you sleep at night, because it's about risk,” she said.
Medicare Advantage plans also tend to have more limited networks of providers. If someone with a Medicare Advantage HMO (health maintenance organization) plan sees a provider out of the network, they’ll get hit with the full cost. If someone with a PPO (preferred provider organization) plan goes to an out-of-network provider, they just have to pay a higher fee.
The tradeoff? HMO plans tend to have lower premiums than PPOs.
The provider networks can also change at any time, based on insurance companies’ bottom lines. Beneficiaries of UnitedHealthcare may have watched last year as the company and Duke Health battled over contract negotiations. They reached a last-minute agreement on Nov. 1, WRAL reported, avoiding loss of coverage for more than 172,000 Duke patients.
Patients and doctors also may have to jump through more hoops to get insurance companies that run Medicare Advantage plans to agree to provide coverage, in a process known as prior authorization.
In contrast, those with Original Medicare can go to any doctor or hospital in the country that takes Medicare, providing you with more flexibility.
Where can I find extra assistance with my health care costs?
Medicare Savings Programs are available to eligible individuals to help pay for premiums, deductibles, coinsurance and copayments. The Extra Help program also helps qualified beneficiaries pay for prescription drug costs.
Anyone who qualifies for the Medicaid program is automatically eligible for Extra Help, Narron said. Many North Carolinians are likely eligible for Extra Help but don’t know about it or don’t know how to apply, Narron said, so more people should inquire into the program.
ResourcesWhere to find your local SHIIP counselor: Call 1-855-408-1212, email ncdoi.ncshiip@ncdoi.gov or visit the website and select your county.
Also: Medicare help page for signing up.
Social Security online Medicare sign-up page OR call +1 800-772-1213.
Available in most U.S. time zones Monday through Friday, 8 a.m. to 7 p.m., in English, Spanish, and other languages. Tell the representative you want to sign up for Medicare Parts A and B, or Part A only.
Call TTY +1 800-325-0778 if you're deaf or hard of hearing.
Other resources:
Durham-based Senior PharmAssist has a Medicare help page.
This article first appeared on North Carolina Health News and is republished here under a Creative Commons Attribution-NoDerivatives 4.0 International License.
