Understanding Your Medicare Options

Navigating Medicare doesn’t have to feel like rocket science. Let us simplify the process for you.

Discover the Benefits of Choosing
a Medicare Advantage Plan

When deciding on your Medicare coverage, you have the choice between Original Medicare and a Medicare Advantage plan like eternalHealth, which is also known as Medicare Part C. Medicare Advantage plans encompass all the services covered by Original Medicare, plus extras like dental, vision, hearing, transportation, fitness, and more. Many Medicare Advantage plans also include prescription drug coverage (Part D). The right plan can deliver exceptional care while helping you keep money in your pocket. 

Review frequently asked questions about Medicare and Medicare Advantage below, or join eternalHealth at an educational event in your community so you feel empowered to take your healthcare into your own hands!

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Frequently Asked Questions

Part A: Provides inpatient/hospital coverage
Part B: Provides outpatient/medical coverage
Part C: Offers an alternative way to receive Medicare benefits and includes Part A and Part B coverage
Part D: Provides prescription drug coverage

Generally, Medicare is available for people:
– Age 65 years or older
– Those younger than 65 with disabilities
– Those with End Stage Renal Disease

You may be eligible to receive Part A with no premium to pay at age 65 if:

  • You are receiving retirement benefits from Social Security or the Railroad Retirement Board.
  • You are eligible to receive Social Security or Railroad benefits but you have not yet filed for them.
  • You or your spouse had Medicare-covered government employment.

To find out if you are eligible and your expected premium, head to the Medicare.gov eligibility tool.

Generally, if you are already receiving benefits from Social Security, you will automatically be enrolled in Parts A and B on the first day of the month of your 65th birthday. If your birthday is on the first day of the month, then you would receive it the month before your birthday month.

If you are not currently receiving Social Security benefits within 3 months of turning 65 or older, you will need to enroll in Medicare through the Social Security Administration.

In case you have Part A, but do not have Part B, it is advised to enroll in Part B to eliminate any late penalties that may occur otherwise.

In order to join a Medicare Advantage Plan, beneficiaries must be enrolled in both Part A and Part B.

Almost everyone will pay no premium for Part A. The standard premium for Part B is $170.10 per month as of 2022. The premium for Part B is income based.  You could pay more for your Part B premium.

Medicare Advantage Plans and Part D prescription drug plan premiums vary based on the plan.

You are eligible to enroll into Medicare 3 months before your 65th birthday, the month of your birthday, and you have until 3 months after your birthday month, which is a total of 7 months. If you do not enroll in this timeframe you must wait until the next enrollment period.

If you are 65 or older and are not getting social security benefits you will need to sign up for Part A and Part B (Optional, but you will need Part B if you want to enroll into a Medicare Advantage program).

You will have Original Medicare unless you choose to receive your benefits from a Medicare Advantage plan (also called Part C), such as eternalHealth. If you do choose to enroll in a Medicare Advantage plan, you are still responsible for your Original Medicare premiums.

To enroll into Medicare or if you have questions regarding eligibility you can call the Social Security Administration at 1 (800) 772-1213 or visit their website at www.socialsecurity.gov.

There are 4 total enrollment periods throughout the year:

Initial Enrollment Period – This is the 3 months before your 65th birthday month, your birthday month, and the three months after your birthday month. During this month you can sign up for a plan.

Medicare Annual Enrollment Period – Begins October 15th and ends on December 7th of each year. During this time you can sign up for a plan. switch your plan, or leave a plan.

Special Enrollment Period – This period depends on your personal situation. For example if you are moving, if you change careers, or if you have lost your current insurance coverage.

Medicare Open Enrollment Period– Begins January 1st and ends on March 31st each year. During this period you can change from one Medicare Advantage plan to another, or change from a Medicare Advantage plan to original Medicare. You may only make one change.

HMO: Plans that offer a specific network of physicians, provide integrated care, and often focus on prevention and wellness. Most HMO’s require referrals from your primary care physician to ensure your care is coordinated.

PPO: Plans that offer a specific network of physicians, but also gives you the freedom to use out-of-network providers without referrals, usually at a higher cost

The Medicare Part D “Donut Hole” is a temporary coverage gap that will cause you to pay more for your prescription drugs than you may have expected.

It is important to note that not everyone with part D coverage will reach the donut hole, but if your cost of medication goes over a specified dollar amount within a calendar year, you will reach this gap.

During this time, you will see an increase in cost of your medications, as you will be responsible for 25% of the retail cost out of pocket, for both brand name and generic drugs, which is typically higher than a standard copay.

The extra help program, also known as Low Income Subsidy (LIS) is a federal program that you must qualify for, based on your income and assets. If you do qualify the program will pay for a portion of your prescription drug plan costs including Part D Premiums, Deductibles and copayments. You can apply for extra help through the Social Security Administration online.

Medicare star ratings can assist you in learning which plans are performing best in your area. Each plan gets one to five stars, with five being the best and one being the worst. Star Ratings are based on categories such as customer service, member complaints, and quality of care.

CMS, The Centers for Medicare Medicaid Services, put a five-star rating system into place to allow for beneficiaries to compare plans. The plans are rated by measuring the experiences of beneficiaries and is rated from 1 star, being poor, to 5 star being excellent.

Ratings are in five different categories:

  1. Preventative Services
  2. Plan Responsiveness
  3. Chronic Condition Management
  4. Customer Service
  5. Management of Member Complaints

You can visit Medicare.gov to search for physicians that accept Medicare. If you are a member of eternalHealth, you can use our online look-up tool to find an in-network doctor. 

You have options when it comes to Medicare and finding a plan that offers benefits you’ll actually want and need while saving you money. Each year during the Annual Election Period (October 15 – December 7) plans will release their benefits. Take the time to shop and compare for a plan that best meets your healthcare needs and your budget. Be sure to check monthly premiums, prescription drug costs, and that your providers are in-network.

Medicare has some restrictions in place on when a beneficiary can leave Medicare Advantage plans. You will need to review the enrollment periods or determine if you are
qualified for a Special Enrollment Period (SEP).

The two main enrollment periods are:

Annual Enrollment Period (AEP) that takes place every year from October 15 to December 7.

During this time you can:

  • Switch from Original Medicare to a Medicare Advantage or Medicare Supplement Insurance (Medigap) plan.
  • Switch from a Medicare Advantage plan to Original Medicare
  • Or change from one Medicare Advantage plan to another Medicare Advantage plan

Open Enrollment Period (OEP) that takes place every year from January 1 to March 31.

During this time you can:

  • Switch from on Medicare Advantage plan to another Medicare Advantage plan
  • Disenroll from a Medicare Advantage plan and return to Original Medicare
Page Last Updated On: October 25, 2023
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Tom Cunniffe

Tom Cunniffe

Director of Operations 

Tom Cunniffe comes to eternalHealth with over 20 years of healthcare operations’ experience, having held leadership positions in Call Center, Enrollment, Credentialing, UAT and Reimbursement teams. Tom has worked with Medicaid, Commercial and Medicare lines of business and has consistently built teams who are metrics driven with proven successful outcomes. Making sure our business strives for an efficient, best-in-class customer experience is at the center of Tom’s philosophy.

Tom has a bachelor’s degree from Fordham University and a master’s in business administration from University of Massachusetts at Amherst.

Tom Lawless

Tom Lawless

Chief Financial Officer

Tom Lawless has spent the past 20+ years building, sustaining, and growing new healthcare-related programs that balance fiscal responsibility & prudence with creativity & innovation, focusing on models of care that are novel, person-centered, and improve the social welfare of those who are served. He is very excited to continue doing so in his role as the Chief Financial Officer of eternalHealth.

Tom comes to eternalHealth from a not-for-profit, member-centric, health insurance cooperative. He helped the company continuously strive toward its dual goals of thriving financially, while keeping members at the very epicenter of its mission and service model. While there, Tom also spearheaded the creation of a brand new private, charitable foundation, which will be meaningfully giving back to those in need in the surrounding communities for years to come. Previously, Tom worked in the finance department of a successful hospice that provided high-quality care to persons experiencing their unique and poignant end-of-life journeys, assuring that the appropriate financing was always available. Tom’s career began as a civil servant in the Wisconsin Medicaid program, where he helped to create a program that expanded the institutional entitlement to care into home and community-based settings. Starting with only a blueprint in hand, the program now serves more than 57,000 frail elders and disabled adults and is considered a national model. Growing into a senior leadership role, Tom was a key architect of an innovative financing model, through which the public and private sectors successfully collaborated to better the lives of persons in great need.

Tom holds undergraduate and graduate degrees from the University of Chicago, with additional graduate work in economics completed at the University Wisconsin-Madison.

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