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Medicare

Medicare is a federal health insurance program.

Who is Eligible?

You are eligible for Medicare if you:

  • Are age 65 or older.
  • Have been receiving Social Security Disability Income (SSDI), usually for two years or more.
  • Have End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS, also called Lou Gehrig’s disease), and you receive SSDI or you, your spouse, or a parent are receiving or will receive Social Security or Railroad Retirement benefits.

Types of Medicare

Original Medicare (Parts A and B)

Unless you choose a Medicare Advantage Plan (see below), you will be enrolled in Original Medicare, also known as Traditional or Fee-for-Service Medicare. Under Original Medicare, the federal government will pay healthcare providers directly for some care that you receive. See “What Medicare Covers” below to learn about what Medicare will pay for.

Medicare Advantage Plans (Part C)

These plans are operated by private health insurance companies. They include the same benefits as Original Medicare, but may also include additional benefits, like paying for prescription drugs.

Medicare Prescription Drug Coverage (Part D)

These plans are operated by private health insurance companies to help cover the costs of prescription drugs for people who are enrolled in Original Medicare or a Medicare Advantage Plan that does not cover prescription drugs. Before you decide to purchase Part D, take the time to learn how Part D works with your existing insurance and the Indian Health Service (IHS) or Veterans’ Benefits.

Medicare Savings Programs, Extra Help, and Medigap 

These programs can help cover some of the costs of Medicare.

Medicaid Dual Eligibility

If you are eligible for both Medicare and Medicaid, you can enroll in both programs to get services that are not covered by Medicare alone, such as long-term care. See the Seniors and Medicare and Medicaid Enrollees page on the Medicaid website for information.

What Medicare Covers

Medicare Part A covers:

  • Inpatient care in a hospital, including prescription drugs administered while in a hospital
  • Skilled nursing facility care, with some restrictions
  • Some home healthcare
  • Hospice care

 

Medicare Part B covers:

  • Physical health services, such as check-ups, preventative care, diagnostic tests, and treatment for illnesses and injuries
  • Behavioral health services, meaning mental health and substance abuse services
  • Some home healthcare, such as intermittent skilled nursing care, physical therapy, and occupational therapy
  • Some prescription drugs, such as those administered by a doctor
  • Some durable medical equipment, such as oxygen equipment, wheelchairs, and blood sugar test strips, if they are “medically necessary” to treat an illness or injury
  • Ambulance services for emergencies and medically necessary transportation assistance if there is no safe way for you to get to your appointment without assistance (for example: you are confined to a bed or you need medical services during the trip)

 

Medicare Part D covers:

  • Prescription drugs on your Part D plan’s formulary, meaning the list of drugs that your health plan will pay for

 

Medicare Advantage Plans may cover a number of additional services, such as dental care, long-term care, and alternative therapies. To find out exactly what your health plan will cover, call the number on the back of your health insurance card or review your Member Handbook.

What Medicare Costs

Medicare costs will differ depending on what Parts you enroll in and how long you or your spouse have paid Social Security taxes while working. If you or your spouse have paid Social Security taxes for more than ten years, you will be eligible for Medicare Part A for free. If you or your spouse have not paid Social Security taxes for ten years, you can still get Medicare, but you will have to a pay a “premium” or monthly fee for each Part that you enroll in.

Applying for Medicare

If you receive Social Security or Railroad Retirement benefits, you will automatically be enrolled in Medicare three months before you turn 65.

If you do not already receive Social Security benefits, you will need to enroll in Medicare. You can enroll starting three months before you turn 65 and until 3 months after you turn 65. This is called the 7-month initial enrollment period.

If you are not automatically enrolled in Medicare Parts A and B, you can apply in person at your local Social Security office or online.

You can get help applying, answering questions about Medicare or making changes to your health plan from the Benefits Coordinator at your local IHS or tribal clinic, or a Patient Navigator or insurance broker. Call BeWellNM at 1-833-862-3935 or TTY 1-855-851-2018 to find one. BeWellNM has counselors specifically for Native Americans; call 1-855-241-8137 or visit their office at 6403 Menaul Blvd. NE in Albuquerque, New Mexico.

You can also see the How Do I Get Parts A and B page on the Medicare website for detailed information on getting Parts A and B.

 

When you apply for Medicare, you may need to provide the following documents or information.

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  • Proof of age (for example: birth certificate, driver’s license, passport)
  • Proof of citizenship (for example: birth certificate, passport, Tribal enrollment card, Certificate of Degree of Indian Blood)
  • Social Security card
  • Proof of all your sources of income (for example: paystubs, Social Security, SSI, Veterans benefits, any other income)
  • Proof of assets (for example: bank statements)
  • Proof of disability
  • Proof of residence (for example: recent mail addressed to you, rent receipts, a copy of your mortgage)
  • Proof of any other health insurance (any other current health insurance cards)

 

You can also apply online. See the How to Apply Online for Just Medicare page on the Social Security website. You can also download a Checklist for Online Medicare, Retirement and Spouses Applications.

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Using Medicare & Staying Covered

Whenever you go to a healthcare provider, including the IHS, bring your Medicare card with you and make sure the provider’s office knows you have Medicare. See the Your Medicare Card page on the Medicare website for detailed information on what you need to know about your Medicare card, how to get a replacement card, and how to change your address.

Once you’re enrolled in Medicare, you need to continue to pay monthly premiums to stay enrolled.

Read all the material you receive from your health insurance provider regarding any changes to your insurance that require your attention. 

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