Getting Off to a Good Start with Medicare
What you need to know and do as you near your 65th birthday
Now is the
time to start investigating your health insurance options and gathering accurate
information concerning Medicare and other health insurance so you can make
decisions that can prevent serious, costly problems. Don't rely on someone else
to gather the information you need. This fact sheet is intended to help guide
you in your search.
- You need information from the Social Security Administration about whether
you will be eligible for Medicare. Social Security is responsible for
determining eligibility and enrolling people in Medicare. Please note that the
Railroad Retirement Board handles Medicare enrollment for railroad
- You may be eligible for Medicare on your spouse's work record or as a widow
or widower. You may also have questions about when to enroll in Medicare due to
differences in ages between spouses. If you are not eligible for Medicare on
your own work record or your spouse's work record, you may have the option to
purchase Medicare coverage. Social Security can answer questions about your
- If you will be eligible for Medicare at age 65, you need to take specific actions to ensure
Social Security has accurate information about your situation. If you fail to
take the necessary actions, at the recommended times, you could suffer some very
- If you plan to continue
working when you reach your 65th birthday, you need to take extra
care in making insurance decisions.
- You need information about health insurance to supplement your Medicare
coverage--either an employer group health plan (EGHP) and/or a privately
purchased Medicare supplement policy. Another option for some Medicare
beneficiaries is to join an alternative Medicare Health Plan. *
* For purposes of this document, the term "alternative Medicare Health Plan"
refers to Medicare+Choice plans. Three types of Medicare+Choice plans are
currently available to Illinois residents who have Medicare, depending on where
you live. They are Health Maintenance Organizations (HMOs), Preferred Provider
Organizations (PPOs) and Private Fee-For-Service (PFFS). Please contact
SHIP at 1-800-548-9034 for further information on
these Medicare+Choice plans.
NOTE:It is advisable to research providers in
your area prior to purchasing a PFFS plan to
ensure that your health care will be covered by the PFFS plan.
Your Work Situation
Think about what your work situation will be when you reach your 65th
birthday, as this will influence the health insurance decisions you make and
actions you take.
- You may already be retired.
- You may be planning to retire at age 65.
- You may plan to keep working after age 65.
If you do not fall into one of the previously mentioned categories, contact the
Senior Health Insurance Program (SHIP) at 1-800-548-9034 for guidance.
Deadline for Action
Whether you plan to enroll in Medicare at age 65 or to delay enrollment for a
few years, it is extremely important that you take the actions listed below
within the applicable enrollment period. Failure to act during this time period
may cause major problems with very serious consequences. Our goal is to help
you avoid these
If You Have Already Signed Up for Social Security Benefits:
- Call the Social Security Administration at 1-800-772-1213 about six months
before your 65th birthday and request a Medicare & You
- Study the Medicare & You booklet so you understand what Medicare does and does not cover.
- If your employer provides an employer group health plan (EGHP) to retirees,
talk to your company's benefits officer about the coverage offered under that
plan. If you are not satisfied with the coverage provided by the combination of
Medicare and EGHP, begin shopping for a private Medicare supplement policy or an
alternative Medicare Health Plan. Call SHIP to learn about the ten standardized
Medicare supplement plans and the alternative Medicare Health Plans -- and the
companies selling them in Illinois.
- If an EGHP is not available to you, you should begin shopping for a private
Medicare Supplement policy or an alternative Medicare Health Plan.
Call SHIP if you need assistance.
- You will receive a Medicare card shortly before your 65th birthday. If you
wish to enroll in Medicare Part B, you do not need to do anything further. Your
Medicare card should show Medicare Part A and B coverage effective the first day
of the month you will be age 65.
- Make final arrangements for a private Medicare Supplement policy or an
alternative Medicare Health Plan and/or EGHP coverage.
Program sponsored by the Illinois Department of Insurance. Call the office in Springfield toll-free
at 1-800-548-9034, to ask any questions you might
have about Medicare or other health insurance for people with Medicare. Ask for
the nearest SHIP office, then call and request a meeting (at no charge) with a
trained SHIP counselor.
If You Have NOT Signed Up for Social Security Benefits Before Age 65:
- Call 1-800-772-1213 and request form
SSA-7004-SM (Request for Earning and Benefits Estimate Statement) and a Medicare
& You Handbook. Complete the SSA-7004-SM and send it to Social Security.
When you receive your report back from Social Security, check to see if you are
eligible for Medicare. If you have questions about the report, call Social
- Study the Medicare & You booklet so you understand what Medicare does and does not cover.
- If you do plan to retire, discuss any possible
EGHP coverage with your company's benefits office. If you are not satisfied
with the coverage provided, look for a private Medicare supplement policy or an
alternative Medicare Health Plan. Call SHIP to learn about the ten
standardized Medicare supplement plans or the alternative Medicare Health Plans
-- and the companies selling them in Illinois.
- If you do not plan to retire, you may need
help in determining if your EGHP or Medicare will be primary after you turn 65.
Call SHIP to request the publication entitled "Medicare and Other Health
Benefits: Your Guide to Who Pays First."
- In either case, contact Social Security three months before your 65th
birthday to make an appointment to file for Medicare and/or Social Security
benefits if you plan to retire.
- You will receive a Medicare card. Check the card to be certain it reflects
the options you chose when you filed.
Facts to Understand and Recommendations for Action
FACT:The health insurance coverage you had before age 65 will probably
change when you reach your 65th birthday
and retire. The
way in which it pays claims
assume you have
Parts A and B even if you
- If you are eligible to receive Social Security benefits you will not have to
pay a premium for Medicare Part A (hospital insurance). You may be eligible for
Medicare through your work record or your spouse's work record.
- If you enroll for Medicare Part B (medical insurance), your monthly premium
will be deducted from your Social Security benefits check. If you do not
receive a Social Security check, you will be billed quarterly for the Part B
In most cases, you should enroll in both Medicare
Parts A and B to avoid permanent premium penalties, unless you continue to work
beyond the age of 65.
Medicare Part A and B coverage will not pay all of your health care bills. You
need a good employer group health plan (EGHP) and/or you should select
either an individual Medicare supplement policy
from among the ten standardized plans or join an
alternative Medicare Health Plan.
If you do not have access to a good EGHP, you should try to purchase an
appropriate Medicare supplement plan or Medicare Health Plan.
Some people on Medicare, with low income and assets, are eligible to receive
benefits from Medicare Savings Programs. These programs are administered by the
Illinois Department of Human Services and help cover some Medicare out-of-pocket
If your income and assets are low, ask your local Department of Human Services
office if you are eligible as a Qualified Medicare Beneficiary (QMB), Specified
Low Income Medicare Beneficiary (SLMB), or Qualified Individual 1 (QI1).
Potential Problem Situations
- If you fail to enroll for Medicare Part B during your initial
seven-month window (the
three months before your 65th birthday, the
month of your 65th birthday, and the
three months after your birthday), you will not be
permitted to enroll until the following calendar year (January 1 through March
31). Additionally, your coverage will not begin until July 1 of that year. The
premium will increase to include a permanent penalty of 10% per year for each
year of delayed enrollment into Part B. These same rules apply if you waive
Part B because you have COBRA coverage through your or your spouse’s
previous employer. However, if you delay enrollment into Medicare Part B
because you continue to work beyond the age of 65, you
will not incur the 10% per year penalty. You will be given a special
enrollment period of eight months to enroll in Part B.
- If you fail to apply for a Medicare supplement policy within six months of
enrolling in Medicare Part B (at age 65 or older), you may lose the right to
purchase the Medicare supplement policy of your choice if you have a
- In Illinois, you must have both Medicare Part A and B to join an alternative
Medicare Health Plan or to purchase a Medicare supplement policy.
- Be cautious when canceling an EGHP benefit
plan because you may waive your right to ever re-enroll in the plan.
Sources of Information
Social Security Administration
To request SSA-7004-SM; handles Medicare eligibility and enrollment.
Medicare, Medicare supplement, and Medicare Health Plan information, free health
insurance counseling, and consumer publications.
Illinois Department of Human Services
Medicare Savings Program eligibility information and applications.
Illinois Department on Aging
Senior Help Line
Circuit Breaker/Pharmaceutical Assistance eligibility information and
Illinois Partners for Medicare Consumers
Centers for Medicare & Medicaid Services
CMS is the federal agency that administers the Medicare program.
1-800-MEDICARE staff answer general questions on
Wisconsin Physicians Service
Medicare Part B Carrier
For questions or problems with Medicare Part B claims
Medicare Part A Fiscal Intermediary
877/602-2430 TTY/TDD 866/737-6930
www.medicare.gov or www.adminastar.com
For questions or problems with Medicare Part A claims
Durable Medical Equipment Regional Carrier
800/270-2313 TTY/TDD 866/284-0881
For questions or problems with Medicare Durable
Medical Equipment claims or appeals
Illinois Foundation for Quality Health Care
Quality Improvement Organization
Provides nursing home quality information,
Medicare hospital rights and responds to inquiries
regarding the quality of health care Medicare
beneficiaries have received.
Senior Health Insurance Program
800/548-9034 TTY/TDD 866/323-5321
Provides free, confidential and objective insurance
counseling to people on Medicare and their families regarding Medicare,
Medicare supplement insurance, Medicare+Choice products and long term care