Medicare FAQs
What is Medicare?
Medicare is a federal health insurance program in the United States, primarily for individuals who are 65 and older, though it also covers some younger people with certain disabilities and those with End-Stage Renal Disease (ESRD). Medicare is divided into four main parts, each covering different healthcare services:
Medicare Part A (Hospital Insurance): Covers hospital stays, skilled nursing facility care, hospice care, and some home health care. Most people don’t pay a premium for Part A if they or their spouse paid Medicare taxes while working.
Medicare Part B (Medical Insurance): Helps cover the cost of outpatient care, doctor visits, preventive services (like flu shots), lab tests, mental health services, and durable medical equipment. There is a standard monthly premium for Part B.
Medicare Part C (Medicare Advantage): These are private health plans that combine Medicare Parts A and B, often with additional benefits like vision, hearing, dental, and prescription drug coverage. Medicare Advantage plans are offered by private companies approved by Medicare.
Medicare Part D (Prescription Drug Coverage): Helps cover the cost of prescription medications. It’s optional and available through private insurance companies, either as a stand-alone plan or included in a Medicare Advantage plan.
Who is eligible for Medicare?
You are eligible for Medicare if you meet one of the following criteria:
Age 65 or older: Most people qualify for Medicare once they reach age 65. If you or your spouse have paid Medicare taxes for at least 10 years, you will likely qualify for premium-free Part A.
Under 65 with a qualifying disability: If you have been receiving Social Security Disability Insurance (SSDI) for 24 months, you automatically qualify for Medicare, regardless of age.
End-Stage Renal Disease (ESRD): Individuals with permanent kidney failure requiring dialysis or a kidney transplant may be eligible for Medicare.
Amyotrophic Lateral Sclerosis (ALS): Also known as Lou Gehrig’s disease, people with ALS automatically qualify for Medicare as soon as they start receiving SSDI benefits.
When and how can I enroll in Medicare?
You can enroll in Medicare during specific enrollment periods:
Initial Enrollment Period (IEP): This is a 7-month period starting 3 months before the month you turn 65, including your birthday month, and ends 3 months after. During this time, you can sign up for Medicare Part A and Part B.
Special Enrollment Period (SEP): If you or your spouse are still working and covered by employer health insurance when you turn 65, you may qualify for a Special Enrollment Period to sign up for Medicare after your Initial Enrollment Period ends without a penalty.
General Enrollment Period (GEP): If you missed your IEP and don’t qualify for a SEP, you can enroll in Medicare from January 1 to March 31 each year, but you may have to pay a late enrollment penalty for Part B.
Annual Election Period (AEP): From October 15 to December 7, you can switch from Original Medicare to a Medicare Advantage plan, change Medicare Advantage plans, or join or switch a Medicare Part D (prescription drug) plan.
To enroll, you can visit the Social Security Administration website, apply in person at a local Social Security office, or call their hotline to complete the process.
What are Medicare Advantage Health Plans?
Medicare Advantage Plans, also known as Part C, are an alternative to Original Medicare (Part A and Part B) offered by private insurance companies approved by Medicare. These plans provide all the benefits of Original Medicare and often include additional coverage such as:
- Prescription drugs
- Vision
- Dental
- Hearing
- Fitness programs (like gym memberships)
Medicare Advantage plans come in several types, including Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service Plans (PFFS), and Special Needs Plans (SNPs). The costs and coverage can vary depending on the plan you choose, and many include networks of doctors and hospitals you must use for the plan to cover your care.
Unlike Original Medicare, which is managed by the federal government, Medicare Advantage plans may offer added benefits and can help reduce out-of-pocket costs, but they typically require staying within the plan’s network of providers.
What is Medicare Supplement (MediGap)?
A Medicare Supplement plan, also called Medigap, is private health insurance that helps cover some of the out-of-pocket costs not included in Original Medicare, such as copayments, coinsurance, and deductibles. Medigap plans are designed to fill the “gaps” in coverage left by Medicare Parts A and B, providing additional financial protection for healthcare expenses.