This collection of Frequently Asked Questions (FAQs) is designed to demystify Medicare for you. From eligibility criteria and enrollment periods to coverage details and cost considerations, we’ve compiled the most common questions and concerns people have about Medicare. Our aim is to provide you with concise, straightforward answers that will guide you through understanding Medicare’s structure, benefits, and options available to you.

What Exactly is Medicare?

Medicare is a federal health insurance program primarily for individuals who are 65 years of age and older. It also extends coverage to certain younger people who have disabilities, as well as individuals suffering from End-Stage Renal Disease (ESRD), a condition requiring dialysis or a kidney transplant. Established to ensure that eligible individuals have access to essential healthcare services, Medicare helps cover a wide range of medical expenses, from hospital stays and doctor visits to preventive services and prescription drugs, depending on the specific parts of the program in which an individual is enrolled.

Who Qualifies for Medicare?

Eligibility for Medicare is primarily determined by age, disability status, and specific medical conditions. Individuals aged 65 or older are eligible for Medicare, regardless of their income or medical history. People under 65 can qualify for Medicare if they have been receiving Social Security Disability Insurance (SSDI) benefits for at least 24 months or have certain conditions. These conditions include Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s disease, where eligibility begins the month disability benefits start, and End-Stage Renal Disease (ESRD), requiring regular dialysis or a kidney transplant, where individuals must apply specifically for Medicare coverage.

Is Medicare Free?

Medicare Part A, which covers hospital insurance, typically does not require a monthly premium for most individuals. This is because they have already contributed to Medicare through payroll taxes under the Federal Insurance Contributions Act (FICA) during their working years. Similarly, individuals may also be eligible for premium-free Part A through their spouse’s work history. However, those who haven’t paid sufficient Medicare taxes may need to pay a premium for Part A coverage. Unlike Part A, other parts of Medicare, including Part B (medical insurance), do require participants to pay a monthly premium.

When and How Can I Enroll in Medicare?

You can enroll in Medicare during specific periods: the Initial Enrollment Period (IEP), the General Enrollment Period (GEP), and Special Enrollment Periods (SEP).

• Initial Enrollment Period (IEP): This is a 7-month period that starts 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after that month. If you’re eligible for Medicare due to age, this is your first chance to sign up.
• General Enrollment Period (GEP): If you miss your IEP, you can enroll between January 1 and March 31 each year, with coverage starting July 1. This period is for signing up for Part A and/or Part B.
• Special Enrollment Periods (SEP): If you didn’t sign up for Part A and/or Part B during your IEP because you were covered under a group health plan based on current employment, you can sign up during a SEP. You can enroll anytime you’re still covered by the group plan or during the 8-month period that begins the month after employment ends or the coverage ends, whichever happens first.

How to Enroll:

• Online: The easiest way to enroll in Medicare is through the Social Security Administration (SSA) website at www.ssa.gov.
• By Phone: You can also enroll by calling the Social Security Administration at 1-800-772-1213.
• In Person: Visit your local Social Security office to enroll in person. It’s wise to call ahead and make an appointment to reduce wait times.

What are the Different Parts of Medicare?

Medicare is divided into four main parts, each covering different healthcare services:

• Part A (Hospital Insurance): Covers inpatient hospital stays, care in skilled nursing facilities, hospice care, and some home health care. Most people don’t pay a premium for Part A because they or their spouse paid Medicare taxes while working.
• Part B (Medical Insurance): Covers certain doctors’ services, outpatient care, medical supplies, and preventive services. Part B requires a monthly premium, which most people pay directly from their Social Security benefits.
• Part C (Medicare Advantage Plans): Offered by private companies approved by Medicare, these plans provide all your Part A and Part B benefits. Many also include Part D (prescription drugs) and additional benefits like dental, vision, and hearing, often for an extra cost. These plans may have different rules, costs, and coverage restrictions.
• Part D (Prescription Drug Coverage): Adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans. Part D plans are offered by insurance companies and other private companies approved by Medicare and include a monthly premium.

Does Medicare Cover Prescription Drugs?

Yes, Medicare covers prescription drugs through Part D, which is optional and available to anyone who has Medicare. Part D plans are offered by private insurance companies approved by Medicare and vary in terms of cost and drugs covered.

How to Join Part D:

• You can join a Medicare Prescription Drug Plan when you first become eligible for Medicare during your Initial Enrollment Period.
• If you don’t sign up when you’re first eligible, you can join during the Open Enrollment Period, which runs from October 15 to December 7 each year.
• Joining a Part D plan can be done by enrolling directly with the plan, using the Medicare Plan Finder on Medicare.gov, or calling 1-800-MEDICARE.

What Part D Covers:

• Part D plans must cover a wide range of prescription drugs that people with Medicare take, including most drugs in certain protected classes, like drugs to treat cancer or HIV/AIDS. Each plan has its own formulary (list of covered drugs), which can change each year.
• Plans can vary in cost and the specific drugs covered. You’ll typically pay a monthly premium, an annual deductible, and copayments or coinsurance for each prescription.
• It’s important to review a plan’s formulary to ensure it covers your prescriptions. You can switch plans during the Open Enrollment Period if your needs change.

Can I Keep My Doctor with Medicare?

Whether you can keep your doctor with Medicare depends on the type of Medicare coverage you have and whether your doctor accepts Medicare.

• Original Medicare (Parts A and B): If you have Original Medicare, you can see any doctor or healthcare provider in the U.S. who accepts Medicare. Most doctors do accept Medicare patients, but it’s always best to ask your doctor directly if they accept Medicare patients before receiving services.
• Medicare Advantage (Part C): If you are enrolled in a Medicare Advantage plan, your ability to keep your current doctor will depend on whether your doctor is in your plan’s network. Medicare Advantage plans are offered by private insurance companies and have specific networks of doctors and hospitals. If your doctor is not in the network, you may need to choose a new doctor who is, or you may face higher out-of-pocket costs for seeing an out-of-network provider.

What Should I Do If I’m Still Working at 65?

If you’re still working at 65 and have health insurance through your employer, you have options regarding Medicare enrollment:

• Employer Coverage Consideration: If your employer has 20 or more employees, your employer’s health insurance will be the primary insurer, and you can delay enrolling in Medicare Part B without penalty. You should still sign up for Medicare Part A, which is premium-free for most people and can work alongside your employer coverage.
• Enrollment Timing: You can delay Part B enrollment until your employment or employer coverage ends. Once it does, you’ll have an 8-month Special Enrollment Period (SEP) to sign up for Part B without facing a late enrollment penalty. This SEP also allows you to join a Medicare Part D plan and a Medicare Advantage Plan.
• Evaluate Your Coverage: Compare your employer’s insurance with Medicare to see which offers better benefits or lower costs, especially if your employer has fewer than 20 employees. In this case, Medicare will be the primary insurer, and you might need to enroll in Parts A and B to have full coverage.
• Consult with Your Benefits Administrator: Talk to your employer’s benefits administrator to understand how your employer insurance works with Medicare. This can help you decide whether to take Medicare Part B or defer it until later.
• Consider HSA Contributions: If you contribute to a Health Savings Account (HSA) and plan to continue working past 65, enrolling in Medicare will make you ineligible to make further HSA contributions. Plan accordingly based on your healthcare spending and savings strategy.

How Do I Choose Between Medicare Advantage and Medigap?

Choosing between Medicare Advantage (Part C) and Medigap (Medicare Supplement Insurance) depends on your healthcare needs, financial situation, and preferences for how you access and pay for healthcare.

Medicare Advantage plans are offered by private insurance companies and bundle Medicare Parts A and B, and usually Part D (prescription drug coverage). They often offer additional benefits, such as dental, vision, and wellness programs, but require you to use doctors and hospitals within the plan’s network. Costs vary by plan, and you may pay a monthly premium on top of your Part B premium, along with copayments and deductibles for services.

Medigap policies are also sold by private companies but are designed to supplement Original Medicare by covering some out-of-pocket costs not covered by Parts A and B, such as deductibles, copayments, and coinsurance. Medigap policies do not include prescription drug coverage, so you may need to join a separate Part D plan. Medigap policies allow you to see any doctor that accepts Medicare, providing more flexibility in healthcare providers compared to Medicare Advantage plans.

What Is Not Covered by Medicare?

Medicare excludes several key healthcare services from its coverage. Significantly, it does not cover long-term or custodial care. While Medicaid, the federal program designed to assist those with lower incomes, covers the costs associated with custodial care, Medicare does not offer this benefit.

Additionally, Medicare does not provide coverage for the following services:

• Eye exams and eyeglasses
• Dentures
• Most dental care
• Medical care overseas
• Cosmetic surgery
• Massage therapy

The Bottom Line

Medicare stands as a cornerstone of healthcare for over 60 million Americans, providing a critical foundation of coverage for those aged 65 and older, as well as for individuals with certain disabilities. This vital program ensures access to a wide range of medical services, significantly reducing healthcare expenses and improving the quality of life for millions. With Medicare’s comprehensive coverage, beneficiaries gain peace of mind knowing that essential healthcare needs, from hospital stays to preventive services, are addressed.