FAIR Health Consumer Access

What You Need to Know about Medicare

If you’re 65 or older, figuring out how Medicare works and when to sign up can be challenging. It can be hard to know what kind of coverage you’ll need. There are Part A, Part B, Part D, Medicare Advantage plans (Part C) and Medigap. There also are other complex terms to know. This article will cover the basics of what you need to know about Medicare.

What Is Medicare?
Medicare is the US health insurance program for people 65 and older (and for those under 65 with disabilities or certain illnesses). To be eligible, you must be a US citizen or legal resident. It has different parts that cover different things. You can choose the parts that best meet your healthcare needs.

How Does Medicare Work?
Original Medicare (Parts A and B). Part A is hospital insurance. It covers inpatient hospital stays, skilled nursing facility care, hospice care and some home health care. If you’ve worked and paid for Medicare taxes for a certain period of time, you most often don’t pay a monthly premium for Part A. This is called “premium-free Medicare.” Find out if you qualify here.

Part B is medical insurance. It covers certain doctors’ services, outpatient care, medical supplies and preventive services. If you have Part B, you’ll need to pay a monthly premium. To find out more about Part B costs, click here.

Parts A and B together are known as Original Medicare. Click here for more facts on Original Medicare.

How and when to sign up for Original Medicare. If you’re getting Social Security benefits, you’ll get Original Medicare (Parts A and B) automatically once you’re eligible for it. If not, you’ll have to sign up for Parts A and B. Here’s more information about how to sign up.

If you have a health plan through your (or your spouse’s) employer, you can probably wait and sign up for Medicare when you (or your spouse) retire, even if it’s after you turn 65. But in some cases, you may want to sign up for Medicare when you turn 65. This will help you avoid gaps in coverage or late enrollment costs.

If you do want to sign up for Original Medicare around the time you turn 65, your initial enrollment period starts three months before you turn 65. It ends three months after the month you turn 65. If you miss the enrollment period, you may have to pay a penalty for joining late. More information about signing up for Original Medicare and when coverage starts can be found here.

Keep in mind that Original Medicare doesn’t cover most dental care. Find out more about dental coverage for retirees here.

Part D. Prescription drugs are not covered under Original Medicare. If you need prescription drug coverage, you’ll need to add a separate plan. This is known as a Medicare prescription drug plan (Part D). These plans are offered by private insurance companies.

Whether to get Part D is up to you. What if you decide not to get it when you first can, and you don’t have other drug coverage (like drug coverage from an employer)? Then you’ll probably pay a late enrollment penalty if you sign up for it later. You may owe the penalty if you go without Part D or other drug coverage for a continuous period of 63 days or more after the end of your initial enrollment period for Part D coverage. For more on the Part D late enrollment penalty, see this site.

You may qualify for a program called “Extra Help” that assists in paying costs related to Medicare drug coverage. To qualify, you must have limited resources and income. Find out more here.

Medicare Advantage (Part C). Part C can give you coverage for Parts A, B and often Part D in one bundle. Part C plans, known as Medicare Advantage plans, are offered by Medicare-approved private companies. They also may include extra services generally not covered by Original Medicare, like vision, hearing and dental. Common types of Medicare Advantage plans include Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) plans. You can learn more about these plans and how to join here.

Medigap. There’s another health insurance plan option, called a Medicare supplemental insurance policy (Medigap). You can add this to Original Medicare. A Medigap policy can help pay for certain healthcare costs, such as deductibles and copays. Keep in mind that you generally can’t have a Medicare Advantage plan and Medigap at the same time. You’ll need to choose one or the other.

Want information about specific Medicare drug plans, Medicare Advantage plans and Medigap policies in your area? Visit Medicare.gov/plan-compare.

Dual eligibility for Medicare and Medicaid. If you’re eligible for Medicare and Medicaid, you’re considered dual eligible. If you’re dual eligible and visit a doctor who accepts Medicare and Medicaid, Medicare will cover the services first. Medicaid will cover most costs that Medicare won’t pay, such as copays and any deductibles. To learn more about how Medicare and Medicaid work together, click here.

Helpful Resources about Medicare
There are many websites that offer helpful resources about Medicare, such as the Medicare Rights Center and AARP. The Centers for Medicare & Medicaid Services (CMS) and the State Health Insurance Assistance Program also offer information about how Medicare works. You also can check out the Social Security Administration and the US Department of Health & Human Services for more information.