Medicare frequently asked questions
Who qualifies for Medicare? When should you enroll in a Medicare plan? What does Medicare cover? If you’re approaching Medicare age — or even if you already have a Medicare plan — these are just a few of the questions you may be asking.
We’ve gathered answers to some of the most-asked questions about Medicare to help you understand your options and find a Medicare plan that best meets your needs.
What is Medicare?
While "What is Medicare?" may seem like a basic question, it’s actually very common. Here’s what Medicare is, at its core:
Medicare is a federally funded and operated health insurance program originally designed for people who are 65 or older. Throughout the years, Medicare has expanded to include disabled people under 65 and those with special circumstances. The program is divided into four parts: A, B, C and D.
While that’s the textbook description of Medicare, there’s clearly more to know. The questions below dive into some of the details you may be looking for — like when to apply for Medicare, what your Medicare coverage options may be and more.
Medicare eligibility, enrollment and when to apply
You’re eligible for Medicare if you meet the following requirements:
- You must be a U.S. citizen or a qualified legal resident
- Both U.S. citizens and qualified legal residents have to be one of the following:
- Age 65 or older
- Younger than 65 with a qualifying disability
- Any age with a diagnosis of End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS, also called Lou Gehrig’s Disease)
To qualify as a legal resident, you must have lived in the United States for at least 5 years in a row before applying for Medicare.
Enrollment in Original Medicare (which includes Medicare Part A and Part B) may or may not be automatic — it depends on your situation.
You’re automatically enrolled if you already receive Social Security or Railroad Retirement Board benefits or become eligible early due to disability. Otherwise, you’ll need to enroll yourself during your Initial Enrollment Period (IEP).
You can enroll in Part A, Part B, or both. You don’t have to enroll in Part B right away, because you’ll be charged a premium. Just remember that if you choose to wait to enroll in Part B, you’ll be charged a late enrollment penalty, and Part B coverage will cost you more. Learn how to avoid a Medicare Part B late enrollment penalty.
You can enroll in Original Medicare online at the Social Security website or by calling or visiting your local Social Security office.
You have to have both Part A and Part B to enroll in a Medicare Advantage (Part C) or a Medicare Supplement plan. For a Medicare prescription drug (Part D) plan, you only need Part A or Part B.
You can apply anytime during the Initial Enrollment Period (IEP). IEP is a 7-month window around your 65th birthday. It covers your birth month, plus the 3 months before and the 3 months after.
After you enroll in Original Medicare and during your IEP, you can add a Medicare Advantage (Part C) plan or a Medicare prescription drug (Part D) plan.
The General Enrollment Period is available to you if you didn't sign up during your IEP. The GEP runs January 1 to March 31 each year.
If you enroll in Original Medicare during the GEP, you can add a Medicare Advantage (Part C) plan or a Medicare prescription drug (Part D) plan between April 1 and June 30 of the same year.
The Special Enrollment Period lets you enroll in Original Medicare outside of your IEP due to certain life changes. For example, you might wait to enroll if you're still working. Timing depends on when those life changes happen.
After you retire, you have 8 months to enroll in Original Medicare without a late penalty. The 8-month period begins after the month your employment or employer coverage ends, whichever comes first. This is also true if you are covered under your spouse's employer coverage.
If you want a Medicare Advantage (Part C) plan or a Medicare prescription drug (Part D) plan after an SEP, you need to act quickly. You have just 2 months after the month your employment or employer coverage ends to enroll in a Medicare Advantage (Part C) or Medicare prescription drug (Part D) plan—but you have to enroll in Original Medicare first.
If you’re still working when you turn 65, you will need to make some decisions around Original Medicare — even if you’re covered by your employer’s health plan. When you turn 65, you may want to enroll in Medicare Part A, which is premium free. If you have qualified insurance from your employer, you may be able to delay enrolling in Part B and Part D without penalty. Talk to your employer’s benefit administrator to help you learn more about your choices.
If you're a veteran and you become eligible for Medicare, you may already have other insurance such as from an employer, the Veterans Administration (VA) benefits or TRICARE. There a number of details to know about how Medicare may work with VA benefits and TRICARE.
Overall, it's important to know that nobody is required to enroll in Medicare, but also that if you do so outside of your Initial Enrollment Period (IEP) without creditable coverage from an employer, you could face late enrollment penalties. Neither VA benefits nor TRICARE will qualify you to delay Medicare without financial penalty. Learn more about applying for Medicare if you're a veteran.
Medicare coverage and plan options
When looking at Medicare coverage choices, there’s a lot to consider. You can enroll in Medicare Part A (hospital insurance), Medicare Part B (medical insurance), or both.
Once you enroll in Medicare, there are more coverage choices you can make. These include options to enroll in a Medicare Advantage plan (Part C) , a Medicare prescription drug plan (Part D) , or a Medicare Supplement insurance plan (Medigap) to complete your Medicare coverage. A prescription drug plan may also be combined with a Medicare Supplement insurance plan or certain types of Medicare Advantage plans that don’t include drug coverage, like a Private Fee-for-Service (PFFS) plan.
Medicare provides hospital coverage (Part A) and medical coverage (Part B). You can choose additional coverage options such as Medicare Supplement plans, Medicare prescription drug plans (Part D) or opt for a Medicare Advantage plan.
Read on to review details on what is covered under each type of Medicare part/plan, A, B, C, D and Medicare Supplement plans.
Original Medicare consists of Medicare Part A (hospital coverage) and Medicare Part B (medical coverage). It’s a federal health insurance program for individuals 65 or older; under 65 who have a qualifying disability, and of any age with a diagnosis of End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS, also called Lou Gehrig’s disease).
Medicare Part A is hospital coverage. It helps pay for hospital stays and inpatient care in hospitals.
Medicare Part B is medical coverage. It helps pay for doctor visits and outpatient care.
Medicare Part A is hospital coverage. It helps pay for hospital stays and inpatient care in hospitals. This includes:
- Care in special units, like intensive care
- Skilled nursing services
- Drugs, medical supplies and medical equipment used during an inpatient stay
- Lab test, X-rays and medical equipment used as an inpatient
- Operating room and recovery room services
- Hospice care for the terminally ill
Medicare Part B is medical coverage. It helps pay for doctor visits and outpatient care. This includes:
- Doctor visits, including when you are in the hospital
- An annual wellness visit and preventive services such as flu shots and mammograms
- Medically necessary services and supplies needed to treat your medical condition
Medicare Part C is known as Medicare Advantage. Medicare Advantage plans cover and combine Original Medicare Part A and Part B benefits into one plan. Most Medicare Advantage plans also include: prescription drug coverage (Part D) and offer additional benefits not covered by Original Medicare, often with no additional premium.
Medicare Part C (Medicare Advantage) are plans that cover and combine Original Medicare Part A and Part B benefits into one plan. Additionally, most plans include coverage for additional benefits such as:
- Prescription drugs
- Dental care
- Fitness memberships
Medicare Advantage (Part C) plans can offer coverage for dental and vision health items in addition to also offering the same coverage as Original Medicare. Most also include prescription drug coverage as well as other benefits such as hearing health coverage and gym memberships.
What specific dental and vision items are covered and how much they cost will vary from plan to plan.
Medicare Part D is prescription drug coverage. Medicare Part D plans (PDP) help pay for medications prescribed by a doctor. Part D plans are offered by private insurance companies approved by Medicare. The types of drugs covered is decided by the U.S. government. Beyond that list, every Medicare Part D plan covers a different set of drugs. When choosing a Part D plan, you need to make sure it covers the drugs you take.
Most Medicare Advantage (Part C) plans already include Part D prescription drug coverage, combined into a single plan with hospital and medical. Another option is to have a separate Part D plan in addition to Original Medicare, a Medicare Supplement Insurance plan, or a Private Fee-For-Service plan without drug coverage.
All Medicare Part D plans have a drug list — also called a formulary — that gives you the information you need about which drugs are covered. The formulary can change, but your plan will let you know ahead of time if it does. The formulary will also tell you if your drug has any special rules or limits. Your plan will send you your formulary and/or give you a way to get all of your drug list information online. Learn more about Medicare Part D coverage.
Medicare Supplement insurance, often called "Medigap," helps pay some of the out-of-pocket costs not paid by Original Medicare (Parts A and B). There are ten plans standardized by the federal government. Each Medicare Supplement plan offers the same basic benefits no matter which insurance company sells it.
Note: In Massachusetts, Minnesota and Wisconsin, there are different standardized plan options available.
A Medicare Supplement insurance plan works with Original Medicare, which includes Part A and Part B. It helps cover some of the out-of-pocket health care costs that Original Medicare doesn’t pay for. For instance, Medicare Part B generally covers about 80% of Part B expenses. You’re responsible for paying the rest. A Medicare Supplement insurance plan could help pay your share. Learn more about Medicare Supplement coverage.
Medicare Advantage (Part C) plans can offer coverage for dental care, in addition to also offering the same coverage as Original Medicare.
Original Medicare generally doesn’t cover dental exams, procedures or supplies. Part A, however, may help with certain dental services while you’re in the hospital.
Medicare Part B may cover some things for vision including preventive or diagnostic eye exams, including glaucoma tests, yearly eye exams to test for diabetic retinopathy and eye tests for macular degeneration, cataract surgery and prescription lenses or eyeglasses in certain situations.
In addition, Medicare Advantage (Part C) plans can offer coverage for dental and vision health items in addition to also offering the same coverage as Original Medicare.
Medicare Advantage plans are offered by private insurance companies. The plans available to you depend on where you live. What specific dental and vision items are covered and how much they cost will vary from plan to plan.
A copayment, or copay, is a fixed amount of money that you pay out-of-pocket for a specific service. Copays generally apply to doctor visits, specialist visits, and prescription drug refills. Most copay amounts are in the $10 to $45+ range, but the cost depends entirely on your plan.
Under Medicare Part B, you are covered for outpatient services for the prevention, diagnosis, and treatment of medical conditions. Part B also covers you for mental health services, durable medical equipment, and some medications and vaccines. Learn more about what’s covered by Medicare Part B.
Choosing a Medicare plan that fits your needs
Original Medicare (Parts A & B) covers many medical and hospital services but doesn’t cover everything you may want or need for your health, such as coverage for prescription drugs, dental or vision care, hearing aids and more. Many people opt to get coverage for these items through a Medicare Advantage or Prescription Drug plan offered by private insurers.
Medicare parts and plans can be combined for the coverage you want. The combinations depend on whether you stay with Original Medicare or choose a Medicare Advantage plan.
There’s no “one size fits all” when it comes to Medicare. Your Medicare choices need to reflect your personal health care needs. Once you have a handle on that, the rest may begin to fall into place. Medicare parts and plans can be combined for the coverage you want.
It’s important to understand the basics of Medicare costs. Most people pay no premium for Medicare Part A. The premium for Medicare Part B depends on your income. For both Part A and Part B, there are also deductibles and coinsurance. You may also qualify for help paying for Medicare costs.
Medicare costs for 2021
Depending on what coverage you choose, your costs can be different. To get an idea of 2021 costs directly from Medicare, go to Medicare costs at a glance on the Medicare.gov website.