Medicare

Medicare is the federal health insurance program primarily for people who are 65 or older. It is also available to certain younger people with disabilities and individuals with End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS).

You are generally eligible for Medicare if you are a U.S. citizen or a legal resident who has lived in the United States for at least 5 consecutive years and one of the following applies to you:

• You are age 65 or older.
• You are under 65 but have been receiving Social Security Disability Insurance (SSDI) for 24 months.
• You have End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS).

• Part A (Hospital Insurance): Helps cover inpatient care in hospitals, skilled nursing facility care, hospice care, and home health care.
• Part B (Medical Insurance): Helps cover services from doctors and other health care providers, outpatient care, durable medical equipment (like walkers and wheelchairs), and many preventive services.
• Part C (Medicare Advantage): An “all-in-one” alternative to Original Medicare (Parts A and B) offered by private insurance companies. These plans bundle Parts A, B, and usually Part D.
• Part D (Prescription Drug Coverage): Helps cover the cost of prescription drugs. This is also run by private insurance companies.

This is a key choice for every beneficiary.

• Original Medicare consists of Part A and Part B. You can see any doctor or visit any hospital in the U.S. that accepts Medicare. Most people add a Part D plan for drugs and a Medicare Supplement (Medigap) plan to help pay for out-of-pocket costs.
• Medicare Advantage (Part C) plans are offered by private companies approved by Medicare. They must cover everything Original Medicare covers. They often have specific networks of doctors (like an HMO or PPO) and may include extra benefits not covered by Original Medicare, such as dental, vision, and hearing.

Costs can vary. Here’s a general breakdown:

• Part A Premium: Most people get premium-free Part A if they or their spouse paid Medicare taxes for at least 10 years while working.
• Part B Premium: Most people pay a standard monthly premium. In 2025, the standard premium is projected to be around $174.70, but it can be higher based on your income.
• Deductibles & Coinsurance: Both Part A and Part B have deductibles you must meet. After your deductible is met, you typically pay 20% of the Medicare-approved amount for most Part B services.
• Part C & D Costs: Premiums, deductibles, and copayments for Medicare Advantage and Part D plans vary widely between plans.

This is your Initial Enrollment Period (IEP). It’s a 7-month window that includes:

• The 3 months before your 65th birthday month.
• Your 65th birthday month.
• The 3 months after your 65th birthday month.

It is highly recommended to enroll during this period to avoid potential late enrollment penalties.

If you don’t sign up for Part B or Part D when you’re first eligible, you could face a life-long late enrollment penalty added to your monthly premium. You will have to wait for the General Enrollment Period (January 1 – March 31) to enroll, with coverage starting July 1.

It depends on the size of your employer.

• If your employer has fewer than 20 employees, you should generally sign up for Medicare Parts A and B, as Medicare will be your primary insurer.
• If your employer has 20 or more employees and you have credible group health coverage, you may be able to delay enrolling in Part B without a penalty. It’s crucial to talk to your benefits administrator to understand how your employer coverage works with Medicare.

Medigap plans are sold by private insurance companies to help fill the “gaps” in Original Medicare, such as your 20% coinsurance and deductibles. You must have Part A and Part B to buy a Medigap policy. These plans do not work with Medicare Advantage.

No. Original Medicare (Parts A and B) does not generally cover the prescription drugs you take at home. You need to enroll in a separate Medicare Part D plan or get a Medicare Advantage plan that includes drug coverage (known as an MA-PD).

Original Medicare does not cover most routine dental care, eye exams for prescription glasses, or hearing aids. Some Medicare Advantage (Part C) plans offer these benefits as part of their package.

Yes. Every year, Medicare has an Annual Enrollment Period (AEP) that runs from October 15 to December 7. During this time, you can switch between Original Medicare and Medicare Advantage, change your Medicare Advantage plan, or change your Part D prescription drug plan.

• Coinsurance is a percentage of the cost of a service you pay (e.g., you pay 20% of the cost of a doctor’s visit).
• A Copayment is a fixed amount you pay for a service (e.g., you pay a $25 copay for a specialist visit or a $10 copay for a generic drug).

No. Medicare does not cover long-term custodial care, which is assistance with daily activities such as bathing, dressing, and eating. It may cover short-term stays in a skilled nursing facility for rehabilitation after a qualifying hospital stay, but not for ongoing long-term care.