What is Medicare?

Fact Checked

Medicare is a federal health insurance program for qualifying individuals, including people age 65 and older, those with certain disabilities, and individuals with end-stage renal disease (ESRD), also known as permanent kidney failure.

Some people may confuse Medicaid and Medicare programs. Though both are federal health insurance programs run by the Centers for Medicare and Medicaid Services, the primary difference is that Medicaid is a needs-based insurance program while Medicare isn’t. Your income isn’t a determining factor for Medicare qualification.

There are monthly premiums for certain parts of Medicare. Additionally, Medicare does have some limitations and regulations on what it’ll cover for health care costs. Read on to learn more about each part of Medicare, what’s covered, and how to enroll.

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Medicare Parts

When you become eligible for Medicare, you have choices to make. First, you must decide whether you’ll enroll in Part A and B or Part A only and defer Part B. Most people choose Part A because it is premium-free. If you’re enrolled in a health savings account (HSA), you won’t be able to continue contributing to it if you enroll in Part A. Once your A and B choices are made, you can keep Original Medicare and add a supplement and Part D plan or opt for a Medicare Advantage Plan for your health care coverage.

Here’s what each part of Medicare covers and costs:

Medicare Part A
  • Medicare Part A is considered the hospital insurance portion of Original Medicare. Part A coverage includes health care costs associated with hospital stays and limited stays at a nursing home, hospice care, and some costs for home health care.
  • You don’t have to pay a monthly premium for Medicare Part A hospital insurance if you or your spouse paid qualifying taxes during employment. If you don’t qualify for premium-free Part A, you can pay for it. The premium amount you have to pay varies based on how long you or your spouse worked and paid Medicare taxes. For instance, if you paid taxes for less than 30 quarters, you’ll pay $499 per month based on 2022 premiums. But if you worked and paid taxes between 30 and 39 quarters, you’ll only pay a $274 monthly premium.
Medicare Part B
  • Medicare Part B is considered the medical insurance portion of Original Medicare. Similar to health insurance, Part B coverage is for everyday health care expenses such as trips to the doctor’s office for a checkup or a sick visit, any outpatient care you might receive, certain medical supplies, and preventive care like an annual wellness visit.
  • Medicare Part B medical insurance requires monthly premiums from nearly everyone. The standard amount for 2022 is $170.10. If your gross income on your tax return is high enough, you’ll be required to pay both the standard monthly premium and an Income Related Monthly Adjustment Amount (IRMAA). You’re also responsible for 20% of the costs of your health services after your annual deductible ($233 in 2022) is met.
Medicare Part C
  • Medicare Part C, commonly referred to as Medicare Advantage, is offered by health insurance companies approved by Medicare. If you choose a Medicare Advantage Plan as an alternative to Original Medicare, it becomes your primary coverage. Think of Medicare Advantage Plans as “Medicare bundles” because these plans cover everything that Part A and Part B do. Most Medicare Advantage Plans include Part D Medicare prescription drug coverage. Some Medicare Advantage Plans offer additional coverage for dental and vision and even fitness memberships. For example, Medicare Advantage Plans cover in-patient hospital stays, stays in a skilled nursing facility, and home health care like Original Medicare Part A. Part C also covers outpatient care such as Medicare Part B does, including doctor visits, lab tests. X-rays, outpatient surgery, and emergency services.
  • Original Medicare Part A and Part B only cover 80% of the costs of services received. Meanwhile, Medicare Advantage Plans cover everything Part A and Part B cover but charge a small copayment and coinsurance for services. Most Medicare Advantage plans also have maximum out-of-pocket costs per year, and many come with a $0 monthly premium, which can make these plans more affordable. The costs of Medicare Advantage plans vary since private companies offer them, but you can expect to pay both a monthly premium and a monthly Part B premium, unless the plan is a $0 premium plan. Plan costs can vary depending on whether other benefits like Part D, dental, vision, and hearing are included.
Medicare Part D
  • Medicare Part D refers to prescription drug coverage, so it’ll help cover the costs of medications prescribed for your health condition. Individual Medicare drug coverage plans use a formulary developed by a pharmacy and therapeutics committee composed of pharmacists and physicians to regulate which medications they’ll cover. The United States Centers for Medicare and Medicaid Services (CMS) must approve the formulary. Part D plans are required to offer two medications in all categories necessary to treat your health condition. In most cases, if a name-brand medication isn’t covered, a generic will be.
  • Medicare Part D does have costs associated with it. The costs vary based on which type of plan you choose. In general, you can expect to pay a monthly premium ― this can be deducted directly from your Social Security if you choose ― and a yearly deductible. The deductible can’t be more than $480 in 2022. You’ll pay a copayment or coinsurance percentage for each drug after your deductible is met. If you have low income and resources, you may be able to get help with Part D costs through Extra Help.
  • Medigap insurance is commonly known as Medicare Supplemental Insurance. As the name implies, it’s used as a supplemental health insurance program to cover health care costs that Original Medicare does not. You can only purchase Medigap insurance if you’re enrolled in Original Medicare. It cannot be used with a Medicare Advantage Plan. Medigap insurance is offered through private insurance companies approved by Medicare.
  • You pay a monthly premium for Medigap as well as your regular monthly Part B Medicare premium. Your Medigap premium is paid directly to the health insurance company you got your Medigap policy through while the Part B premium is paid to the Social Security Administration.
  • Medigap insurance can help cover your deductible costs, copayments, and coinsurance under Original Medicare. For people newly eligible for Medicare on or after January 1, 2020, Medigap insurance can no longer cover the Part B deductible. If you were eligible for Medicare before January 1, 2020, you may be able to purchase Plan C or F, which will cover the Medicare Part B deductible cost. If you already have a Plan C or F, you can keep it. Medigap insurance can’t be used to cover the costs of certain health care expenses, including long-term care, vision care, and eyeglass, dental care, hearing aids, or private-duty nursing care.

What isn't Covered by Medicare?

Original Medicare doesn’t cover specific services, including:

  • Long-term care
  • Dental care (with some exceptions)
  • Vision exams needed to prescribe glasses
  • Dentures
  • Cosmetic surgery
  • Acupuncture
  • Hearing aids and related exams
  • Routine foot care

If Medicare doesn’t provide adequate coverage for your health care needs, consider a Medicare Supplement Insurance Plan (Medigap) or a Medicare Advantage Plan, which can offer coverage Original Medicare doesn’t.

How Do I Enroll in Medicare?

There are a few different ways to enroll in Medicare. Some people are enrolled in Medicare automatically, and others will have to sign up on their own. Everyone should check with the Social Security Administration three months before their expected start date to ensure everything is in order.

You’ll be enrolled automatically in Medicare if you:

  • Are already receiving Social Security benefits (at least four months prior to start)
  • Receive U.S. Railroad Retirement Board (RRB) benefits (at least four months prior to start)
  • Are under age 65 but have a Social Security disability for 24 months
  • Have amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease or ESRD

You’ll have to enroll in Medicare on your own if you:

  • Are about to turn 65
  • Are already age 65 but not receiving Social Security benefits

There are also some individual circumstances that may change the timing of your enrollment. For instance, if you have an employer-sponsored health insurance program, you may be able to wait to apply for Medicare Part B instead of being required to apply when you’re age 65.

Medicare enrollment periods

The Initial Enrollment Period (IEP) for Medicare is a seven-month period beginning three months before you turn 65, the month in which you turn 65, and three months after you turn 65. For example, if you turn 65 on June 14, your IEP is from March 1 through September 30.

If you don’t sign up during your initial enrollment period, and you aren’t covered by an employer health plan or are volunteering overseas for at least 12 months, you’ll begin accruing Part B late enrollment penalties. You’ll only be able to enroll during the General Enrollment Period (GEP). The GEP runs from January 1 through March 31 each year, with coverage starting July 1st.

Medicare Advantage plans cannot start before your Part B start date, so if you don’t enroll in Part B by the end of your IEP, you’ll have to wait until the GEP for Medicare Advantage enrollment also. If you enroll in Part B during the GEP, you can join a Medicare Advantage Plan or a Medicare Prescription Drug Coverage (Part D) between April 1 and June 30. Your Medigap open enrollment period starts the first month you have Part B and lasts for six months.

When does Medicare coverage start?

Your Medicare coverage start date depends on when you enroll. Remember, during the IEP, you can enroll three months before you turn 65, the month you turn 65, and three months after you turn 65.

For example:

When You Enroll When Coverage Starts Example: Turning 65 on May 10
The three months before you turn 65 The first day of the month you turn 65 May 1
The month you turn 65 The first day of the month after you turn 65 June 1
The month after you turn 65 Two months after you sign up August 1
Two or three months after you turn 65 Three months after you sign up October 1 (if you enroll in July)

November 1 (if you enroll in August)

If you enroll during your IEP, you can coordinate your ancillary coverage, that is, Medigap and Medicare Part D or Medicare Advantage to start the same day as your Medicare Part A and B coverage.

If you enroll during a Special Enrollment Period, coverage generally starts the month after your sign up.

When you’re ready to apply for Medicare, you can fill out an online application through the Social Security Administration website or in-person at your local Social Security Administration office.

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Certified Senior Advisor (CSA)®

As a health care professional since 1987, Kelly Blackwell has walked alongside and cared for seniors as they journey through the season of their fourth quarter of life. Blackwell holds a Bachelor of Science in nursing from the University of Northern Colorado, a Master of Science in health care administration from Grand Canyon University, an interprofessional graduate certificate in palliative care from the University of Colorado Anschutz Medical Campus and holds a Certified Senior Advisor® credential from the Society of Certified Senior Advisors.

Blackwell contributes to the University of Colorado-Anschutz blog and has been published in “The Human Touch” distributed by the University of Colorado Center for Bioethics and Humanities. She cowrote “Dying Is” for Pathways Hospice.

A registered nurse, Blackwell understands health insurance choices influence quality of life and are driven by values, goals, and beliefs. She’s passionate about engaging with, educating, and empowering seniors as they navigate the health care system. She’s equipped to lend an experienced, compassionate voice to beneficiaries seeking information about Medicare Advantage Plans.

As a CSA®, Blackwell has access to valuable resources for Medicare beneficiaries. Her work as a bedside nurse and clinical manager has given her the opportunity to see how Medicare rules, regulations, and benefits work when patients need them. With a passion to learn and to make a difference in the lives of seniors, Blackwell supports seniors through Medicare and fourth-quarter life decisions.