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Medicare

Medicare Explained

What is Medicare?

Medicare is the United States’ federal health insurance program for people who are 65 or older. It is also available for certain people younger than 65 with disabilities or people with End-Stage Renal Disease. There are several parts to Medicare that contain different coverage.

When Am I Eligible to Enroll in Medicare?

Individuals can enroll in Medicare during specific enrollment periods. The initial enrollment period (IEP) occurs when someone is first eligible for Medicare, starting three months before the month they turn 65 and ending three months after. Another opportunity to enroll is during the general enrollment period (GEP), which runs from January 1st to March 31st each year, allowing those who missed their IEP to sign up for Medicare Part A and/or Part B. Additionally, there is the annual enrollment period (AEP) from October 15th to December 7th, during which individuals can make changes to their Medicare Advantage or Medicare prescription drug coverage. It's important to note that specific circumstances may also qualify individuals for special enrollment periods (SEPs) throughout the year.

What is Medicare?

You can qualify for Medicare coverage at 65 if you are a US citizen or a permanent resident and you’ve lived here continuously for at least five years. If you are under 65, you can also qualify if you meet these criteria:
- You are permanently disabled and you have been receiving Social Security disability income benefits for 24 months.
- You have end-stage renal disease.
- You have Amyotrophic Lateral Sclerosis (Lou Gehrig’s Disease).

Medicare Part A

What Does Medicare Part A Cover?

Part A of Medicare covers hospitalization, inpatient care, skilled nursing facility care, and some home health services for eligible individuals.

Part A of Medicare provides coverage for inpatient hospital care, skilled nursing facility care, hospice care, and some home health services.

  1. Inpatient Hospital Care: Part A covers expenses related to hospital stays, including semi-private rooms, meals, general nursing care, and necessary hospital services and supplies. This includes surgeries, diagnostic tests, medications administered during the hospital stay, and other medically necessary treatments.
  2. Skilled Nursing Facility SNF) Care:  Part A also provides coverage for skilled nursing facility care, but certain conditions must be met. This includes services like nursing care, semi private rooms, meals, physical therapy, and other necessary skilled services following a minimum 3 day hospital stay.
  3. Hospice Care: Part A covers hospice care for those what are terminally ill and have a life expectancy of six months or less.  Hospice care focuses on providing comfort and support rather than curative treatment.
  4. Home Health Services: Part A covers limited home health services on a part-time or intermittent basis, including skilled nursing care, physical therapy, occupational therapy, and speech-language pathology services.

Part A is a premium free for those who have paid Medicare taxes while working, while others may need to pay a monthly premium.

Sometimes particularly healthy people wonder if they may need only Part A.  Perhaps they don’t use many medical services yet.   There are many things that happen in a hospital that fall under another part of Medicare – Part B, so it’s important that you enroll in both A&B unless you have other coverage coordinating with Medicare.  It is best to review all of your options accordingly.

Am I Eligible for Medicare Part A?

You are eligible for Medicare Part A coverage at no cost at age 65 as long as you or your spouse has worked for at least 10 years in the United States.

If you haven’t worked for 10 years, you can still purchase Part A coverage.

As long as you have already enrolled in Social Security, you will be automatically enrolled in Part A. If not, you will have to contact the Social Security office to enroll.

Your Medicare card will arrive around one month before you turn 65.

Medicare Part A Costs

Part A monthly premium

Most people don’t pay a Part A premium because they paid Medicare taxes while working. If you don’t get premium-free Part A, you pay up to $506 each month. If you don’t buy Part A when you’re first eligible for Medicare (usually when you turn 65), you might pay a penalty.

Hospital stay

In 2023, you pay:

  • $1,600 deductible per benefit period
  • $0 for the first 60 days of each benefit period
  • $400 per day for days 61–90 of each benefit period
  • $800 per “lifetime reserve day” after day 90 of each benefit period (up to a maximum of 60 days over your lifetime)

Skilled Nursing Facility stay

In 2023, you pay:

  • $0 for the first 20 days of each benefit period
  • $200 per day for days 21–100 of each benefit period
  • All costs for each day after day 100 of the benefit period

Medicare Part B

What Does Medicare Part B Cover?

Part B of Medicare is the component that covers outpatient medical services, including doctor visits, preventive care, medical supplies, and certain medical equipment.

Part B of Medicare is for outpatient services that are deemed medically necessary. Medicare Part B includes coverage for services like doctor office visits, lab testing, diagnostic imaging, preventive care, surgeries, ambulance rides, chemotherapy and radiation, and even extensive dialysis care for people with renal failure. Many of these procedures may occur in a hospital. However, they fall under Part B because physicians provide them, so it’s not always easy to determine what is inpatient vs outpatient care.

Now those two different parts of Medicare – Parts A and B together – make up what we call Original Medicare. They are only two parts that you will sign up for at the Social Security office or Railroad Retirement Board.

Am I Eligible for Medicare Part B?

The same eligibility requirements for Part A apply for Part B.

However, there is a monthly premium for Medicare Part B. This premium is determined by Medicare and could be higher based on income.

Medicare Part B Costs

Part B monthly premium

Most people pay the standard Part B monthly premium amount ($164.90 in 2023). Social Security will tell you the exact amount you’ll pay for Part B in 2023. You pay the standard premium amount if you:

  • Enroll in Part B for the first time in 2023.
  • Don’t get Social Security benefits.
  • Are directly billed for your Part B premiums.
  • Have Medicare and Medicaid, and Medicaid pays your premiums. (Your state will pay the standard premium amount of $164.90 in 2023.)

If your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you’ll pay the standard Part B premium and an income-related monthly adjustment amount.

2023 Part B deductible—$226 before Original Medicare starts to pay.

Medicare Part C

What Does Medicare Part C Cover?

Part C of Medicare, also known as Medicare Advantage, is an all-in-one alternative to Original Medicare that offers coverage through private insurance companies, often including additional benefits such as prescription drugs, dental, vision, and hearing services.

Part C of Medicare is somewhat confusing. Unlike the other parts of Medicare, which cover specific medical benefits, Medicare Part C is just another name for private Medicare insurance. The Balanced Budget Act of 1997 created Part C, which is now referred to as Medicare Advantage.

Medicare Advantage plans are private health plans that you can choose instead of Medicare. You would get your Part A, Part B, and sometimes also Part D all from one insurance carrier. Advantage plans usually have a network of providers from whom you will seek your care.

Part C plans can often have lower premiums than Medigap plans. However, you’ll pay more copays as you go along so they are not necessarily cheaper over the long term.

Am I Eligible for Medicare Part C?

To be eligible for Medicare Part C, or Medicare Advantage, you must first be enrolled in Medicare Part A and B. Once your Medicare Part A and Part B start dates  are determined you can begin to enroll in a Medicare Advantage Plan.

Medicare Part C Costs

Visit Medicare.gov/plan-compare to find and compare plan premiums. You can also call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

Medicare Part D

What Does Medicare Part D Cover?

Part D of Medicare is the prescription drug coverage program that helps beneficiaries pay for their prescription medications, offered through private insurance companies and available as a standalone plan or as part of a Medicare Advantage plan.

Part D is a federally created program to help you lower the cost of your retail prescription drugs. Unlike Medicare Part A & B, you will not enroll in Part D through the Social Security office. Instead, you will select one of the Part D plans available in your county from private insurance carriers.

By signing up for that plan, you will have enrolled in Part D.

Medicare drug plans are optional. You’ll have a monthly premium that you will pay to the insurance carrier. In return, they give you significantly lower copays on your medicines than you would pay if you had no Part D insurance.

Am I Eligible for Medicare Part D?

You are eligible for Part D as long as you are enrolled in either Part A or B. You can enroll in Part D with only Part A. You can also enroll in a Part D plan with only Part B.

Medicare Part C Costs

Part D monthly premium The chart below shows your estimated drug plan monthly premium based on your income. If your income is above a certain limit, you’ll pay an income-related monthly adjustment amount in addition to your plan premium. 2023 Part D national base beneficiary premium—$32.74

The national base beneficiary premium is used to estimate the Part D late enrollment penalty and the income-related monthly adjustment amounts listed in the table above. It can change each year. If you pay a late enrollment penalty, these amounts may be higher. See your Medicare & You handbook or visit Medicare.gov for more information.

Need a Medicare Plan?

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Care Access

Medicare beneficiaries have coverage with any healthcare provider that accepts Medicare.

Medicaid beneficiaries may have more difficulty finding healthcare providers that accept Medicaid as full payment for covered services.

Eligibility

Medicare is for Americans age 65 or older or those with disabilities. If you have received disability benefits from Social Security or the Railroad Retirement Board for 24 months, you will be automatically enrolled in Medicare. People with ALS automatically receive Medicare benefits the same month they begin receiving disability benefits. People with ESRD are eligible for Medicare coverage in the fourth month of a regular course of dialysis treatment.

Medicaid is intended to help people with low incomes and limited resources to afford their health coverage. Beneficiaries must meet income and resource requirements.

People may be eligible for both Medicare and Medicaid. These dual-eligible beneficiaries can take advantage of Special Needs Plans designed for their situation.

Funding

Medicare is primarily handled by the Social Security Administration. The Centers for Medicare and Medicaid Services (CMS) makes a lot of the administrative and policy decisions, updating the resources and producing helpful guides for these services such as the Medicare & You Handbook.

Medicare is funded by payroll taxes through Social Security. Money gets taken out of each American’s paycheck and this is pooled and distributed to current Medicare beneficiaries. The money taken out of your paycheck is not saved for you; rather, the workforce of the future will pay for your Medicare benefits.

Medicaid is jointly funded by the state and local governments. For that reason, states have the jurisdiction to choose which savings programs to offer beneficiaries.

2022 Costs

How Medicare Agents Are Paid

As an independent Medicare insurance broker, we give you an unbiased opinion on different Medicare plans. Because we are partnered with many different insurance carriers, we do not show favoritism to any carrier and represent  YOU , not the insurance companies.

You can rest assured that we have your best interest in mind and will recommend a plan that will not only fit in your budget but provide you with proper healthcare coverage.

You do not pay us anything and your premiums do not increase because you have worked with us.

An independent Medicare broker will contract with many different insurance carriers. The reason they do this is that they are then able to shop your policy through various carriers and provide you with the most competitive price and coverage. Savvy shoppers know that an independent broker focuses on educating their clients first, then letting them decide. This is the most ethical way we have found to do things.

So, this is how the process works:

  1. You call or submit your request for Medicare information
  2. We explain Medicare thoroughly
  3. We compare your rates with the companies we work with
  4. You choose the policy that fits you best
  5. Our commission is paid by the insurance company
  6. We continue to provide you with our free support

Eligibility

Medicare is for Americans age 65 or older or those with disabilities. If you have received disability benefits from Social Security or the Railroad Retirement Board for 24 months, you will be automatically enrolled in Medicare. People with ALS automatically receive Medicare benefits the same month they begin receiving disability benefits. People with ESRD are eligible for Medicare coverage in the fourth month of a regular course of dialysis treatment.

Medicaid is intended to help people with low incomes and limited resources to afford their health coverage. Beneficiaries must meet income and resource requirements.

People may be eligible for both Medicare and Medicaid. These dual-eligible beneficiaries can take advantage of Special Needs Plans designed for their situation.

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