Get What's Yours for Medicare

1. Medicare Enrollment: Timing is Everything

One of the greatest shocks that many people have when leaving their employer-provided health insurance is how complicated it is even to sign up for Medicare.

Enrollment periods. Medicare has a mix of enrollment periods, including the initial enrollment period (3 months before you turn 65, your birthday month, and 3 months after), general enrollment period (January 1 to March 31 each year), and special enrollment periods (for those who have moved or lost employer coverage). Missing these periods can result in lifetime premium surcharges.

Avoiding penalties. To avoid penalties, it's crucial to enroll in Medicare at the right time. If you have active employer group health insurance, you usually don't have to sign up for Medicare Part B. However, if you work for a small employer (fewer than 20 employees), you may need to enroll in Medicare when you turn 65.

Social Security and Medicare. If you're already receiving Social Security benefits when you turn 65, you should be automatically enrolled in Parts A and B. However, if you're not receiving Social Security, you'll need to contact the Social Security Administration to enroll in Medicare.

2. Original Medicare: The Foundation with Gaps

Original Medicare can be great. But it requires beneficiaries to fork over a 20 percent copay for most covered Part B services. Forever. There is no ceiling on this copay.

Parts A and B. Original Medicare includes Part A (hospital insurance) and Part B (medical insurance). Part A covers inpatient care, skilled nursing facility care, home health care, and hospice. Part B covers doctors' services, outpatient care, medical equipment, and some preventive services.

What's not covered. Original Medicare doesn't cover everything. It doesn't cover long-term care, most dental care, vision care, hearing aids, or routine foot care. It also doesn't cover prescription drugs (unless administered in a hospital or doctor's office).

Cost-sharing. Original Medicare requires you to pay deductibles, coinsurance, and copays. Part A has a deductible for each benefit period, while Part B has an annual deductible. Part B also has a 20% coinsurance for most covered services, with no annual limit.

3. Medigap: Filling the Original Medicare Gaps

Medigap policies, also known as Medicare supplement plans, are private insurance plans that fill a lot of the gaps that expose Original Medicare beneficiaries to enormous medical expenses.

Supplementing Original Medicare. Medigap policies, also known as Medicare supplement insurance, are private insurance plans that help pay for some of the out-of-pocket costs not covered by Original Medicare, such as deductibles, coinsurance, and copays.

Standardized plans. Medigap policies are standardized, meaning that each plan with the same letter (e.g., Plan A, Plan B, Plan C) offers the same basic benefits, regardless of the insurance company. However, premiums can vary widely.

Guaranteed issue rights. You have a six-month open enrollment period for Medigap that starts when you're 65 or older and enrolled in Part B. During this period, insurers must sell you any Medigap policy they offer, and they can't charge you more because of your health condition.

4. Medicare Advantage: The All-in-One Alternative

MA plans already look a lot like ACA exchange plans, and the two will morph in ways that make them increasingly alike.

Private insurance option. Medicare Advantage (MA) plans are private health insurance plans that contract with Medicare to provide Part A and Part B benefits. They often include extra benefits, such as dental, vision, and hearing coverage.

Network restrictions. Most MA plans have provider networks, meaning you may need to use doctors, hospitals, and other providers within the plan's network to get the lowest costs. Out-of-network care may be more expensive or not covered at all.

Cost-sharing. MA plans typically have lower premiums than Original Medicare with a Medigap policy, but they may have higher cost-sharing, such as copays and coinsurance. They also have an annual out-of-pocket maximum to protect you from catastrophic costs.

5. Part D: Navigating the Prescription Drug Maze

Of all the things that Medicare is authorized to regulate, it is expressly forbidden to negotiate drug prices with pharmaceutical companies.

Prescription drug coverage. Part D is Medicare's prescription drug program. It's optional, but if you don't enroll when you're first eligible, you may face a late enrollment penalty.

Coverage stages. Part D has four coverage stages: deductible, initial coverage, coverage gap (donut hole), and catastrophic coverage. During the coverage gap, you pay a higher share of your drug costs until you reach the catastrophic coverage threshold.

Formularies and tiers. Part D plans have formularies, which are lists of covered drugs. Drugs are often grouped into tiers, with different cost-sharing amounts for each tier. It's important to check if your medications are on the formulary and what tier they're in.

6. Money Matters: Costs, Savings, and Subsidies

Ruinous health expenses are a major if not the major cause of personal bankruptcies in the United States.

Premiums, deductibles, and cost-sharing. Medicare has various costs, including monthly premiums for Part B and Part D, deductibles, coinsurance, and copays. Understanding these costs is essential for budgeting and planning.

Income-related adjustments. Higher-income beneficiaries pay higher premiums for Part B and Part D, known as income-related monthly adjustment amounts (IRMAA). These surcharges are based on your modified adjusted gross income (MAGI) from two years prior.

Extra Help and MSPs. Medicare offers financial assistance programs for low-income beneficiaries, including Extra Help for Part D and Medicare Savings Programs (MSPs) for Part A and Part B premiums and cost-sharing.

7. Know Your Rights: Appealing Medicare Decisions

Every interaction between a consumer and their insurance company is a problem waiting to happen.

Beneficiary rights. As a Medicare beneficiary, you have the right to be treated with dignity and respect, to get information in a way you understand, to access doctors and hospitals, and to appeal decisions about your care.

Appeals process. If you disagree with a Medicare decision, you have the right to appeal. The appeals process has multiple levels, starting with a redetermination by the plan and potentially going all the way to federal court.

Expedited appeals. In certain situations, such as a hospital discharge or denial of a prescription drug, you have the right to an expedited or "fast" appeal.

8. Quality Counts: Choosing Providers Wisely

Having access to your preferred doctors continues to be the most important variable that people cite in explaining their Medicare insurance purchases.

Provider networks. If you have a Medicare Advantage plan, you'll likely need to use doctors, hospitals, and other providers within the plan's network. Check if your preferred providers are in the network before enrolling.

Star ratings. Medicare uses a star rating system to evaluate the quality of Medicare Advantage and Part D plans. Plans receive from 1 to 5 stars, with 5 stars being the highest rating.

Ratings tools. There are various online tools that provide ratings and information about hospitals, nursing homes, doctors, and other health care providers. Use these tools to research providers and make informed choices.

9. Annual Open Enrollment: Your Medicare Do-Over

Open enrollment is the annual equivalent of a Medicare do-over. It permits people to choose new plans, usually with no adverse coverage or pricing consequences.

October 15 to December 7. Medicare's annual open enrollment period runs from October 15 to December 7. During this time, you can switch Medicare Advantage plans, Part D plans, or return to Original Medicare.

Review your coverage. Each year, review your current Medicare coverage and see if it still meets your needs. Consider changes in your health, medications, and financial situation.

Compare plans. Use Medicare's Plan Finder tool to compare different plans and see which one offers the best coverage and value for your specific needs.

10. End-of-Life Planning: Making Your Wishes Known

To the day when good health care is a birthright.

Advance directives. Create advance directives, such as a living will and health care power of attorney, to document your wishes for end-of-life care. This ensures that your preferences are followed if you're unable to make decisions for yourself.

The conversation. Have conversations with your family and loved ones about your end-of-life wishes. This can help them understand your values and make informed decisions on your behalf.

Hospice and palliative care. Learn about hospice and palliative care, which can provide comfort and support during the final stages of life. Medicare covers hospice care for terminally ill individuals.

Last updated: February 24, 2025