Jane Dotson
Medicare is a federal health insurance program for individuals aged 65 and above, as well as some people under 65 with specific disabilities or conditions. It is different from private insurance in that it does not offer couple or family plans. There are two main ways to get Medicare coverage: Original Medicare and Medicare Advantage. Original Medicare includes Part A (Hospital Insurance) and Part B (Medical Insurance), covering inpatient hospital care, doctors' services, and tests. Medicare Advantage combines Part A, Part B, and often Part D (drug coverage) into a single plan, offered by Medicare-approved private companies.
| Characteristics | Values |
|---|---|
| Type of insurance | Federal health insurance |
| Who it covers | Anyone age 65 and older, and some people under 65 with certain disabilities or conditions |
| Cost | Most people get Part A for free, but some have to pay a premium for this coverage |
| How to sign up | Sign up for Part A (Hospital Insurance) and Part B (Medical Insurance) at certain times |
| Coverage | Inpatient hospital care, doctors' services and tests, and preventive services |
| Supplemental coverage | Medicare Supplement Insurance (Medigap) coverage, coverage from a former employer or union, or Medicaid |
| Drug coverage | Medicare drug coverage is optional and available to everyone with Medicare |
| Medicare Advantage | Medicare Advantage bundles your Part A, Part B, and usually Part D coverage into one plan |
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What You'll Learn
Medicare Part A and Part B
Medicare is federal health insurance for anyone aged 65 and older, and some people under 65 with certain disabilities or conditions. Original Medicare includes Part A (Hospital Insurance) and Part B (Medical Insurance). Most people get Part A for free, but some have to pay a premium for this coverage. To be eligible for premium-free Part A, an individual must be entitled to receive Medicare based on their own earnings or those of a spouse, parent, or child. To receive premium-free Part A, the worker must have a specified number of quarters of coverage (QCs) and file an application for Social Security or Railroad Retirement Board (RRB) benefits. The exact number of QCs required depends on whether the person is filing for Part A based on age, disability, or End Stage Renal Disease (ESRD). Individuals are eligible for premium-free Part A if they receive regular dialysis treatments or a kidney transplant, have filed an application for Medicare, and meet one of the following conditions: they have worked the required amount of time under Social Security, the RRB, or as a government employee; they are getting or are eligible for Social Security or RRB benefits; they are the spouse or dependent child of a person who has worked the required amount of time under Social Security, the RRB, or as a government employee; or they are getting Social Security or RRB benefits.
Part A helps cover inpatient care in hospitals, skilled nursing facility care, hospice care, and home health care. Part B is typically paid for with a premium. Once you've signed up for Part A and Part B, you can choose how you get your health coverage. There are two main ways to get your Medicare coverage: Original Medicare and Medicare Advantage. With Original Medicare, you pay for services as you get them. When you get a covered service, Medicare pays part of the cost and you pay your share. You can see any doctor or hospital that accepts Medicare, anywhere in the US.
You can also shop for and buy supplemental coverage to help pay your out-of-pocket costs (like your 20% coinsurance). Medicare Supplement Insurance (Medigap) is extra insurance you can buy from a private company that helps pay your share of costs in Original Medicare. Generally, you need Part A and Part B to buy a Medigap policy. Some Medigap policies offer coverage when you travel outside the US. Generally, Medigap policies do not cover long-term care, vision, dental, hearing aids, private-duty nursing, or prescription drugs. Medicare Advantage is a Medicare-approved plan from a private company that offers an alternative to Original Medicare for your health and drug coverage. These "bundled" plans include Part A, Part B, and usually Part D. In many cases, you can only use doctors who are in the plan's network. Plans often have different out-of-pocket costs than Original Medicare or supplemental coverage like Medigap. You may also have an additional premium. Plans may offer some extra benefits that Original Medicare doesn't.
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Medicare Advantage
There are several types of Medicare Advantage Plans, including Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Special Needs Plans (SNPs), Medicare Medical Savings Accounts (MSAs), and Private Fee-for-Service Plans (PFFS).
It is important to note that a Medicare Advantage Plan can disenroll you for several reasons, such as moving outside the plan's service area, losing Medicare or Medicaid eligibility, or joining a drug plan (in some cases). Joining a Medicare Advantage Plan might also cause you to lose your employer or union coverage, which could extend to your spouse and dependents.
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Medicare drug plans
Medicare is a federal health insurance program for people aged 65 and over, as well as younger people with disabilities or those with End-Stage Renal Disease. There are two main ways to get your Medicare coverage: Original Medicare and Medicare Advantage.
Original Medicare includes Medicare Part A (Hospital Insurance) and Part B (Medical Insurance). It covers things like inpatient hospital care, doctors' services and tests, and preventive services. With Original Medicare, you pay for services as you get them, and Medicare pays part of the cost while you pay your share.
If you choose Original Medicare and want to add drug coverage, you can join a separate Medicare drug plan. This coverage is optional and available to everyone with Medicare. Each plan has a list of covered drugs called a "formulary," which can vary in cost and specific drugs covered. Most plans have a monthly premium that you pay in addition to your Part B premium.
Most Medicare Advantage Plans include Part D coverage, which is prescription drug coverage. In most cases, you cannot join a separate Medicare drug plan if you have a Medicare Advantage Plan.
It is important to note that if you do not join a Medicare drug plan when you first become eligible, you may have to pay a Part D late enrollment penalty. This penalty increases the longer you wait to join a plan, and you may have to pay it for as long as you have Part D coverage.
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Supplemental coverage
If you want to add drug coverage to Original Medicare, you can join a separate Medicare drug plan. This is optional and available to everyone with Medicare. Most Medicare Advantage Plans include Part D coverage, so you can't join a separate Medicare drug plan. Medicare drug coverage plans cover a variety of brand-name and generic prescription drugs. Each plan has a list of covered drugs, called a "formulary", that can vary in cost and specific drugs covered. Most plans have a monthly premium that you pay in addition to your Part B premium.
You may pay a Part D late enrollment penalty if you don't join a Medicare drug plan when you first get Medicare and go 63 days or more without creditable drug coverage. This penalty increases the longer you wait to join a plan, and you will pay it for as long as you have Part D coverage, even if you switch plans. Some Medigap policies offer coverage when you travel outside the U.S., but generally, they do not cover long-term care, vision, dental, hearing aids, private-duty nursing, or prescription drugs. If you're under 65, you might not be able to buy a Medigap policy, or you may have to pay more.
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Eligibility and enrollment
Medicare is health insurance for people aged 65 or older. However, eligibility for Medicare can begin earlier if you have a disability, End-Stage Renal Disease (ESRD), or ALS (also known as Lou Gehrig's disease). There are two main ways to get Medicare coverage: Original Medicare and Medicare Advantage.
Original Medicare includes Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). Most people get Part A for free, but some have to pay a premium for this coverage. To be eligible for premium-free Part A, an individual must be entitled to receive Medicare based on their own earnings or those of a spouse, parent, or child. To receive premium-free Part A, the worker must have a specified number of quarters of coverage (QCs) and file an application for Social Security or Railroad Retirement Board (RRB) benefits. The number of QCs required depends on whether the person is filing for Part A based on age, disability, or ESRD.
If you pay a premium for Part A, you must actively sign up for Medicare by contacting the Social Security Administration. You must also enroll in or already have Part B. To keep premium Part A, you must continue to pay all monthly premiums and stay enrolled in Part B. This means that you must pay both the premium for Part B and the premium for Part A to keep this coverage. Premium Part A coverage begins the month after enrollment. A person who is entitled to monthly Social Security or RRB benefits on the basis of disability is automatically entitled to Part A after receiving disability benefits for 24 months. Disabled federal, state, and local government employees who are not eligible for monthly Social Security or RRB benefits may get deemed entitlement to disability benefits and automatically qualify for Part A after being disabled for 29 months.
Individuals who did not enroll in Part B or premium Part A when first eligible because they were performing volunteer service outside of the US for at least 12 months on behalf of a tax-exempt organization and had health insurance that provided coverage for the duration of their volunteer service may enroll using a Special Enrollment Period (SEP). The SEP is a 6-month period that begins the earlier of the first day of the month following the month for which the individual was no longer serving as a volunteer outside of the United States. Individuals who enroll in Part A based on disability or ESRD but do not enroll in Part B because they were eligible for TRICARE Standard or TRICARE Prime may also enroll using this SEP.
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Frequently asked questions
Traditional Medicare insurance, also known as Original Medicare, includes Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance).
Original Medicare covers inpatient hospital care, doctors' services and tests, and preventive services. It covers most, but not all, of the costs for approved health care services and supplies.
Original Medicare is available to anyone aged 65 and over and some people under 65 with certain disabilities or conditions. You must be lawfully present in the US for Medicare to pay for Part A and Part B covered services.
Medicare Advantage, or Part C, is a Medicare-approved plan from a private company that offers an alternative to Original Medicare for your health and drug coverage. It bundles your Part A, Part B, and usually Part D (drug coverage) into one plan.
Yes, you can have other insurance and Medicare. When you have both, one will pay first (the "primary payer") and the other will pay second (the "secondary payer"). Which pays first depends on factors like your work status, the type of insurance you have, and your health situation.
