Submitted by Brenda Murray, a senior health advocate from Edgewood
Medicare was introduced in 1965, but despite its long history still seems intimidating to many. If you find Medicare confusing, you are not alone. This article is meant to provide some basics about what Medicare does and does not do, its costs and how to access it. It will answer many of your questions. If it creates more, that’s OK too! When it comes to Medicare, no questions are inappropriate and no two situations are alike.
Medicare is a federally funded health insurance program for individuals. It also provides health care for younger individuals under certain conditions. Medicare is available to US citizens or those who have been permanent legal residents for 5 years. It is not the same as Medicaid or Social Security. It does not cover families.
Medicare is divided into “Parts.” Part A helps pay for inpatient hospital stays, skilled nursing, some medically necessary home care and hospice. Part B helps cover outpatient physician visits, diagnostic tests and certain specialty medications. Together, Parts A and B comprise “Original Medicare.” Medicare Part D covers prescription drugs. Part C (Medicare Advantage) includes Parts A and B and usually Part D. It may also cover additional benefits such as hearing, vision and dental.
Medicare is not free. You have paid for part of it through your taxes during your working years. If you ( or a spouse ) have worked at least 40 quarters, there is no premium for Part A. You DO have a monthly premium for Part B ($185 in 2025 ). You may also pay a premium for your Part D prescription plan. Something called an IRMAA ( Income Related Monthly Adjustment Amount ) is an additional charge added to your Part B and Part D premiums if your income is above a certain level.
Medicare eligibility begins on the first day of the month you turn 65. If your birthday is on the first day of the month, you become eligible for Medicare on the first day of the month before your birthday. People under 65 who have been on SSDI qualify for Medicare after 24 months of disability.
Delaying enrollment in Medicare can be costly. You should only delay enrolling in Medicare Part B if you have qualified group insurance that is considered “creditable” according to the government. BeWell, COBRA, VA coverage and Retiree Health Insurance do not qualify. If you fail to sign up for Medicare Part B when first eligible, you will incur a lifetime penalty for late enrollment.
Even if you take no medications, Medicare requires that you have prescription drug coverage ( Part D ) from the time you turn 65 and have Medicare Part A. If you do not have prescription drug coverage, you will be subject to a lifetime late enrollment penalty. An employer plan may provide creditable coverage for prescriptions, but high deductible plans do not. Always check with your HR department to determine if your coverage is “ creditable.”
Enrollment in Medicare is automatic if you have been collecting Social Security benefits before age 65. You will receive your card about 3 months before your 65th birthday. If you are not receiving Social Security when you turn 65, you will need to sign up for Medicare. You can do this by calling 1-800-772-1213 or applying online at ssa.gov/medicare.
Your initial enrollment period ( IEP ) for Medicare is the 3 months before your 65th birthday, the month of your birthday, and the 3 months after your birthday. Medicare Annual Enrollment ( AEP ) is from October 15-December 7 of every year. The Open Enrollment Period (OEP ) is from January 1- March 31 of each year. Special enrollment periods ( SEPs ) that accommodate special life events may also be available.
Medicare plans should always be chosen based on your personal needs. You should carefully consider your health history, medications and finances. You should also decide upon the degree of flexibility you want and how much you need to access services not covered by Medicare, such as vision, hearing or dental.
I have listed general information regarding your options below. You should consult with someone who is well-versed in Medicare to choose the one that is best for you. Whatever you choose (unless you qualify for certain levels of Medicaid ), you must still pay your Part B Medicare premium each month.
Original Medicare covers Medicare Parts A and B. Deductibles ( for 2025 ) are $1676 for each inpatient hospital benefit period of 60 days for Part A and $257 annually for Part B. Original Medicare pays for 80% of the cost of allowable Medicare services. However, there is no ceiling on the remaining 20% of pocket costs. Vision, dental and hearing services are not covered. You must purchase a separate Part D plan for your prescriptions.
Medicare Supplement Plans ( Medigap) are extra insurance you buy from a private company to pay for some or all of the out-of-pocket costs not covered by Original Medicare. You have Guaranteed Issue for 6 months from your Part B effective date, after which your acceptance by the plan depends on medical underwriting. With a Supplement Plan, you must also enroll in a separate Prescription Drug Plan
Medicare Advantage Plans ( Part C ) are offered through private companies and cover Medicare Parts A and B ( except for hospice, which is covered by original Medicare ). Most ( not all ) cover prescription drugs. Plans may also add benefits for vision, dental and hearing. Copays and coinsurance and the maximum you pay out of pocket vary by plan. Medicare is complex.
Additional questions? Please reach out to me at SeniorHealthAdvocate@proton.me or at 505-228-3456.
