Turning 65: What You Need to Know About Medicare

1. What is Medicare?

Medicare is a program of health insurance provided by the federal government for people who are 65 or older. It is also available to people of any age who have certain disabilities; especially End Stage Renal Disease (ESRD) requiring dialysis or kidney transplant.

2. How do I sign up for Medicare?

If you apply to receive your Social Security benefits, You will automatically be signed up for Part A, and offered Part B, within 3 months of your 65th birthday. Otherwise, you’ll need to sign up through Social Security. This can be done in person, or easily done online, by going to: https://www.socialsecurity.gov/medicare/apply.html .  This should be done, even if you’re not ready to retire. If you’re losing health insurance benefits, you need to sign up for Part B, to avoid costly penalties. If you have health insurance coverage due to continued employment, or if you are covered by your spouse’s group plan, it may be considered “creditable coverage,” and you don’t need to enroll in Part B until that ends. Be aware that COBRA coverage does not count.  More information about that can be found here: why-you-need-medicare-part-d/

 3. What are the different parts of Medicare?

Medicare Part A  (Hospital Insurance)     

Helps cover:

  • Inpatient care in hospitals
  • Skilled nursing facility, hospice, and home health care.

Medicare Part B  (Medical Insurance)     

Helps cover:

  • Services from doctors and other healthcare providers, hospital outpatient care.
  • Durable medical equipment, and home health care.
  • Many preventive services for maintaining your health, and keep certain illnesses from getting worse. 

Medicare Part C  (Medicare Advantage)

Offered as an alternative way to receive benefits:

  • Plans are run by private companies, approved by Medicare, and include all benefits and services covered under Original Medicare Parts A and B,
  • Often include prescription drug coverage (Medicare Part D) as part of the plan.
  • May include extra benefits and services for extra cost. 

Medicare Part D  (Medicare Prescription Drug Coverage)

  •  Helps cover the costs of prescription drugs.     
  •   May help lower prescription drug costs.

Note:  Complete information about what Medicare covers can be found at Medicare.gov, and is beyond the scope of this paper. An especially detailed and informative free publication can be downloaded at: https://www.medicare.gov/Publications/Search/results.asp?PubID=10116&PubLanguage=1&Type =PubID.

4. What is Medigap?

Medigap is another name for Medicare Supplement insurance. If you choose to receive coverage from Original Medicare (Parts A & B), there are deductibles and copays (usually 20%), as well as possible “excess charges,” with no cap on the maximum out-of-pocket costs. Medigap plans can pay these expenses, and help contain out-of-pocket costs.  More information and a comparison of plans are available at: Medigap Plans.  

5. What is not covered by Medicare?

Some important items and services are not covered by Original Medicare (Parts A & B). They may be covered by some Medicare Advantage Plans, or by separate supplemental policies.

Some of the items and services that Medicare doesn’t cover include:

  • Long-term care (also called custodial care)
  • Most dental care
  • Eye examinations related to prescribing glasses
  • Dentures
  • Cosmetic surgery  
  • Acupuncture 
  • Hearing aids and exams for fitting them
  • Routine foot care

6. What will this cost me?

There are 2 basic ways to receive Medicare benefits, and your costs will depend on which you choose:

  • Original Medicare (Parts A & B), plus Part D for prescription drugs. Usually, recipients purchase a supplemental policy to cover out of pocket costs (Medigap); otherwise, there is no maximum cap on out-of-pocket costs. Part A is free for insured people and helps pay for inpatient hospital care and certain follow-up services. in 2021, people enrolling for the first time will pay the Part B premium of $148.50 each month. OR:
  • Medicare Advantage (Part C), either an HMO or PPO style plan offered by private insurers. The Part B premium of $148.50 must be paid, even with a “Zero Premium” plan. Some people who get health coverage from their union or their employer will automatically be enrolled in a Medicare Advantage plan when they become eligible for Medicare if their employer sponsors one, and must opt out of the Plan.

Points to remember:

  •   Everyone has a choice about how to get Medicare health benefits.
  • Everyone must choose one way or the other; you cannot, for example, choose Medicare  Advantage and also choose Medigap.

    Here’s a quick summary of typical costs:
 Original Medicare (Parts A & B)Medicare Advantage 
Part B Premium$148.50 / month$148.50 / month
Private Insurance Premium$75 to $125 / month (Optional Medigap coverage)0 to over $100 / month
Part D Premium$25 / monthUsually included.
Other Out of Pocket Costs (Maximum)0 to $166/ yearUp to $3,400 to $6,700 / year

7. How do I choose the plan that fits me best?

 It’s important to understand your Medicare coverage choices, and to pick your coverage carefully. How you choose to get your benefits can affect not only your budget, but also your quality of care. 

Here’s a side-by-side comparison of the two:

 Medicare Supplement (Medigap)Medicare Advantage
Relationship to  Original Medicare (Parts A & B)Supplemental coverage provided by private insurer that pays all or most out-of-pocket costs not covered by Medicare.Private health plan that takes the place of Medicare, and provides Part A & B benefits. 
PremiumAverage of about $75 to $125 a month. Can vary by age, health history, or both.Depending on plan chosen, cost may be $0 to more than $100 a month. All plan subscribers pay the same, regardless of age or health history.
Out-of-pocket costsLow to none (other than premium).Depending on plan chosen, in network medical deductibles and copays of up to $3,400 to $6,700 a year. 
Choice of doctors and hospitalsAny in the U.S. that participate in Medicare.HMOs: Plan providers only.* PPOs: Any provider,  but out-of-network providers cost more.
When you can buyThe first six months after you sign up for Part B and are at least 65 years old, are your Open Enrollment Period. You may select any plan, and cannot be turned down, regardless of pre-existing health conditions. After that, there are no guarantees of acceptance.When you first enroll in both Medicare A and B and annually thereafter during Open Enrollment (Oct. 15-Dec. 7).
Part D (drug) coverageNot included. You must buy a separate Part D plan for this.Many plans include Part D coverage.
PaperworkLittle to none. Providers are paid automatically by the Medigap insurer after Medicare pays its share.Some; you pay deductibles and copays directly to providers.

*Note: if a provider leaves a Plan mid-year, either voluntarily or involuntarily, you must choose another, but have no right to change Plans.

8. Where can I get additional information?

  • For general information, as well as information about specific circumstances, CMS, which operates the Medicare program, has an excellent web site:  http://medicare.gov . They can be reached by phone: (800) 633-4227.
  • For enrollment information, go to Social Security’s web site: https://www.socialsecurity.gov/medicare/apply.html .This is also the best contact for people with eligible disability.
  • For a comparison of Medigap plans, and help finding the lowest premiums available to you, we suggest our site: nestlerinsurance.com. You can also see a more detailed discussion of Original Medicare vs. Medicare Advantage.There are many informative articles on how Medicare works, as well as the latest news on what’s going on with the Medicare program. 
    We offer an unbiased comparison of plans, an excellent reputation for service and integrity, and no cost, obligation, or sales pressure.
  • If you need financial assistance in order to pay for coverage, there are a number of governmental programs, including Medicaid. For a more information, call 1-800-MEDICARE (1-800-633-4227). TTY: 1-877-486-2048. You may also qualify for Extra Help to pay for your Part D drug coverage.

Click here to download a PDF of this Guide.

Get Assistance with Medicare 

I’m happy to offer a free consultation to answer your questions and help you get the coverage you need. Please call (434)373-0051.