Medicare FAQ: 50 Common Questions Answered

Medicare is the U.S. federal health insurance program primarily for people age 65 and older. It also covers certain people under 65 with qualifying disabilities, End-Stage Renal Disease (ESRD), or ALS (Lou Gehrig's disease). Medicare covers more than 65 million Americans and is administered by the Centers for Medicare & Medicaid Services (CMS), a federal agency. It is divided into four parts: Part A (hospital), Part B (medical), Part C (Medicare Advantage), and Part D (prescriptions).

You qualify for Medicare if you are (1) age 65 or older AND (2) a U.S. citizen or permanent legal resident who has lived in the U.S. for at least 5 consecutive years. Under-65 eligibility pathways include: receiving Social Security Disability Insurance (SSDI) for 24 months, having ALS (eligibility is immediate), or having End-Stage Renal Disease requiring dialysis or a transplant. Full eligibility guide →

Sign up during your Initial Enrollment Period (IEP) — a 7-month window that starts 3 months before your 65th birthday month, includes your birthday month, and ends 3 months after. Enrolling in the first 3 months ensures your coverage starts the first day of your birthday month. Waiting until after your birthday month delays coverage. Missing your IEP without a qualifying Special Enrollment Period results in permanent late enrollment penalties. Full enrollment guide →

If you miss your IEP and don't qualify for a Special Enrollment Period, you must wait for the General Enrollment Period (January 1–March 31), with coverage starting July 1. You'll also face permanent late enrollment penalties: 10% added to your Part B premium for each 12-month period you delayed, and 1% per month for Part D. These penalties last as long as you have Medicare.

Only if you're already receiving Social Security or Railroad Retirement Board benefits — in that case, you'll be automatically enrolled in Parts A and B about 3 months before your 65th birthday, and your red, white, and blue Medicare card will arrive by mail. If you're not yet receiving those benefits (e.g., you're still working), you must actively enroll. You can do so online at SSA.gov, by phone (1-800-772-1213), or in person at a Social Security office.

Medicare is a federal program primarily for people 65 and older (and qualifying disabled individuals) regardless of income. Medicaid is a joint federal-state program for people with low incomes and limited assets, at any age. Some people qualify for both — called "dual eligible" — and may receive significant help with Medicare premiums and cost-sharing through Medicaid.

Yes. If you qualify for both, you're called "dual eligible." Medicaid may cover Medicare premiums, deductibles, and coinsurance, leaving you with very little or no out-of-pocket costs. Dual-eligible beneficiaries automatically qualify for Extra Help with Part D drug costs. Contact your state Medicaid office to apply.

No — they are separate programs, though both are administered through Social Security for enrollment purposes. Social Security provides monthly income payments. Medicare provides health insurance coverage. They are funded differently: Social Security through payroll taxes on earnings, Medicare through payroll taxes (for Part A), premiums, and general revenue. You can receive one without the other.

Yes. If you have active employer coverage through a company with 20+ employees, you can delay Part B without penalty and use a Special Enrollment Period (up to 8 months after that coverage ends) to sign up later. Part A is usually still worth enrolling in at 65 if it's free — it serves as secondary coverage. If your employer has fewer than 20 employees, Medicare generally becomes your primary insurance at 65 even if you're still working.

You can check eligibility and your enrollment status at SSA.gov or by calling Social Security at 1-800-772-1213. If you're already enrolled, you can log into MyMedicare.gov to view your coverage details, claims history, and enrollment information. Your state's SHIP (State Health Insurance Assistance Program) also provides free, unbiased Medicare counseling.

Part A: $0 for most people (those with 40+ work quarters). Part B: $185.00/month standard premium. Part D: varies by plan (~$40/month average). Medicare Advantage: often $0 beyond Part B. Higher-income earners pay IRMAA surcharges on Parts B and D. Adding Medigap costs $80–$300+/month depending on plan and age. Full 2025 cost breakdown →

Part A is premium-free for most people who (or whose spouse) worked and paid Medicare taxes for at least 10 years (40 quarters). However, Medicare is not "free" overall — you pay a monthly premium for Part B ($185/month in 2025), plus deductibles, copays, and coinsurance when you use services. Part D and Medigap also charge separate premiums. Some low-income beneficiaries can get help paying costs through Medicare Savings Programs.

The Part A inpatient hospital deductible is $1,676 per benefit period in 2025. This is not an annual deductible — a new benefit period (and new deductible) begins each time you're admitted to the hospital after being out for 60+ consecutive days. After the deductible, hospital days 1–60 are covered in full; days 61–90 cost $419/day in coinsurance. Full Part A details →

IRMAA (Income-Related Monthly Adjustment Amount) is a surcharge added to your Part B and Part D premiums if your income exceeds certain thresholds. It's based on your income from 2 years prior (2025 premiums use your 2023 income). The standard Part B premium is $185/month; IRMAA can raise it up to $628.90/month. If your income has dropped significantly, you can appeal with SSA Form SSA-44. See the full IRMAA bracket table →

Original Medicare (Parts A and B alone) has no out-of-pocket maximum — your costs are theoretically unlimited. This is why many people add Medigap or choose Medicare Advantage. Medigap plans cap your costs by covering deductibles and coinsurance. Medicare Advantage plans are required by law to cap in-network out-of-pocket spending (maximum $9,350 in 2025, though many plans set lower limits). Part D now has a $2,000 OOP cap in 2025.

Several strategies: (1) Apply for Medicare Savings Programs if your income is limited — they help pay premiums and cost-sharing. (2) Apply for Extra Help with Part D drug costs. (3) Add a Medigap plan to cap out-of-pocket spending. (4) Appeal IRMAA if your income dropped since the reference year (SSA Form SSA-44). (5) Use generic drugs when possible. (6) Use your Part D plan's preferred pharmacy. (7) Review your plan annually during OEP. Full cost reduction guide →

Medicare Savings Programs (MSPs) are state programs that help low-income Medicare beneficiaries pay for premiums, deductibles, and coinsurance. The four levels are: Qualified Medicare Beneficiary (QMB) — covers most cost-sharing; Specified Low-Income Medicare Beneficiary (SLMB) — covers Part B premium; Qualifying Individual (QI) — covers part of Part B premium; and Qualified Disabled Working Individual (QDWI) — covers Part A premium for working disabled individuals. Apply through your state Medicaid office.

If you don't enroll in Part B when first eligible (and don't have a qualifying SEP), you pay a permanent 10% penalty for each full 12-month period you delayed. For example, if you delayed 2 years, your premium would be 20% higher for as long as you have Part B — so instead of $185/month, you'd pay about $222/month forever. This penalty never goes away.

Part A covers inpatient hospital stays, skilled nursing facility care, hospice, and home health. Part B covers doctor visits, outpatient care, preventive services (many at $0), durable medical equipment, mental health, and lab work. Medicare Advantage includes all of the above plus drug coverage and often dental/vision/hearing extras. Part D covers prescription drugs. Full Medicare basics guide →

Original Medicare generally does not cover: routine dental care (cleanings, fillings, dentures), routine vision exams or eyeglasses, hearing aids, long-term custodial care (help with daily activities), most care outside the U.S., cosmetic surgery, and most prescription drugs (covered separately through Part D). Medicare Advantage plans often add dental, vision, and hearing benefits as extras.

Original Medicare does not cover routine dental care — cleanings, fillings, extractions, dentures, or implants. Medicare may cover dental procedures that are medically necessary in connection with other covered services (e.g., jaw surgery related to a covered hospitalization). Many Medicare Advantage plans include routine dental coverage as an extra benefit. If dental coverage is important to you, it's a reason to consider Medicare Advantage or a separate dental insurance plan.

Original Medicare does not cover hearing aids or routine hearing exams. It does cover diagnostic hearing and balance exams when ordered by a doctor to diagnose a medical condition. Many Medicare Advantage plans include a hearing benefit — typically an annual allowance (e.g., $500–$2,000) toward hearing aids. If hearing coverage is important, compare Medicare Advantage plans with hearing benefits in your area.

Medicare does not cover custodial long-term care — help with daily activities like bathing, dressing, and eating in a nursing home. Medicare does cover short-term skilled nursing facility care (up to 100 days) after a qualifying hospital stay, and home health care for skilled services when you're homebound. Long-term care coverage generally requires a separate long-term care insurance policy or spending down assets to qualify for Medicaid.

Part B covers ambulance transportation when it is medically necessary and other transportation could endanger your health. After your deductible, you typically pay 20% of the Medicare-approved amount. Medicare generally does not cover non-emergency ambulance rides or air ambulance unless ground transportation would be dangerous. Always check with your plan before using non-emergency ambulance services to confirm coverage.

Yes. Part B covers outpatient mental health services including visits to psychiatrists, psychologists, clinical social workers, and other licensed mental health providers. After your deductible, you pay 20% coinsurance — the same as other Part B services (mental health was once subject to higher coinsurance, but that changed). Part A covers inpatient psychiatric care, including up to 190 lifetime days in a freestanding psychiatric hospital.

Part B covers many preventive services at $0 when you see a Medicare-participating provider, including: Annual Wellness Visit, flu and pneumococcal vaccines, mammograms, colorectal cancer screenings, diabetes screenings, bone density tests, depression screening, lung cancer screening, and more. To get these at no cost, you must not be receiving additional paid services at the same visit. Full Part B coverage list →

Yes, Medicare covers medically necessary, intermittent home health care when ordered by a doctor. Covered services include skilled nursing care, physical therapy, occupational therapy, and speech-language pathology. You must be homebound (leaving home requires considerable effort). There's no deductible for home health services themselves, and you pay $0 — though you may pay 20% for durable medical equipment provided at home. Purely custodial care (help with bathing, cooking) is not covered.

Generally, Original Medicare does not cover healthcare received outside the United States. There are narrow exceptions (e.g., if you're in the U.S. and the nearest hospital is in Canada or Mexico). Some Medigap plans (Plans D, G, M, and N) include foreign travel emergency coverage at 80% after a $250 deductible, up to a $50,000 lifetime limit. Medicare Advantage plans typically cover emergency care abroad at the same cost as domestic emergency care.

Medicare Advantage (Part C) is an alternative to Original Medicare offered by private insurance companies approved by Medicare. These plans must cover everything Original Medicare covers (except hospice). Most also include Part D drug coverage and extra benefits like dental, vision, and hearing. You enroll in an Advantage plan instead of Original Medicare (but you still pay your Part B premium). Full Medicare Advantage guide →

Pros: Often $0 additional premium; annual out-of-pocket maximum caps spending; usually includes drug coverage; often includes dental, vision, and hearing extras; fitness benefits like SilverSneakers.
Cons: Network restrictions (must use in-network providers for HMO); prior authorization requirements can delay care; plan benefits, networks, and formularies can change each year; switching back to Original Medicare may limit Medigap options; emergency coverage only outside service area.

Yes, during the Annual Open Enrollment Period (Oct 15–Dec 7) or the Medicare Advantage Open Enrollment Period (Jan 1–Mar 31). However, the challenge is getting Medigap coverage after you switch. Once you're past your initial Medigap open enrollment window, insurers can deny you a Medigap policy or charge more due to health conditions in most states. The Medicare Advantage 12-month trial right (for first-time MA enrollees) provides a guaranteed-issue Medigap window.

CMS rates Medicare Advantage plans on a 1–5 star scale based on quality measures including customer service, member complaints, managing chronic conditions, member experience, and health outcomes. 4–5 star plans are considered high quality. Plans with 5 stars can be enrolled in year-round (not just during OEP). Plans that fall to very low ratings can lose their contracts. Check a plan's star rating at Medicare.gov Plan Finder before enrolling.

Prior authorization (PA) means your Medicare Advantage plan requires advance approval before you receive certain services, procedures, or medications. Services commonly requiring PA include specialist visits (in some HMO plans), non-emergency surgeries, inpatient stays, certain diagnostic imaging, and some specialty drugs. Original Medicare rarely requires prior authorization. Unnecessary PA denials can be appealed — you have the right to a timely appeal and review by an independent organization.

You can change plans during: (1) Annual Open Enrollment Period — Oct 15 to Dec 7 each year, changes effective Jan 1; (2) Medicare Advantage Open Enrollment Period — Jan 1 to Mar 31, one change allowed, effective first of the following month; (3) Special Enrollment Periods triggered by qualifying events such as moving, plan changes, or qualifying for Extra Help. Outside these windows, you generally cannot change plans.

HMO (Health Maintenance Organization): You must use the plan's network providers (except emergencies). You typically need a primary care doctor who provides referrals to specialists. Generally lower premiums and copays, but least flexible. PPO (Preferred Provider Organization): You can see out-of-network providers at higher cost. No referrals required. More flexibility, but usually higher premiums. For most people who have preferred doctors, checking whether those doctors are in-network is the most important factor when choosing between plan types.

Many Medicare Advantage plans include routine dental and vision benefits — unlike Original Medicare, which excludes them. Dental benefits typically include cleanings, X-rays, and sometimes fillings and extractions; major dental (crowns, implants) may be partially covered with a limit. Vision benefits typically cover an annual eye exam and a glasses/contacts allowance (e.g., $100–$300/year). Coverage and limits vary significantly by plan — review the Evidence of Coverage carefully.

Even if you're currently healthy and take no medications, it's generally wise to enroll in a Part D plan when first eligible to avoid the permanent late enrollment penalty. Some low-premium "basic" Part D plans cost as little as $0–$10/month. If you go 63+ consecutive days without creditable drug coverage after your enrollment window, you'll face a permanent penalty added to your premium for life. The financial risk of skipping Part D usually outweighs the cost of a minimal plan.

A formulary is the list of prescription drugs covered by a Part D plan, organized into tiers. Tier 1 (preferred generics) has the lowest copays; Tier 5 (specialty drugs) has the highest costs. Not all drugs are on every plan's formulary — if your medication isn't covered, you may need a formulary exception, try an alternative drug, or switch plans during OEP. Always check that your specific drugs are on a plan's formulary before enrolling. Full Part D guide →

Starting in 2025, there is a $2,000 out-of-pocket cap on Part D drug costs. Once you've paid $2,000 in out-of-pocket drug costs in a calendar year, you pay $0 for covered drugs for the rest of the year. This is a major improvement under the Inflation Reduction Act — the old "donut hole" (coverage gap) has been eliminated. The $2,000 cap applies to all Part D enrollees.

Extra Help (also called the Low Income Subsidy or LIS) is a federal program that helps low-income Medicare beneficiaries pay for Part D drug costs. Benefits include reduced or eliminated premiums, lower deductibles (often $0), and significantly reduced copays (as low as $1.10–$11.20 per prescription in 2025). Eligibility is generally for individuals with incomes at or below 150% of the federal poverty level. Apply at SSA.gov or through your state Medicaid office. If you receive Medicaid, SSI, or a Medicare Savings Program, you likely qualify automatically.

The best Part D plan depends on your specific medications. Use Medicare.gov's Plan Finder: enter your drugs, dosages, and preferred pharmacy, and it will show you the estimated annual total cost (premium + deductible + drug costs) for each available plan. The cheapest-looking plan may not be cheapest if your drugs are on a high tier. Also consider: preferred pharmacy network (lower copays), star rating, and whether mail order is available for maintenance medications.

Most Medicare Advantage plans already include Part D drug coverage — these are called MAPD (Medicare Advantage Prescription Drug) plans. If your Medicare Advantage plan includes drug coverage, you cannot also enroll in a standalone Part D plan. If your Medicare Advantage plan does NOT include drug coverage (rare), you can enroll in a standalone PDP. If you switch from a MAPD plan to Original Medicare, you'll need to separately enroll in a standalone Part D plan.

Creditable drug coverage is prescription drug coverage that is at least as good as Medicare's standard Part D benefit. If you have creditable coverage (from an employer, union, VA, TRICARE, FEHB, etc.) you can delay Part D enrollment without penalty. Your coverage provider is required to send you an annual letter stating whether your coverage is creditable. Keep these letters — you may need to show them if you enroll in Part D later to prove you didn't have a gap.

The maximum Part D deductible in 2025 is $590 per year. However, many Part D plans waive the deductible for lower-tier drugs (Tier 1 and 2 — generics). Some plans waive the deductible entirely. The deductible applies before your plan begins paying its share of drug costs. After the deductible, you pay your tier copays/coinsurance until you reach the $2,000 out-of-pocket cap, after which your drugs are free for the rest of the year.

Medigap (Medicare Supplement Insurance) is private insurance that pays costs Original Medicare doesn't cover — like deductibles, coinsurance, and copays. After Medicare pays its share of a claim, your Medigap plan pays its portion. There are 10 standardized plan types (A through N), each offering a different level of coverage. Medigap only works with Original Medicare — you cannot use it with Medicare Advantage. Full Medigap guide →

Plan G covers everything except the Part B deductible ($257/year in 2025). After you pay that deductible, Plan G covers 100% of your remaining Medicare-approved costs — giving you very predictable annual expenses. Plan N is similar but has small copays: up to $20 for office visits and up to $50 for ER visits (waived if admitted). Plan N also doesn't cover Part B excess charges (the 15% extra some non-participating providers can charge). Plan N premiums are lower than Plan G, making it attractive for relatively healthy people who rarely see doctors.

The best time is during your 6-month Medigap open enrollment window, which starts the month you are both age 65+ AND enrolled in Part B. During this window, insurers must sell you any Medigap plan at standard rates — no medical questions, no denials, no higher prices for health conditions. After this window, insurers can use medical underwriting in most states, potentially denying you coverage or charging more. Don't delay — you can't get this guaranteed-issue protection back.

No. Medigap is designed to work alongside Original Medicare only. If you're enrolled in Medicare Advantage, your Medigap policy provides no benefit — Medicare Advantage replaces Original Medicare, so there are no Medicare gaps for Medigap to fill. If you're paying for both a Medicare Advantage plan and a Medigap policy, you're wasting money. Contact your Medigap insurer if you need to cancel a policy.

No. Medigap plans do not include prescription drug coverage. If you choose Original Medicare and add Medigap, you still need a separate Part D plan for prescription drugs. The only exception is very old Medigap policies (Plans H, I, J) that were sold before 2006 — these included drug coverage but are no longer available to new purchasers. Today's standardized Medigap plans (A through N) do not cover drugs.

Medigap premiums vary significantly by plan type, your age, location, and insurer. Rough 2025 ranges: Plan G typically $120–$300/month; Plan N typically $80–$200/month; Plan K typically $50–$120/month. The same plan (e.g., Plan G) from different companies can vary by $100+/month for identical coverage — shopping multiple insurers is worthwhile. Prices also depend on the pricing method used (community-rated, issue-age-rated, or attained-age-rated). Full Medigap guide →