It’s no secret that the US has one of the highest costs of healthcare in the world. And that can make it difficult to find affordable health insurance that suits your specific needs—especially if you’re older or require ongoing treatment for a particular disease.
Understanding how Medicare works—including its many moving parts—is essential for knowing what expenses you’ll face. The good news? We’ve got you covered there. Keep reading to learn how Medicare works and how it will benefit you and your loved ones.
What is Medicare?
Medicare is a national health insurance program provided by the Centers for Medicare & Medicaid Services (CMS). It’s best known for providing health insurance coverage to individuals who are age 65 and over, but it also applies to those under 65 with certain health conditions. Medicare consists of four parts, which helps ensure an ideal coverage plan based on your specific needs and budget—more on that below.
Who Qualifies for Medicare?
Contrary to popular belief, Medicare isn’t just meant for individuals who are age 65 and over.
It also covers some disabled and medically affected folks under the age of 65, as well. Wondering if you qualify? If you’re a US citizen (or have been a permanent legal resident for the past five years) and can answer yes to one of the following statements, you are eligible to receive Medicare:
I am 65 years of age or older
I am under 65, but I receive disability benefits from the Social Security Administration (SSA) or the Railroad Retirement Board (RRB)
I have amyotrophic lateral sclerosis (ALS, or Lou Gehrig’s disease)
I have end-stage renal disease (ESRD)
How Does it Work? The Different Parts of Medicare Explained
If you’ve ever felt confused while reading about Medicare, you’re not alone. Medicare is a complicated program, and it can be tricky to keep track of the many options and layers of information. Thankfully, the program has been broken down into four basic parts that make it clear and easy to understand:
Part B (when combined, Part A & Part B are referred to as “Original Medicare)
Part C (also known as Medicare Advantage)
Here’s a detailed rundown of each of the four parts of Medicare and how they may apply to you:
Medicare Part A: This first part covers your stays for inpatient care in a hospital or a skilled nursing facility, which may be necessary for rehabilitation after a stroke or serious injury. It also covers hospice care and limited home health care (but not custodial or long-term care).
Medicare Part B: Medicare’s second part covers doctor visits. It also takes care of medically necessary services and supplies, which includes preventive services, ambulance services, medical equipment, mental health coverage and a few types of outpatient prescription drugs.
What is the Medicare Part B penalty? If you’re not automatically enrolled in Medicare (more on that below), you’ll need to sign up when you’re first eligible. If you miss the deadline, you could face a penalty each time you pay your monthly premium. To avoid penalties, take a look at Medicare Enrollment and Election Periods to find out when to sign up. However, you may be able to avoid the permanent penalty if you had health insurance through your job or your spouse’s job when you first became eligible.
Medicare Advantage (Part C) Looking for an all-in-one alternative to Original Medicare (Part A and Part B)? A Medicare Advantage Plan, also known as “Part C” or an “MA plan” covers everything that Original Medicare covers, including Part A (hospital insurance) and Part B (medical insurance). It may also cover extra benefits as well, including vision, hearing, dental, and/or health and wellness programs.
Medicare Advantage Plans are offered by private companies that must follow rules set by Medicare. However, it’s important to know that each Medicare Advantage Plan can charge different out-of-pocket costs and may enforce different rules for how you get services (such as requiring a referral before you can see a specialist, etc).
Medicare Part D: Medicare Part D helps pay for the medications your doctor prescribes. It’s important to know that Original Medicare (Parts A and B) does not cover prescription drugs. That’s why most people who choose Original Medicare add a prescription drug (Part D) plan or choose a Medicare Advantage plan that includes Part D.
Every Medicare Part D plan is required to cover certain common types of drugs, which will be listed on their drug list (also known as formulary). However, each plan may choose which specific drugs it covers, so make sure you choose a plan that covers your medications before you enroll.
How Do I Enroll in Medicare?
Now you know how the different parts of Medicare work. So the next question is, how do you enroll? Some people will automatically qualify for Medicare Part A and Part B, while others will need to sign up for it. In most cases, it depends on:
Whether or not you’re receiving Social Security benefits.
Here’s what you need to know about whether or not you qualify—and how to enroll if you don’t.
You Automatically qualify for Medicare Parts A and B if:
You’ll be getting benefits from Social Security or the Railroad Retirement Board (RRB) at least four months before you turn 65. Medicare enrollment begins three months before your 65th birthday and continues for seven months. If you are receiving Social Security benefits at this point, you don’t need to do anything. You will be automatically enrolled in Medicare Parts A and B and will receive your Medicare card in the mail three months before your 65th birthday.
You have ALS (Amyotrophic Lateral Sclerosis, also known as Lou Gehrig’s disease): You’ll automatically qualify and will receive a Medicare card the month your disability benefits begin.
You’re under 65 and have a disability: You’ll automatically receive parts A & B after you’ve received disability benefits from either Social Security or the RRB for 24 months. You’ll receive your Medicare card in the mail three months before your 25th month of disability.
You Do Not Automatically Qualify for Medicare Parts A and B if:
You won’t be receiving benefits from Social Security (or the RRB) at least four months before you turn 65.To avoid permanent penalties (see Medicare B penalty above), you should enroll within the seven-month window of time around your 65th birthday. This includes the three months before the month you turn 65, your birthday month, and the three months after your birthday month.
You have End-Stage Renal disease (ESRD): To sign up for Medicare Part A and Part B, you’ll simply apply online or visit your local Social Security office.
If you don’t automatically qualify for Medicare Parts A and B, you’ll need to sign up. Here are the different ways you can enroll:
Call Social Security at 1-800-772-1213 (TTY users 1-800-325-0778). You can speak with a representative Monday through Friday, from 7 a.m. to 7 p.m.
Visit your local Social Security office to enroll in person.
If you worked for a railroad, call the RRB at 1-877-772-5772. You can speak with a representative Monday through Friday, from 9 a.m. to 3:30 p.m.
If you already have Part A and want to sign up for Part B, complete an Application for Enrollment in Part B (CMS-40B). Get this form and instructions in Spanish.
Note: If you are required to enroll for Medicare, you won’t need to sign up each year. However, each year you’ll have a chance to review your coverage and change plans.
The Many Parts of Medicare: Summing it All Up
Already forgot which part of Medicare is which? This handy cheat sheet will help!
Part A: Hospital insurance
Part B: Medical insurance
Parts A & B: Also known as Original Medicare, this plan covers both hospital and medical insurance.
Part C: Also known as Medicare Advantage, an MA plan covers Part A and Part B and may also cover extra benefits as well.
Part D: Prescription drug insurance
Looking for Affordable Medicare? Look No Further
Now that you’re well-equipped to choose the Medicare plan that suits you best, it’s time to find the best possible coverage rates. We’re here to take the stress out of insurance shopping with our fast and affordable online insurance quotes. Get yours right now, and enjoy the peace of mind that your health care coverage is comprehensive and affordable.