Medicare Education

What is Medicare?

Medicare debuted in 1965 when President Lyndon B. Johnson signed a bill that created both Medicare and Medicaid. The programs’ purpose was to provide health care access for Americans who had difficulty getting it—namely older adults and those with limited incomes.

The Medicare program is administered by The Centers for Medicare & Medicaid Services (CMS), a division of the US Department of Health and Human Services (HHS) that is overseen by the President.

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Medicare Dos and Don'ts

If you’re new to Medicare, you may worry about making a mistake. Whether you’re anxious about missing those important enrollment periods or picking the right plan, we’re here to help. Here are a few Medicare dos and don’ts to ease the anxiety.

1. Do become a Medicare know-it-all. We understand; Medicare can be complicated. Take a moment to educate yourself early on to help save time and money.

2. Do learn how and when to sign up. To avoid coverage gaps and late enrollment fees, learn when enrollment periods are and the rules for signing up.

3. Do consider Part A even if you don’t qualify for premium-free coverage. Are you one of those who must pay if you want to get Part A coverage? You may still want to enroll to protect yourself in case you need care.

4. Do understand how your other coverage works with Medicare. Check out the section below about Medicare and other insurance. You may be able to keep your current coverage when you’re eligible for Medicare.

5. Do know what’s covered and what you’ll pay for care. Whether you enroll in Medicare Advantage, Medicare Supplement, or prescription drug coverage—or you keep Original Medicare—learn the details. Each plan has different rules, benefits, and costs. Learn what’s covered and how much you’ll have to pay—before you need care.

6. Do ask which type of plan may be best for you. Get help deciding which kind of Medicare coverage may be the right fit for your health and budget needs. A good starting point is our Plan Wizard tool.

7. Don’t drop your employer coverage just because you have Medicare. If you’re enrolled in your or your spouse’s employer or retirement plan, don’t assume you need to get rid of it. You may be better off keeping the plan and delaying your Medicare start date. (Just make sure you won’t be penalized!)

8. Don’t put off treatment if you need care. Medicare may not cover every penny of your health costs, but don’t put off getting care if you need it to stay well. Staying healthy should be your top priority.

9. Do consider getting more help with costs. If you have limited resources, you may qualify for one of several programs that could help you pay for your Medicare costs and coverage. Medicaid, Medicare savings accounts, and Extra Help are three programs that you may consider.

10. Don’t do it alone. Medicare can seem daunting if you’re figuring it out alone. Reach out to friends and family or talk to licensed insurance agents who can guide you through the process. If you need to talk, we can help! Contact one of our licensed insurance agents at: 1 (816) 866-5046, TTY 711

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The Parts of Medicare

Medicare first had two parts: Part A and Part B. Together, these parts are often called “Original Medicare” or sometimes “Traditional Medicare.” Both are still around today. Because of the different types of care each covers, people sometimes call Part A “hospital insurance” and Part B “medical insurance.” If you have Medicare coverage, you’re called a “beneficiary.”

The government established Medicare Part C in 1977 as a way to allow private insurance companies to offer coverage to beneficiaries. After several changes, Part C is now widely known as Medicare Advantage. Today, it’s a common way for beneficiaries to access care. Medicare Advantage replaces your Original Medicare (Part A and Part B) coverage and often includes extra benefits.

In the 1980s, Medigap was introduced to help beneficiaries pay for some of the costs left over by Original Medicare. Private insurance companies sell Medigap plans, which are also called “Medicare Supplement” plans.

Part D is the most recent piece of the Medicare puzzle. It helps beneficiaries pay for the costs of prescription drugs. Like Part C and Medigap, private insurance companies provide Part D coverage. You can purchase Part D as a stand-alone plan along with Original Medicare or packaged in with a Medicare Advantage plan.

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Your coverage choice

One of the trickiest parts of Medicare is knowing when you can enroll in coverage or when you can make changes. There are several different spans of time called “enrollment periods” that you should be aware of. These are the periods that may affect you:

• Initial Enrollment Period (IEP)
• General Enrollment Period (GEP)
• Medicare Advantage and Prescription Drug Plan Annual Enrollment Period (AEP)
• Medicare Advantage Open Enrollment Period
• Special Enrollment Periods (SEPs)

Initial Enrollment Period (IEP)

The IEP is your first chance to sign up for Medicare when you’re granted beneficiary status. Usually, this happens around your 65th birthday but may also be triggered if you acquire a disability or certain conditions.

General Enrollment Period (GEP)

If you don’t sign up for Medicare when you first have the chance, you’ll get another chance. The GEP is a yearly period from January 1 to March 31. Waiting until the GEP to sign up may mean you must pay a late enrollment penalty to get coverage.

Medicare Advantage and Prescription Drug Plan Annual Enrollment Period (AEP)

Sometimes referred to as “Annual Election Period,” AEP is the time when you may be able to make changes to your Medicare coverage. AEP is October 15 to December 7 each year. Changes you might be able to make include the following:

• Switching from Original Medicare to Medicare Advantage (with or without prescription drug coverage)
• Switching from Medicare Advantage to Original Medicare

Medicare Advantage Open Enrollment Period

This enrollment period replaces the Medicare Advantage Disenrollment period. From January 1 to March 31 each year, beneficiaries who are already enrolled in a Medicare Advantage plan can make a one-time change to their Medicare Advantage plan or switch back to Original Medicare.

Special Enrollment Period (SEP)

Certain circumstances may qualify you to make changes to your health plan outside of the regular enrollment and election periods.  SEPs include, but are not limited to, the following events:

• You move and your plan isn’t offered at your new address.
• You move and your current health plan has more options than it did at your previous address.
• You used to live outside the United States and have now moved back to the States.
• You now live in a long-term care situation, such as skilled nursing care.
• You were just released from incarceration.
• You’ve lost coverage, including Medicaid, employer, or COBRA coverage.
• You or your spouse can now get other coverage such as a retirement plan.
• Your health plan changes or ends its Medicare contract.
• Your health plan didn’t give you certain information about your plan’s coverage.
• You qualify for Medicaid.
• You lose or newly qualify for certain programs such as Part D Extra Help.
• You newly qualify for a Special Needs Plan due to a disability or condition.

Check with Medicare for more details and whether you qualify for an SEP.

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When and how to enroll

Your costs for Medicare coverage include several different parts. Each portion varies by the type of plan you choose and even sometimes your location and health and information.

Cost overview

• Premium: This is the amount (usually monthly) that you pay to have Medicare coverage.
• Deductible: This is a yearly amount that you must pay for certain services before your plan kicks in and starts covering the costs.
• Cost sharing: Many plans include cost sharing, which means you pay a part of the costs for a service while the plan pays the rest. Cost sharing can be a copayment or a coinsurance. Copayments are often a set dollar amount like $25. Coinsurance may be a set dollar amount or a percentage of the cost such as 20%.
• Penalties and extra costs: In certain instances, you may have to pay extra costs or penalties due to Medicare rules. Each Medicare type has different rules, so be sure to learn the costs before you enroll in a plan.

Part A costs

Original Medicare Part A is often called “hospital insurance” because a large portion of the coverage goes to pay for inpatient (overnight) stays in a hospital. Although most people get Part A premium-free, you’ll likely pay some costs associated with the coverage.¹

• Premium: In general, if you’re turning 65 and you or your spouse have worked and paid Medicare taxes, you get Part A premium-free. Certain disabilities and conditions, like end-stage renal disease (ESRD), also qualify you for premium-free Part A. Others may have to pay a Part A premium. The amount in 2022 can be up to $499 each month depending on how much you paid in Medicare taxes during your lifetime.
• Deductible: Part A has a yearly $1,556 deductible in 2022. This deductible applies to your inpatient hospital visits.
• Cost sharing: After you meet your Part A deductible, you’ll pay a different coinsurance depending on the length of your hospital stay. For the first 60 days, your coinsurance is $0. Days 61 through 90 require $389 per day. After that, you pay $778 per day as you use up your 60 “lifetime reserve days.” If you use up all lifetime reserve days in a single year, you’ll pay the full cost for hospital stays after day 90.²
• Late enrollment penalty: People who don’t get Part A automatically must sign up when they are first eligible. Otherwise, they pay a 10% penalty in addition to their Part A premium for twice as long as they’ve gone without Part A coverage. For example, going six months without coverage results in paying the penalty for one year.³

Part B cost

Part B helps pay for preventive care (care that keeps you from getting sick) and care that Medicare considers medically necessary. Your costs for Part B vary depending on the type of service, which we break down below.⁴

• Premium: Most people pay the standard Part B premium, which is $170.10 if you enroll for the first time in 2022. Some people pay more than the standard premium because their income is higher, while others with a lower income pay a smaller or even zero premium. For more details, visit our page on Part B premiums.
• Deductible: The 2022 Part B deductible is $233. It applies to most care that Medicare considers medically necessary like doctor visits, outpatient hospital care, and medical equipment.
• Cost sharing: In general, you’ll pay 20% for covered Part B services after you meet your deductible. Some services, like preventive care, don’t require cost sharing. You can visit medicare.gov to find out the cost for specific services.
• Late enrollment penalty: If you don’t enroll in Part B coverage when you’re first eligible, you may have to pay a late enrollment penalty. The penalty raises your premium by 10% for each 12-month period you didn’t have coverage when you could have.⁵

If your yearly income in 2020 (for what you pay in 2022) was:
File individual tax return	File joint tax return	File married & separate tax return	You pay each month (in 2022)
$91,000 or less	$182,000 or less	$91,000 or less	$170.10
above $91,000 up to $114,000	above $182,000 up to $228,000	Not applicable	$238.10
above $114,000 up to $142,000	above $228,000 up to $284,000	Not applicable	$340.20
above $142,000 up to $170,000	above $284,000 up to $340,000	Not applicable	$442.30
above $170,000 and less than $500,000	above $340,000 and less than $750,000	above $91,000 and less than $409,000	$544.30
$500,000 and above	$750,000 or above	$409,000 or above	$578.30

Prescription drug coverage costs

There are two ways to get Medicare coverage for prescription drugs. The first is to buy a Medicare Advantage plan that includes prescription drug coverage. Your other option is to buy a stand-alone Part D Prescription Drug Plan (PDP) from an insurance company. The costs for drugs on these plans vary depending on the plan you choose and the drugs covered on the plan.

• Premium: In general, if you’re turning 65 and you or your spouse have worked and paid Medicare taxes, you get Part A premium-free. Certain disabilities and conditions, like end-stage renal disease (ESRD), also qualify you for premium-free Part A. Others may have to pay a Part A premium. The amount in 2022 starts from $170.10 to $578.30 a month, depending on how much you paid in Medicare taxes during your lifetime.
• Deductible: Part A has a yearly $1,556 deductible in 2022. This deductible applies to your inpatient hospital visits.
• Cost sharing: After you meet your Part A deductible, you’ll pay a different coinsurance depending on the length of your hospital stay. For the first 60 days, your coinsurance is $0. Days 61 through 90 require $389 per day. After that, you pay $778 per day as you use up your 60 “lifetime reserve days.” If you use up all lifetime reserve days in a single year, you’ll pay the full cost for hospital stays after day 90.²
• Late enrollment penalty: People who don’t get Part A automatically must sign up when they are first eligible. Otherwise, they pay a 10% penalty in addition to their Part A premium for twice as long as they’ve gone without Part A coverage. For example, going six months without coverage results in paying the penalty for one year.³

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How Much it Costs

Medicare is designed to help Americans pay for health care costs, but sometimes people need more coverage. Certain rules apply to having more than one kind of coverage.

Employer coverage: If you or your spouse get health insurance from an employer or retirement plan, you may be able to keep your current plan when you enroll in Medicare. But specific rules apply, so make sure you speak to your plan sponsor before you decide.

Medicaid: Many Americans qualify for both Medicare and Medicaid, the US program for people with limited resources. These “dual eligibles” have most of their health care covered, but Medicare always pays first.

Veterans benefits: Current or former US military members and their families usually get health care through Tricare, and they may also have Medicare. Medicare is the primary payer except when you get care from a military or federal facility.

Affordable Care Act: You may have individual health coverage through the Affordable Care Act (ACA or Obamacare) Marketplace. If so, you’ll need to decide whether to keep the Marketplace plan when you become eligible for Medicare. But you can’t keep receiving tax credits for Marketplace plans once you enroll in Medicare.

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How It Works with Other Insurance

Because Original Medicare doesn’t cover everything, it may leave some beneficiaries with high out-of-pocket costs. Purchasing a Medicare Advantage, Medicare Supplement, or Part D prescription drug plan may help with these costs. These plans could help ease the financial burdens of relying solely on Part A and Part B for your health coverage.

It’s important to remember that private plans often charge a monthly premium* for the added coverage that goes beyond what Original Medicare typically pays for.

Medicare Advantage

Part C, or Medicare Advantage, plans come in a few different flavors and, depending on what’s available in your area, you may get to choose from any of them. The primary difference between the five plan types is how flexible your provider choices are.

• Health Maintenance Organization (HMO) plans: These plans are the most restrictive of all Medicare Advantage plans. Usually, you can visit providers only within the HMO network. You may also have to get a referral to see a specialist. HMO plans tend to have the lowest premiums on average when compared to the other Advantage plan types.
• Preferred Provider Organization (PPO) plans: PPO plans give you greater flexibility than HMOs when choosing where to get care. But these plans still have a provider network, and you might have to pay more to see a provider outside the network. Your premium* may also be higher with a PPO plan than an HMO plan.
• Private Fee-for-Service (PFFS) plans:‡ For the greatest flexibility when choosing providers, PFFS plans offer wide access. Unlike most Advantage plans, for which Medicare sets the costs of services, a company that offers PFFS plans can choose the prices it will pay providers and the costs you’ll pay. This greater degree of flexibility usually means PFFS plans are more expensive than HMOs or PPOs.
• Special Needs Plans (SNPs): Individuals with certain conditions or a particular living situation may be able to choose an SNP Advantage plan. Companies can tailor the coverage for SNPs to suit the unique health needs of beneficiaries in those circumstances. Common reasons for getting an SNP include living in a nursing home or having a chronic condition like diabetes or HIV/AIDS. SNPs typically have some provider restrictions like networks or specialist referrals.
• Health Maintenance Organization–Point of Service (HMO-POS) plans: This is a long name for a less commonly purchased plan. It’s like an HMO but with the option to choose out-of-network providers for some care. You’ll pay a higher cost to see the POS providers rather than stay within the HMO network.

Medicare Supplement

Your choices for Medigap differ based on the individual lettered plan. Some offer comprehensive coverage for your Part A and Part B expenses, while others cover just a part. Also, a few plans help pay for services that Original Medicare doesn’t, like foreign travel emergency services or the Part B excess charges.

All plans cover your Part A coinsurance costs for inpatient hospital stays, with a limit of 365 days after you used up the Part A benefits.

Each plan also covers at least part of your coinsurance or copayment for Part B services, hospice care, and up to three pints of blood you receive while in the hospital.

Every plan except Plan A covers all or part of your Part A deductible. In some areas, you may be able to buy special versions of Medigap plans. These have slightly different coverage than the standard plans listed in the chart above.

• Medigap Select plans: You may be able to choose a special “Select” version of a Medicare Supplement plan that offers a lower premium for benefits similar to those offered in a traditional Medigap plan. But Select plans require you to use the plan’s provider network for care. These plans are often named SELECT Plan A, SELECT Plan N, etc.

Prescription drug coverage

You have two basic options for getting Medicare prescription drug coverage. You can purchase a stand-alone Part D Prescription Drug Plan (PDP) or Medicare Advantage Prescription Drug Plan (MA-PD).

With MA-PD plans, prescription drug coverage is built into a Medicare Advantage plan. This means you may not have a choice of different types of prescription coverage in this market. Your choice may be either a Medicare Advantage plan with prescription coverage or without.

Stand-alone PDP choices vary in premium* costs, formulary,† and utilization requirements like step therapy.

With either type of prescription drug coverage, you’ll want to make sure that any medication you currently take or expect to take in the future is covered—and that you’re comfortable with the drug’s cost charged under the plan.

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Glossary of Terms

Confused about what the donut hole is? Not sure what the difference between HMO and PPO is? Let us try to clear up some of the common terms and abbreviations you may see when learning about Medicare.

 1. CMS: The Centers for Medicare & Medicaid Services (CMS) is the US federal agency tasked with running the Medicare and Medicaid program.

2. Coinsurance: You may have to share the cost of care with your health plan. A coinsurance usually refers to a percentage, like 20%, of the overall cost.

3. Copay/copayment: Either way it’s spelled, many health plans require you to pay a copayment for services. Usually, it means a set dollar amount, such as $15.

4. Cost sharing: Coinsurance and copayments are both methods of cost sharing between you and your health plan.

5. Coverage: Often used interchangeably with “plan,” health coverage refers to the balance of liability that you and your insurance plan (or the government) agree to.

6. Donut hole/coverage gap: Until recently, Part D plans included certain phases in which your prescription drugs had different costs. The donut hole, or coverage gap, was a phase in which your costs could rise until before you met your full out-of-pocket costs.

7. Deductible: Many insurance plans have a yearly deductible you must meet before the coverage kicks in.

8. Enrollment period: Different rules apply for when you can sign up for Medicare coverage, including the time periods during which you can do so. See the section above about enrollment periods for more information.

9. Extra Help: You might qualify to get help paying for your Part D prescription drug costs through this federal program.

10. Formulary:† The formulary is the list of covered drugs on a prescription drug plan or Medicare Advantage plan with drug coverage.

11. Health Maintenance Organization (HMO): A type of Medicare Advantage plan, HMOs typically have rules like getting a referral to see a specialist.

12. Late enrollment penalty: If you don’t sign up for Medicare coverage when you’re first eligible, you might have to pay extra when you get it later. Different coverage types have different rules and penalty amounts.

13. Medical Savings Account (MSA): Like some plans in the private insurance market, MSAs pair a high-deductible Medicare Advantage plan with a savings account that allows you to put money aside to pay for health costs.

14. Network: Advantage plans have provider networks, which are the pools of doctors, hospitals, and other providers that they contract with to provide care. Some plans require you to stay within the network and only visit providers participating with the plan’s network.

15. Prescription Drug Plan (PDP): You might get your Medicare Part D coverage in the form of a stand-alone PDP offered by private insurance companies.

16. Private Fee-for-Service (PFFS): Unlike most Advantage plans, a PFFS plan can set its own payment terms for care.

17. Preferred Provider Organization (PPO): For more flexibility when choosing which doctors you can visit, you may enroll in a PPO plan that lets you see out-of-network providers (usually at a higher cost).

18. Premium: The monthly amount you pay for health coverage is your premium.

19. Provider: This is an umbrella term that includes the medical professionals and facilities that provide care, including physicians, specialists, clinics, hospitals, and medical equipment companies.

20. Referral: On some plans, you may have to ask your primary care doctor to give you a referral, or express permission, to visit a specialist.

21. Special Needs Plan (SNP): If you have a certain condition or disability, you may qualify for a unique type of Advantage plan called an SNP.

22. Tiers: Prescription drug coverage is often broken down by categories of drugs called Tiers (e.g., Tier 1, Tier 2). Lower tiers typically have lower copayments than higher tiers.

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