If you want all the details on Medicare for Dummies without reading a whole book, you came to the right place. We’re going to skip the introduction and get right to the point. In this text, we’ll discuss how to get started with Medicare, costs, coverage, eligibility, and enrollment.

Medicare for Dummies

If you’re 65 years or older, or have certain disabilities, you likely have Medicare. When you have Medicare it’s important to understand the details of coverage.

Chapter 1: Getting Started with Medicare

Understanding the ABCD’s of Medicare is the first thing discussed in Medicare for Dummies. Some parts of Medicare are mandatory while other parts are optional.

If you turn 65 and you’re already on Social Security or Railroad Retirement Board benefits, your Part A and Part B should begin automatically. You can call Medicare if you’re unsure.

Medicare Part A

Part A is the hospital portion of your Medicare coverage. If you need inpatient care or a Skilled Nursing Facility, Part A covers 80% of the costs. This means you’ll pay 20% of your Part A costs. There is also a Part A deductible that is subject to change annually. Part A is free for most people.

However, when it comes to hospice, Part A will cover 100% of your hospice care-related costs.

Medicare Part B

Part B is your outpatient coverage for services like doctor’s office visits, preventive screenings, lab tests, outpatient surgery, and Durable Medical Equipment (DME). Also, Part B covers drugs administered by your doctor in the doctor’s office.

Like Part A, Part B covers 80% of your medical services, and you pay 20% of the cost.
There is a Part B deductible that can increase on an annual basis. Also, the premium for Part B can increase on an annual basis. D

Delaying enrollment in Part B can result in a penalty if you don’t have creditable coverage.

Medicare Part C

Medicare Advantage plans are optional. These plans won’t be suitable for everyone. Part C plans combine Part A, Part B, and Part D. These plans usually include basic dental, vision, or hearing benefits.

The coverage for Part C must be at least as good as Medicare. These plans can change benefits each year, so comparing your options regularly is necessary.

There are doctor limitations, frequent out-of-pocket costs, and these plans require you to stay within a service area.

Medicare Part D

Even if you don’t take prescription drugs, enrolling in a Part D plan when you’re first eligible will protect you from the Part D late enrollment penalty. Part D plans cover medications your doctor prescribes for you to take at home.

With Part D coverage there are different tiers depending on your medications. Generally, generic medications are cheaper than brand-name medications.

In some cases, step therapy, prior authorization, or quantity limits depend on your prescriptions. The more medications you take or the more expensive your medications are, the more likely you are to reach the coverage gap.

With Part D coverage you usually pay a copayment or coinsurance on your medications when you go to the pharmacy. Some pharmacies are cheaper to use with certain Part D plans. While you have plenty of choices, you’ll want to make timely decisions.

Chapter 2: What Medicare Covers or Doesn’t cover

Medicare covers a lot, but it doesn’t cover everything. Now you know what Part A and Part B cover from the section above, but it’s also valuable to understand what’s not covered.

Original Medicare won’t cover long-term care, vision, dental, dentures, acupuncture, hearing aids, cosmetic surgery, or routine foot care. Also, Medicare won’t’ cover stairlifts or other home modifications to accommodate a disability.

In some cases, there may be coverage limits, like Part A has limits on hospital stays. Understanding there are limits is important because it can help you decide which supplemental insurance is going to benefit you the most.

Chapter 3: Understanding Your Medicare Costs

Part A is free to most people. The Part B premium can increase annually. Currently, it’s $164.90 each month. There are deductibles as well.

The Part A deductible is $1,600. And the Part B deductible is $226. On top of these costs, you’ll pay 20% coinsurance on the total cost of medical services. Plus, if a Part B excess charge is applied, you could pay an additional 15%.

Those with higher incomes have an Income Related Monthly Adjustment Amount (IRMAA) on Part B and Part D. The IRMAA is based on your income two years ago, so if you had a substantial drop in your income, you could file an appeal to lower your amount.

Part D premiums usually range from $20-$100 depending on the coverage you need and the medications you take.

While Medicare Advantage plans have lower monthly premiums, they have higher out-of-pocket costs. Medigap plans fill the gaps of Medicare, exchanging higher premiums for little to no out-of-pocket costs.

Chapter 4: How to Lower Out-of-Pocket Costs

Buying a Medigap plan can lower your out-of-pocket costs. But, if your income is lower, Medicaid could be an option for you to lower your medical expenses.

If you don’t qualify for Medicaid, you may still be eligible for extra help paying for your Part D costs.

Chapter 5: Medicare Eligibility

If you’re about to turn 65 or you’re already 65, then you’re eligible for Medicare. Also, if you’re on Social Security disability for at least 24 months or have a qualifying disability, you’re eligible for Medicare.

Those that delay Part B because they continue working and have creditable coverage through an employer will be eligible for Medicare when they decide to retire.

Chapter 6: The Right Time to Enroll in Medicare

The right time to enroll in Medicare depends on your situation. Medicare enrollment could be automatic if you’re on Social Security or Railroad Retirement Board benefits.

The Initial Enrollment Period

During the Initial Enrollment Period (IEP), you can sign up for Medicare three months before you turn 65, the month you turn 65, or within three months of turning 65. It’s best to sign up for Medicare as soon as you’re eligible.

The Special Enrollment Period

If you delay Medicare and keep private employer health coverage creditable, you can delay enrollment into Medicare. The employer must have more than 20 employees. When you’re ready to sign up, you’ll qualify for a Special Enrollment Period (SEP).

The General Enrollment Period

Between January 1 and March 31, the General Enrollment Period (GEP) for Medicare occurs. This is for people that didn’t apply for Medicare during their IEP or during a SEP. Those that enroll during this period will have coverage effective July 1.

How to Find Help with My Medicare

Whether you’re new to Medicare or just plain confused, working with an insurance agent can be beneficial. Call one of our Medicare experts to get help navigating your Medicare. You can compare your Medicare options online by filling out an online rate comparison form.

Written By:
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Lindsay Malzone, Lindsay Malzone is the Medicare editor for Medigap.com. She's been contributing to many well-known publications since 2017. Her passion is educating Medicare beneficiaries on all their supplemental Medicare options so they can make an informed decision on their healthcare coverage.
Reviewed By:
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Rodolfo Marrero, Rodolfo Marrero is one of the co-founders at Medigap.com. He has been helping consumers find the right coverage since the site was founded in 2013. Rodolfo is a licensed insurance agent that works hand-in-hand with the team to ensure the accuracy of the content.