YOUR MEDICARE FAQs, ANSWERED
Frequently Asked Medicare Questions
Find answers to common questions about Medicare, our services, and how we can help you navigate your healthcare options with confidence.
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Navigating Medicare can be complex, and it’s common to have many questions. This FAQ addresses some of the most common concerns beneficiaries have. Please note that this information is for educational purposes and should not be considered personalized advice. For specific guidance, you should consult with a licensed Medicare agent or Medicare.gov
The answer depends on your employer’s size and plan. If your employer has 20 or more employees, your group health plan is usually primary. You may then delay Medicare Part B enrollment without a late enrollment penalty. However, if your employer has fewer than 20 employees, Medicare often becomes primary. Delaying Part B could then lead to penalties and coverage gaps. Many people enroll in premium-free Part A even if they delay Part B. We recommend speaking with your employer’s benefits administrator or a licensed Medicare agent to understand your specific situation.
With Original Medicare (Parts A and B), you typically pay a monthly Part B premium. This premium can be higher based on your income (Income-Related Monthly Adjustment Amount or IRMAA). You will also pay an annual Part A deductible for inpatient hospital stays. Additionally, there is an annual Part B deductible. After meeting the Part B deductible, you usually pay 20% coinsurance for most Medicare-approved Part B services. Notably, Original Medicare does not have an annual out-of-pocket maximum. This means there’s no limit to what you might pay for covered services in a year. Many beneficiaries consider supplemental coverage like Medicare Advantage plans or Medigap policies to help manage these potential costs.
Medicare Part D is not automatic with Original Medicare. You must actively enroll in a stand-alone Prescription Drug Plan (PDP) offered by private insurance companies approved by Medicare. If you do not enroll when first eligible and lack other creditable drug coverage, a late enrollment penalty may be added to your Part D premium for as long as you have Part D. To choose a plan wisely, compare plan formularies (lists of covered drugs) to confirm your specific medications are included. Also, check the plan’s deductible, copayments, coinsurance, and pharmacy network. The Medicare Plan Finder tool on Medicare.gov is an excellent resource for comparing plans based on your prescriptions.
Generally, Original Medicare (Parts A and B) does not cover routine dental care (such as cleanings or dentures), routine eye exams, eyeglasses, or hearing aids. However, many Medicare Advantage (Part C) plans often include these “extra” benefits as part of their comprehensive package. If you stay with Original Medicare, you would typically need to purchase separate stand-alone dental, vision, or hearing insurance policies, or pay for these services out-of-pocket.
If you are already receiving Social Security retirement or disability benefits at least four months before you turn 65, you will generally be automatically enrolled in Medicare Parts A and B. Your Medicare card will be mailed to you. If you are not yet receiving Social Security benefits, you will need to proactively sign up for Medicare through the Social Security Administration (SSA) website or by contacting them directly when you become eligible.
While you can enroll in Medicare independently, a licensed Medicare agent offers personalized guidance and support. They understand Medicare’s complexities and can help you discern the differences among Original Medicare, Medicare Advantage plans, Medigap policies, and Part D plans. An agent can compare plans from various insurance companies available in your area. They also explain how each option may fit your specific health and financial needs. Using an agent’s service can save you time and help you make a well-informed decision.
Reputable Medicare agents are usually licensed to represent multiple insurance companies. This allows them to act as brokers, offering you a range of plan options. Insurance companies compensate agents when you enroll in a plan. However, this compensation is generally standardized across similar plan types, which helps reduce bias. To ensure unbiased advice, always ask an agent how many companies they represent. Request that they present you with a variety of plan choices for comparison. A trustworthy agent prioritizes understanding your individual needs.
To receive the most accurate and relevant plan recommendations, be prepared to discuss:
- Any existing employer-sponsored health coverage, retiree benefits, or other health insurance.
- Your current health conditions and any chronic illnesses.
- A comprehensive list of your prescription medications, including dosage and frequency.
- Your preferred doctors, specialists, and hospitals, and whether you wish to continue seeing them.
- Your budget for monthly premiums, deductibles, and potential out-of-pocket costs.
- Your travel habits, as this can impact network considerations for certain plans.
A professional Medicare agent will educate you about your options, answer your questions thoroughly, and present various suitable plans without pressure. If you feel rushed, confused, or pressured into making a decision, it is perfectly acceptable to take a step back, request more time, or seek a second opinion. You should feel confident and empowered in the choices you make regarding your Medicare coverage.
Many licensed Medicare agents provide ongoing support even after enrollment. This support can include helping you understand your plan’s benefits. They can also assist with claims inquiries. Furthermore, they can review your coverage options during the Annual Enrollment Period (AEP) each fall and answer new questions throughout the year. It’s advisable to inquire about the post-enrollment support offered by prospective agents.
While many Medicare Advantage plans have a $0 monthly premium to the insurance company, you must still continue to pay your Medicare Part B premium. The “catch” is that these plans typically have different cost-sharing structures than Original Medicare, such as copayments for doctor visits, hospital stays, and other services. They also often include provider networks (like Health Maintenance Organizations, HMOs, or Preferred Provider Organizations, PPOs) that may require you to seek care from specific doctors and hospitals to receive the highest level of benefits. The $0 premium is possible because Medicare pays a fixed amount to the private insurance company to administer your benefits.
It is absolutely critical to verify that all your current doctors, specialists, and preferred hospitals are part of a Medicare Advantage plan’s network before you enroll. Do not rely solely on plan directories; always call your providers directly and provide them with the specific plan name and ID number to confirm their participation. If your providers are not in the plan’s network, your out-of-pocket costs could be significantly higher, or your services may not be covered at all, depending on the plan type (HMO vs. PPO).
Yes, all Medicare Advantage plans include an annual out-of-pocket maximum (MOOP) for Medicare-covered services. Once you reach this pre-set limit through your copayments, deductibles, and coinsurance, the plan will pay 100% of your covered medical costs for the remainder of the calendar year. This is a key difference from Original Medicare, which has no annual out-of-pocket limit. It’s important to understand what services count towards the MOOP and if there are separate limits for in-network and out-of-network care (for PPO plans).
This is an important consideration for frequent travelers. Most Medicare Advantage plans, particularly HMOs, have defined service areas. While they typically cover emergency and urgent care services anywhere in the U.S. and often globally, routine care outside of your plan’s service area generally may not be covered. Some PPO plans may offer more flexibility for out-of-area non-emergency care, but often at a higher cost-sharing amount. If you travel frequently, carefully review the plan’s network limitations and out-of-area coverage rules to ensure it meets your needs.
- HMO (Health Maintenance Organization) Plans: Generally require you to choose a Primary Care Provider (PCP) within the plan’s network and obtain a referral from your PCP to see specialists. Except for emergency or urgent care, you typically only receive coverage for services from providers within the plan’s network. HMOs often have lower monthly premiums and predictable copayments.
- PPO (Preferred Provider Organization) Plans: Offer more flexibility. You typically do not need a referral to see a specialist, and you have the option to receive care from out-of-network providers, although your out-of-pocket costs (copayments/coinsurance) will usually be higher when going out-of-network. PPO plans may have slightly higher monthly premiums than HMOs.
Neither type is inherently “better”; the optimal choice depends on your preference for flexibility, cost, and whether you are comfortable with referrals and network restrictions.
Your Medigap Open Enrollment Period (OEP) is a crucial, one-time, 6-month period that begins the month you turn 65 and are enrolled in Medicare Part B. During this specific window, federal law dictates that insurance companies offering Medigap policies cannot deny you coverage or charge you higher premiums based on your current or past health conditions. If you miss this special enrollment period, you may be subject to medical underwriting in most states, which means an insurance company could deny your application or charge you more due to your health history.
Medigap plans are standardized by the federal government, meaning that each lettered plan (e.g., Plan A, Plan G, Plan N) offers the exact same basic benefits, regardless of the insurance company selling it. For example, a Medigap Plan G from one insurer provides the identical coverage as a Medigap Plan G from another insurer; the only difference will be the premium they charge and their customer service. The key is to compare the premiums for the same lettered plan from different companies. Plan G is a popular choice for many as it covers all Original Medicare out-of-pocket costs except the annual Part B deductible.
No, it is generally illegal for an insurance company to sell you a Medigap policy if you are enrolled in a Medicare Advantage plan, with very limited exceptions. You must choose one path: either Original Medicare (Parts A and B) plus a Medigap policy (and a separate Part D plan for drug coverage), or a Medicare Advantage plan (which typically combines Part A, Part B, and often Part D, along with other benefits).
Yes, Medigap premiums typically increase annually due to various factors, including inflation, rising healthcare costs, and the pricing method used by the insurer (e.g., “attained-age” policies where premiums increase as you get older, or “issue-age” policies where the premium is based on your age when you first bought it but can still increase due to other factors). While your Medigap policy is “guaranteed renewable” (meaning the insurer cannot cancel it as long as you pay premiums), the premium amount can change. To potentially manage increases, you may be able to shop around for the same lettered plan from a different insurer, especially if your state offers a “birthday rule” or other special enrollment periods that allow you to switch without medical underwriting.
Yes, if you have Original Medicare and a Medigap policy, you will still need to purchase a separate, stand-alone Medicare Part D Prescription Drug Plan to cover your prescription medications. Medigap policies sold after 2005 do not include prescription drug coverage. Enrolling in a Part D plan is crucial to help manage your medication costs and to avoid potential late enrollment penalties.
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