Medicare Guide

Understanding the Three Main Types of Medicare Coverage

Medicare is a federal health insurance program for people age 65 and older, some younger people with disabilities, and people with end-stage renal disease. The program offers several different ways to receive your benefits, and understanding how each works helps you make decisions about your coverage. The main distinction lies in how you receive services and which providers you can visit.

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Original Medicare, also called Traditional Medicare, consists of two parts managed directly by the federal government. Part A covers inpatient hospital care, including hospital stays, skilled nursing facility care, hospice care, and some home health services. Part B covers outpatient services such as doctor visits, lab tests, imaging services, and preventive care. When you have Original Medicare, you can visit any doctor or hospital in the United States that accepts Medicare, which represents the vast majority of providers. You receive a red, white, and blue Medicare card that serves as your insurance identification.

Medicare Advantage plans, also called Part C, are offered by private insurance companies that have contracted with Medicare. These plans must cover at least the same services as Original Medicare, but they do so through a network of doctors and hospitals rather than allowing you to see any provider. Most Medicare Advantage plans include prescription drug coverage built in, unlike Original Medicare Part B. Many plans also offer additional benefits not covered by Original Medicare, such as dental care, vision coverage, hearing aids, or fitness programs. However, these plans typically require you to use their network providers, except in emergency situations. If you travel frequently or live part of the year in different states, a Medicare Advantage plan may be less convenient than Original Medicare.

Medigap plans, also called Medicare Supplement Insurance, are policies sold by private insurance companies that work alongside Original Medicare. These plans don't replace Medicare—instead, they help pay some of the costs that Original Medicare doesn't cover, such as copayments, coinsurance, and deductibles. For example, if you go to a doctor and Original Medicare covers 80 percent of the approved cost, your Medigap plan may cover some or all of the remaining 20 percent, depending on which Medigap plan you choose. There are ten standardized Medigap plans labeled A through N, each offering different combinations of coverage. With a Medigap plan, you still use your Original Medicare card to see any doctor or hospital that accepts Medicare.

Practical Takeaway: Consider your healthcare needs and preferences. If you want flexibility to see any provider and don't mind managing multiple insurance documents, Original Medicare with or without a Medigap plan may work well. If you prefer all-in-one coverage with a defined network and additional benefits, a Medicare Advantage plan might be a better fit. Your choice depends on which doctors you want to see, how much you travel, and what services matter most to you.

Understanding the Costs Associated with Medicare Plans

Medicare coverage comes with several types of costs that you need to understand to budget for your healthcare. These costs vary significantly depending on which type of plan you choose, and knowing the differences helps you estimate your out-of-pocket expenses.

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Premiums are the monthly payments you make to have coverage. For Original Medicare Part B in 2024, the standard premium is $164.90 per month, though higher-income beneficiaries pay more. Part A has no premium for most people because they or their spouse paid payroll taxes while working. However, if you don't have enough work history, you may pay a Part A premium. Medicare Advantage plans have varying premiums—some plans have $0 monthly premiums while others charge $100 or more, depending on the insurer and the level of coverage offered. Medigap plans also have monthly premiums that vary by plan type, your age, your location, and the insurance company selling the plan. Medigap premiums typically range from $100 to $300 or more monthly.

Deductibles are amounts you must pay out of your own pocket before your insurance coverage begins to pay. With Original Medicare Part A in 2024, the hospital deductible is $1,632 per benefit period, which covers the first 60 days of a hospital stay. After that, you pay coinsurance amounts. Original Medicare Part B has an annual deductible of $240. Once you meet this deductible, Part B typically pays 80 percent of approved costs and you pay 20 percent coinsurance. Medicare Advantage plans each set their own deductibles, which may be $0 or several hundred dollars depending on the plan. Some Medigap plans have no deductible at all, while others may have small deductibles of $50 to $300.

Copayments are fixed dollar amounts you pay for specific services. For example, you might pay $15 for a doctor visit or $50 for an emergency room visit under a Medicare Advantage plan. Original Medicare doesn't typically use copayments; instead, it uses coinsurance. Coinsurance is a percentage of the approved cost that you pay after meeting your deductible. With Original Medicare Part B, after you meet your $240 deductible, you typically pay 20 percent of the approved amount for most services while Medicare pays 80 percent.

Prescription drug coverage costs deserve special attention. If you have Original Medicare and want drug coverage, you must enroll in a separate Part D plan offered by private insurers. These plans have their own premiums, deductibles, and copayments. In 2024, Part D deductibles can be up to $545 per year. Once you spend a certain amount on drugs, you enter the "coverage gap" or "donut hole," where you pay a higher percentage of drug costs until you reach the out-of-pocket spending limit of $8,632 in 2024. After that, catastrophic coverage kicks in and you pay a small copayment for the rest of the year. Many Medicare Advantage plans include prescription drug coverage without this coverage gap, though you may pay higher copayments for some drugs.

Practical Takeaway: Create a spreadsheet comparing the total estimated costs of different plans based on your expected healthcare usage. Add up the annual premiums, likely deductibles you'll meet, estimated copayments or coinsurance, and prescription drug costs. Sometimes a plan with a higher monthly premium has lower overall costs because of lower deductibles and copayments. Review your costs annually because Medicare premiums and deductibles change each year.

Timing Your Medicare Enrollment: Periods and Deadlines

When you can enroll in Medicare depends on your age, your situation, and when you first become eligible. Missing certain enrollment periods can result in late enrollment penalties that increase your premiums permanently, so understanding these timeframes is important. There are three main enrollment periods to know about.

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Your Initial Enrollment Period is the first opportunity you have to enroll in Medicare. If you're turning 65, your Initial Enrollment Period is a seven-month window that begins three months before the month you turn 65 and ends three months after the month you turn 65. For example, if you turn 65 in June, your period runs from March through September. During this time, you can enroll in Original Medicare Part A and Part B, choose a Medicare Advantage plan, or select a Medigap plan. If you're already receiving Social Security benefits when you turn 65, you're enrolled in Part A and Part B automatically, and your coverage begins on the first day of the month you turn 65. If you haven't started Social Security, you must take action to enroll in Medicare during this Initial Enrollment Period. People who become eligible for Medicare before age 65 due to disability or end-stage renal disease also have an Initial Enrollment Period specific to when their eligibility begins.

The Annual Enrollment Period, also called the Open Enrollment Period, occurs every year from October 15 through December 7. During these eight weeks, anyone already enrolled in Medicare can make changes to their coverage. You can switch from Original Medicare to a Medicare Advantage plan, switch from one Medicare Advantage plan to another Medicare Advantage plan, switch to Original Medicare, enroll in or switch Part D prescription drug plans, or enroll in or switch Medigap plans. Your changes take effect on January 1 of the following year. This is the only time during the year when you can make most coverage changes without having a qualifying event. The Annual Enrollment Period is crucial if you're unhappy with your current plan or if your healthcare needs have changed.

Special Enrollment Periods are shorter windows outside the normal enrollment periods when you can make changes because of certain life events. Qualifying events include losing employer coverage, moving to a new state or area where your current plan isn't available, getting