Medicare FAQ: Answering Your Common Medicare Questions

Medicare FAQ

If you have Medicare questions, you aren't alone.

This page answers the most common Medicare questions we hear every day. If you're still confused after reading this, give us a call. One of our licensed Medicare agents will answer your questions in plain English. We speak Medicare so you don't have to.

Who is eligible for Medicare?

American citizens aged 65 or older are eligible for Medicare. You may also qualify if you meet at least one of the following conditions:

  • Collect disability benefits from either Social Security or the Railroad Retirement Board for 24 months
  • Have amyotrophic lateral sclerosis (ALS), commonly known as Lou Gehrig's disease
  • Have End-Stage Renal Disease (ESRD)

You are only automatically enrolled in Medicare if you collect retirement benefits from either Social Security or the Railroad Retirement Board for at least four months before you turn 65. If you do, you should receive your red, white, and blue Medicare card in the mail three months before your birthday.

If you do not already receive retirement benefits, you need to apply for Medicare through Social Security. Your Initial Enrollment Period (IEP) lasts for seven months, beginning three months before the month you turn 65 and ending three months after. So, if your birthday is April 19, your IEP begins on January 1 and ends July 31.

Where do I begin if I'm new to Medicare?

In addition to working with a licensed Medicare broker, we recommend that everyone new to the program take some time to learn about the different parts of Medicare.

  • Medicare Part A: Often referred to as hospital insurance, Part A covers inpatient services received in a hospital, skilled nursing facility, nursing home, hospice care, and some home healthcare services. Most people receive premium-free Medicare Part A.
  • Medicare Part B: Also known as medical insurance, Part B covers outpatient services such as you receive in a doctor's office. It also covers some durable medical equipment and other supplies. Most people pay a monthly premium for Medicare Part B.
  • Original Medicare: Includes Parts A and B.
  • Medicare Part C: More commonly known as Medicare Advantage, Part C offers beneficiaries another way to receive their Medicare benefits. These plans more closely resemble the group health insurance many people received through an employer.
  • Medicare Part D: Also known as Medicare Prescription Drug Coverage. Your Part D plan helps pay for covered prescriptions. Most Part D plans have a formulary, or list of covered prescription medications.

Finally, there is Medicare Supplement Insurance, commonly known as Medigap. These plans help pay some of your out-of-pocket costs under Medicare and are offered by private insurers. While Medicare governs what each plan covers, it does not dictate price. That is determined by the insurance provider.

How do I sign up for Medicare?

You sign up for Medicare through Social Security. You have three options:

Unless you qualify for a Special Enrollment Period (SEP), you should sign up for Medicare as soon as you become eligible. This is known as your Initial Enrollment Period (IEP) and it begins three months before the month you turn 65 and continues for three months after your birth month (seven months total).

If you miss your IEP and do not qualify for an SEP, you may have to pay late enrollment penalties.

What do I need to consider when choosing a Medicare plan?

Medicare can be extremely confusing. There are so many options that some people feel overwhelmed. A Medicare broker can help you understand your options to determine the best choice for you. But here are a few ideas to help you get started.

First, how often do you travel? If you live the RV life or spend summers in one place and winters in another, you probably don't want a Medicare Advantage (MA) plan. That’s because MA plans typically only cover you for care received within the plan's network and service area. Original Medicare, however, has no such restrictions. You can visit any doctor in the U.S. who accepts Medicare.

If you opt for Part C instead of Original Medicare, you need to carefully review the plan's coverage and network. Many MA plans offer additional benefits (all must cover at least what Original Medicare covers). But, they may have certain restrictions, such as a provider network. Check to see whether your doctors are on the plan's network.

When comparing Medicare Part D plans, make sure the formulary includes your prescriptions. Also look at the list of preferred pharmacies (if there is one). Many Part D plans implement cost incentives to encourage members to use preferred pharmacies.

Finally, look at the full cost of the plan, not just its monthly premium. Medicare has great coverage but numerous out-of-pocket costs. The monthly premium does not tell the whole story. When comparing plan options, also consider co-pays, co-insurance, deductibles, and any other out-of-pocket costs.

What is the Medicare donut hole?

Also known as the Medicare coverage gap. You enter the donut hole when you and your Part D plan spend a combined total of $4,660 (in 2023; the amount changes yearly). While in the coverage gap, you pay 25 percent of the cost of both brand name and generic prescription drugs.

If your out-of-pocket spending hits a predetermined threshold ($7,400 in 2023), you enter catastrophic coverage. At this point, you have only a small co-insurance or co-payment for covered prescriptions for the rest of the year.

Learn more:Medicare Donut Hole: What to Know

When is the Medicare Annual Enrollment Period?

Medicare Annual Enrollment occurs every year from October 15 through December 7. This is when current Medicare enrollees can make changes to their coverage. You may sign up for a Medicare Advantage (MA) plan, leave your MA plan to return to Original Medicare, or sign up for a Part D plan.

Learn more:When Is Medicare Annual Enrollment?

What is the Medicare Initial Enrollment Period?

The Initial Enrollment Period (IEP) occurs when you first become eligible for Medicare. It lasts for seven months, beginning three months before the month you turn 65 and ending three months after.

If you turn 65 in April, your IEP begins January 1 and ends July 31.

Learn more:Do I Automatically Get Medicare When I Turn 65?

What are Special Enrollment Periods?

You may qualify for a Special Enrollment Period (SEP) if you delay Medicare enrollment and meet certain guidelines.

SEPs let you make changes outside of the standard enrollment periods, assuming you qualify. Qualifying life events include:

  • Changes to where you live
  • Losing your current coverage
  • Having the chance to enroll in a new plan
  • Your current plan's Medicare contract changes
  • Becoming eligible for both Medicare and Medicaid
  • Qualifying for Extra Help

There are literally dozens of ways to qualify for an SEP. See for the full list.

What is the late enrollment penalty?

If you fail to enroll in Medicare Part A, B, or D when you become eligible AND you do not qualify for a Special Enrollment Period (SEP), you may have to pay a late enrollment penalty. This amount varies according to which part and how long you waited.

The Part A late enrollment penalty

Most people do not have a monthly premium for Part A. However, if you do have a premium, the late enrollment penalty for Part A is 10 percent of the monthly premium for every full 12-month period you delayed enrollment AND did not qualify for an SEP.

A full 12 months must pass before you owe a late penalty. You pay this penalty for twice the number of years you could have enrolled in Part A but did not. So, 12 months equals 2 years of late penalties, 24 months equals 4 years, and so on.

The Part B late enrollment penalty

The late enrollment penalty for Part B is 10 percent of the monthly premium for every full 12-month period you delayed enrollment AND did not qualify for an SEP. So, if you became eligible in January and enrolled in December, you would not have a penalty. However, if you became eligible in January and did not enroll until the following January AND you do not qualify for an SEP, you pay an extra 10 percent on top of your regular Part B premium.

If you go 24 months without enrolling, the penalty is 20 percent. It's 30 percent for 36 months, and so on. You pay this penalty for the rest of the time you have Medicare.

The Part D late enrollment penalty

The late enrollment penalty for Part D is based on the national base beneficiary premium, 1 percent for every month you delay enrollment without qualifying for an SEP. So, it's 1 percent for 1 month, 2 percent for 2 months, and so on. You pay this penalty for the entire time you have Medicare Part D.

What is the difference between Medicare and Medicaid?

Medicare is a federal entitlement program that provides healthcare coverage for American citizens aged 65 and older. In addition, citizens with certain medical issues or disabilities may also qualify. There is no income requirement for Medicare.

Medicaid is a state-level program that provides medical coverage to those who meet certain financial requirements. These vary by state but most are based on the national poverty level. In addition, most states restrict eligibility to those who meet specific resource limits.

Learn more:How State-Run Medicaid Differs from Medicare

What types of health plans does Medicare offer?

Medicare health plans are offered by private insurance companies that contract with Medicare to provide benefits. Plan options vary according to state and insurance provider. They may include:

  • Medicare Advantage Plans
  • Demonstrations or Pilot Programs (also known as research studies)
  • Medicare Cost Plans
  • Programs of All-Inclusive Care for the Elderly (also known as PACE)
  • Medicare Medical Savings Account Plans
  • Medication Therapy Management Programs

Learn more:Types of Medicare Advantage Plans

When can I disenroll from a Medicare Advantage plan?

You have two options for disenrolling from a Medicare Advantage plan. The first is during the Annual Enrollment Period, which allows you to make a variety of changes to your Medicare options. Annual Enrollment occurs every year from October 15 through December 7.

You may also disenroll during the Medicare Advantage Open Enrollment Period. From January 1 through March 31, you may enroll in a new plan or return to Original Medicare.

Learn more:The Medicare Disenrollment Period

Should I consider a Medicare Part D Prescription Drug plan?

In a word, yes. Medicare requires beneficiaries to have prescription drug coverage. If you do not have "creditable" coverage, i.e. equal to or better than Medicare's coverage, and delay enrolling in a Part D plan, you'll most likely have to pay a penalty for the entire time you have a Medicare Part D plan.

Learn moreWhat Medicare Part D Drug Plans Offer

Does Medicare pay for preventive care?

Yes, Medicare covers a variety of preventive care services, starting with the Welcome to Medicare exam and Annual Wellness checkup. Medicare also covers some immunizations, such as flu and pneumococcal shots, as well as a variety of screenings, including mammograms, prostate exams, and Pap tests.

Learn moreDoes Medicare Cover Preventive Care, Screenings, and Services?

What is Medicare Advantage?

Also known as Part C, Medicare Advantage is an alternative to Original Medicare (Parts A and B). Plans must offer the same benefits as Original Medicare, but most cover additional services as well. Most provider prescription drug coverage and many include benefits like vision and dental. You still have to pay your Part B premium, even if the Medicare Advantage plan has a premium.

Learn more:What Is Medicare Advantage: Understanding Medicare Part C

What is Medicare Supplement Insurance?

Commonly referred to as Medigap, Medicare Supplement Insurance helps pay some of the costs not covered under Original Medicare (Parts A and B). Private insurance companies offer the plans and set their own prices, but plan benefits are the same from provider to provider.

Learn more:Medigap: The Ultimate Guide

Additional resources

After retiring from a career as an executive travel counselor in 2006, Donna Frederick embarked on a second career as a licensed insurance agent. During that first year, many clients told Donna how overwhelmed they felt by Medicare, but that her assistance helped them finally understand the Medicare program. That experience inspired Donna to focus her efforts on educating her clients to ensure they fully understand their Medicare options. Today, Donna takes pride in providing outstanding customer service and going the extra mile to make sure each client knows all of their options and has a sound understanding of their Medicare plan, from costs to coverage and all points in between.


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