What Is Medicare?
Medicare is federal health insurance for people who qualify.
Generally that means people age 65 or older. Some people qualify earlier because of certain disabilities, End-Stage Renal Disease (ESRD), or ALS.
Part D is optional, separate prescription drug coverage you may choose to add. It is not automatically included with Original Medicare enrollment.
Turning 65: When Do I Enroll?
Your Initial Enrollment Period is generally a 7-month window.
Some people are enrolled automatically. Others need to take action through Social Security. Knowing which one you are is the first thing to find out.
Working Past 65, or Have Other Coverage?
Your current coverage can change what you should do when you become eligible.
Active employer coverage
Don't automatically enroll in — or delay — Part B. Find out how your employer coverage coordinates with Medicare, and whether Medicare would be primary or secondary.
Health Savings Account (HSA)
Once enrolled in Medicare you can no longer contribute to an HSA. If you delay Medicare past 65, check your HSA timing before applying for Medicare or Social Security.
ACA / Marketplace coverage
Turning 65? Watch for a Marketplace notice and don't ignore it. Medicare enrollment is not automatic for everyone. If you are not automatically enrolled, you may need to apply through Social Security during your Initial Enrollment Period.
COBRA / retiree coverage
Don't assume COBRA or retiree coverage works the same as active-employer coverage for delaying Medicare. Check how your coverage coordinates with Medicare before making an enrollment decision.
Late Enrollment & IRMAA
Waiting to enroll, or having higher income, can affect what you pay.
Part B
A late enrollment penalty may apply if Part B is delayed without a qualifying Special Enrollment Period.
Part D
A late enrollment penalty may apply after 63 or more consecutive days without Part D or other creditable drug coverage.
IRMAA — Income-Related Monthly Adjustment Amount
Some higher-income beneficiaries pay an additional amount for Part B and Part D.
Dollar amounts change every year, so they're kept on a separate current-year reference sheet rather than here.
Do It Yourself, or Work With a Licensed Agent
Both are real options. Here's what each one involves.
Do it yourself
- Learn the Medicare rules
- Check doctors and hospitals
- Review prescriptions
- Compare available coverage
- Complete enrollment yourself
Work with a licensed agent
- Learn how the pieces work
- Review doctors and prescriptions
- Compare available options
- Get help with enrollment
- Have a resource for future questions
A + B: Are We Done Yet?
Original Medicare has important gaps worth understanding.
Cost sharing
Part B generally has 20% coinsurance after the deductible. Original Medicare has no annual stop loss — no out-of-pocket maximum.
Drug coverage
Original Medicare does not automatically include Part D drug coverage.
Other needs
Dental, routine vision, hearing and other needs are not automatically filled by Original Medicare.
Option 1: Original Medicare
Keep Original Medicare and add the pieces that fit your needs.
Medicare Supplement (Medigap)
Medigap can help with some of the cost sharing left by Original Medicare. It works with Original Medicare — not with Medicare Advantage.
F, G and N are examples of standardized Medigap plan letters used in most states.
Dental · Vision · Hearing
If wanted, these may be separate coverage pieces under the Original Medicare path.
Option 2: Medicare Advantage
Medicare Advantage is another way to receive your Medicare Part A and Part B benefits through a Medicare-approved private plan.
Most Medicare Advantage plans include Part D. Dental, vision, hearing and other additional benefits vary by plan.
What changes
- The plan has its own network and rules
- Copays or coinsurance may apply as services are used
- Plans have an annual maximum out-of-pocket for covered Part A and Part B services
Option 1 vs. Option 2: Cost & Access
The two paths differ in cost, provider access, networks and how coverage is structured.
Option 1 · Original Medicare path
Potential premium pieces: Part B, Part D, Medicare Supplement, and dental/vision/hearing.
Original Medicare itself has no annual stop loss.
Travel flexibility and broad provider access — generally any doctor or hospital that accepts Medicare.
Option 2 · Medicare Advantage
Part B premium remains. Some plans may also charge a plan premium.
A + B benefits are delivered through the plan; most include Part D and may include extra benefits.
Uses a provider network and plan rules. Copays and coinsurance may apply.
Can feel similar to employer group coverage for people used to networks and copays.
Now You Know the Pieces. How Do They Fit You?
Your doctors, prescriptions, healthcare needs, travel and budget determine the fit.
You now know what the pieces are. The real question is how those pieces fit you.
When Can Medicare Coverage Change?
Different enrollment periods apply to different situations.
AEP · October 15 – December 7
Review or change Medicare Advantage and Part D coverage for the following year.
MA OEP · January 1 – March 31
For people already enrolled in Medicare Advantage. Certain changes are allowed.
Special Enrollment Periods
Certain life events or coverage changes can create another opportunity to enroll or change coverage.
Medicare Is Not One-Size-Fits-All
The right fit depends on your individual needs and preferences.