Medicare FAQ

Have quick questions about Medicare? This FAQ covers the basics—Parts A, B, C, and D, eligibility, enrollment periods, costs, and why most people need extra coverage beyond Original Medicare.

Have quick questions about Medicare? This FAQ covers how Medicare works today, who is eligible, when to enroll, and why most people add extra coverage beyond Original Medicare.wikipedia+1

What is Medicare?

Medicare is a federal health insurance program for people 65 and older, certain individuals under 65 with disabilities, and people with End‑Stage Renal Disease. It is made up of different parts that cover hospital care, medical services, and prescription drugs.

What are the parts of Medicare?

Part A helps cover inpatient hospital stays, skilled nursing facility care, hospice, and some home health care.
Part B helps cover doctor visits, outpatient care, preventive services, and medical equipment.
Part C (Medicare Advantage) bundles Part A and Part B, and often Part D, into one private plan.
Part D helps cover outpatient prescription drugs through private plans approved by Medicare.

Original Medicare is Parts A and B. Most people then add other coverage to help control out‑of‑pocket costs.

What is Original Medicare?

Original Medicare is the combination of Part A and Part B provided directly by the federal government. You can see any doctor or hospital that accepts Medicare in the United States, with no network restrictions.

However, Original Medicare has no out‑of‑pocket maximum, so there is no built‑in cap on what you might spend in a year if you have major health needs. That is why many people add a Medicare Supplement, a Medicare Advantage plan, and/or Part D prescription coverage.

What is a Medicare Supplement (Medigap)?

Medicare Supplement (Medigap) plans are policies from private insurance companies that help pay some of the costs that Original Medicare does not cover, such as deductibles, copayments, and coinsurance. They work with Parts A and B and usually let you see any provider that accepts Medicare.

If you choose a Medigap plan, you generally add a standalone Part D prescription drug plan as well. This combination can give you more predictable out‑of‑pocket costs.

What is Medicare Advantage (Part C)?

Medicare Advantage plans are offered by private insurance companies approved by Medicare. These plans combine Part A and Part B in one plan, and many also include Part D and extra benefits like dental, vision, or hearing coverage.

With Medicare Advantage, you typically use a network of doctors and hospitals, and you pay copays or coinsurance as you go. Each plan has its own rules, premiums, and maximum out‑of‑pocket limit.

What is Medicare Part D?

Medicare Part D is prescription drug coverage offered through private plans that contract with Medicare. You can get Part D as a standalone plan (if you have Original Medicare and/or a Medigap policy) or as part of a Medicare Advantage plan that includes drug coverage.

Part D is important because Original Medicare does not cover most outpatient prescription drugs. Your specific medications and preferred pharmacy will strongly influence which Part D plan is right for you.

How does Medicare Part D work now?

Medicare Part D uses a three‑stage structure each calendar year:

Deductible phase – You pay up to your plan’s annual deductible, if your plan has one for your medications.
Initial coverage phase – After the deductible, you pay copays or coinsurance for covered drugs until your total out‑of‑pocket spending reaches the annual limit.
Catastrophic phase – Once you reach the yearly out‑of‑pocket cap, you pay 0 dollars for covered Part D drugs for the rest of that year.

The older “donut hole” terminology is no longer used because the benefit has been redesigned around this clear out‑of‑pocket limit.

Do I have to enroll in Medicare at 65?

Many people make their Medicare decisions at 65, but whether you must enroll depends on your situation:

If you are already receiving Social Security, you are usually enrolled in Parts A and B automatically around age 65.
If you are still working and have employer group coverage, you may be able to delay Part B without penalty if your coverage is considered creditable.[en.wikipedia]
If you are not working and do not have group coverage, you generally need to sign up during your Initial Enrollment Period to avoid late penalties.healthinsurance+1

What is the Medicare Initial Enrollment Period?

Your Initial Enrollment Period (IEP) is a 7‑month window that includes the three months before the month you turn 65, your birthday month, and the three months after. During this time, you can enroll in Parts A and B, and you can also choose your Medicare Supplement, Medicare Advantage, and Part D coverage.

What if I am still working at 65?

If you or your spouse are still working and covered by an employer group health plan, your choices depend on the size and quality of that coverage:

With large employer coverage (20 or more employees), you may be able to delay Part B and Part D without penalties.
With small employer coverage or more limited benefits, enrolling in Medicare at 65 may provide better protection.

It often makes sense to review both your employer plan and your Medicare options before deciding.

What if my spouse is younger and not yet 65?

When you move to Medicare at 65, a younger spouse may lose access to your employer group plan. They may need individual coverage, such as an Affordable Care Act marketplace plan, until they reach Medicare eligibility at 65. It is important to coordinate both of your timelines so neither of you has a gap in coverage.

What are the main gaps in Original Medicare?

Original Medicare does not cover everything. Key gaps include:

Hospital deductibles and daily coinsurance after certain lengths of stay.
Generally 20% coinsurance for most outpatient services with no out‑of‑pocket maximum.
No coverage for most routine dental, vision, or hearing services.
No coverage for most long‑term custodial care.

That is why many people add a Medicare Supplement or Medicare Advantage plan, plus Part D drug coverage, and sometimes extra policies for dental, vision, hearing, or critical illness.

How can an agent help with my Medicare choices?

A licensed Medicare agent can help you:

Understand what Original Medicare covers and does not cover.
Compare Medicare Supplement and Medicare Advantage options in your area.
Review your prescriptions and pharmacies to find Part D plans that fit your situation.
Coordinate coverage with a working spouse or a transition off employer group insurance.

Working with an independent agent does not increase your premiums, but it can make your decisions easier and help you avoid costly mistakes.