Understanding Medicare

Medicare Eligibility

You're eligible for Medicare if you are:

Age 65 or older
Under 65 with qualifying disabilities
Any age with End-Stage Renal Disease (ESRD)
Any age with ALS (Lou Gehrig's disease)

Most people become eligible for Medicare when they turn 65. If you're already receiving Social Security benefits, you'll be automatically enrolled in Medicare Parts A and B. Otherwise, you'll need to sign up during your Initial Enrollment Period.

The Four Parts of Medicare

Medicare has four different parts that cover specific services:

Part A: Hospital Insurance (inpatient care)
Part B: Medical Insurance (outpatient care)
Part C: Medicare Advantage (alternative to A & B)
Part D: Prescription Drug Coverage

Parts A and B together are known as "Original Medicare." Parts C and D are offered by private insurance companies that follow rules set by Medicare.

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What's the difference between Original Medicare and Medicare Advantage?

Original Medicare vs. Medicare Advantage

You have two main choices for how to get your Medicare coverage:

Original Medicare (Parts A & B)

Run by the federal government
Can use any doctor or hospital that accepts Medicare
Usually pay a deductible and 20% of the Medicare-approved amount
Usually need to join a separate Part D plan for drug coverage
Can purchase supplemental coverage (Medigap) to help pay out-of-pocket costs

Medicare Advantage (Part C)

Run by private insurance companies approved by Medicare
Usually need to use doctors in the plan's network
May have lower out-of-pocket costs than Original Medicare
Usually includes Part D drug coverage
May offer extra benefits not covered by Original Medicare (vision, dental, hearing)
Cannot purchase Medigap policies

Important to Know

You must have both Part A and Part B to join a Medicare Advantage plan.

How do I choose the right Medicare coverage?

Choosing Your Medicare Coverage

Selecting the right Medicare coverage depends on your personal healthcare needs, budget, and preferences. Here are some factors to consider:

Step 1: Decide between Original Medicare and Medicare Advantage

Choose Original Medicare if you:

Want flexibility to see any doctor that accepts Medicare
Travel frequently within the U.S.
Don't mind paying for separate drug coverage (Part D) and supplemental coverage (Medigap)
Have doctors you want to keep who don't participate in Medicare Advantage networks

Choose Medicare Advantage if you:

Prefer a single plan that combines hospital, medical, and usually drug coverage
Want extra benefits like vision, dental, and hearing coverage
Are comfortable with network restrictions
Want an annual limit on out-of-pocket costs

Step 2: If you choose Original Medicare, decide on supplemental coverage

Consider a Medigap policy to help pay your out-of-pocket costs
Enroll in a Part D plan for prescription drug coverage

Step 3: If you choose Medicare Advantage, compare plans in your area

Check if your doctors and hospitals are in the plan's network
Review the plan's drug formulary if you take prescription medications
Compare out-of-pocket costs, including premiums, deductibles, and copayments
Consider which extra benefits are important to you

Original Medicare (Parts A & B)

Original Medicare consists of Part A (Hospital Insurance) and Part B (Medical Insurance). Learn about coverage, costs, and how to enroll in Original Medicare.
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Part A: Hospital Insurance

Medicare Part A covers inpatient hospital care, skilled nursing facility care, hospice care, and some home health care services.
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Part A Coverage

Inpatient hospital care
Skilled nursing facility care
Nursing home care (not custodial or long-term care)
Hospice care
Home health care

Part A Costs for 2025

Part A Premiums

Most people don't pay a monthly premium for Part A if they or their spouse paid Medicare taxes for at least 10 years (40 quarters) while working.

If you don't qualify for premium-free Part A, you can buy it. In 2025, the Part A premium is:
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$278 per month if you paid Medicare taxes for 30-39 quarters
$505 per month if you paid Medicare taxes for fewer than 30 quarters

Part A Deductible and Coinsurance

Service

2025 Cost

Inpatient Hospital Deductible

$1,676 per benefit period

Hospital Coinsurance Days 1-60

$0 after deductible

Hospital Coinsurance Days 61-90

$419 per day

Hospital Coinsurance Days 91+ (lifetime reserve days)

$838 per day (up to 60 days over your lifetime)

Skilled Nursing Facility Days 1-20

Skilled Nursing Facility Days 21-100

$209.50 per day

Skilled Nursing Facility Days 101+

All costs

What is a Benefit Period?

A benefit period begins the day you're admitted to a hospital or skilled nursing facility and ends when you haven't received inpatient care for 60 consecutive days. You may have multiple benefit periods in a year, and you'll pay the deductible for each benefit period.

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Part B: Medical Insurance

Medicare Part B covers medically necessary services and preventive services, including doctor visits, outpatient care, medical supplies, and preventive services.

Part B Coverage

Doctor visits and services
Outpatient care
Preventive services
Laboratory tests
X-rays and imaging
Durable medical equipment
Mental health services
Ambulance services
Some prescription drugs

Part B Costs for 2025

Part B Premiums

The standard Part B premium for 2025 is $185.00 per month. However, if your modified adjusted gross income is above a certain amount, you may pay an Income-Related Monthly Adjustment Amount (IRMAA) in addition to your standard premium. See the IRMAA section for more details.

Part B Deductible and Coinsurance

Service

2025 Cost

Annual Deductible

$257

Coinsurance for most services

20% of Medicare-approved amount (after deductible)

Preventive services

$0 for many preventive services

Mental health services

20% of Medicare-approved amount

Clinical laboratory services

Medicare-Approved Amount

This is the amount that Medicare has approved for a particular service. It may be less than what your provider charges. Medicare pays part of this amount, and you're responsible for the rest.

What's NOT covered by Original Medicare?

Services Not Covered by Original Medicare

Original Medicare doesn't cover:
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Long-term care (also called custodial care)
Most dental care and dentures
Eye exams for prescription glasses
Hearing aids and exams for fitting them
Routine foot care
Acupuncture (except for chronic low back pain)
Cosmetic surgery
Massage therapy
Routine physical exams (beyond the "Welcome to Medicare" visit and annual wellness visits)
Care outside the U.S. (except in limited circumstances)

Coverage Options

Some Medicare Advantage plans cover services that Original Medicare doesn't cover, such as vision, hearing, and dental care. You can also purchase separate insurance policies for some of these services.

How to Enroll in Original Medicare

Enrolling in Original Medicare

Automatic Enrollment

You'll be automatically enrolled in Medicare Parts A and B if:

You're already receiving Social Security or Railroad Retirement Board benefits when you turn 65
You've been receiving Social Security Disability Insurance (SSDI) for 24 months
You have ALS (Lou Gehrig's disease)

If you're automatically enrolled, you'll receive your Medicare card in the mail 3 months before your 65th birthday or your 25th month of disability.

Manual Enrollment

You need to sign up for Medicare if:

You're not receiving Social Security or Railroad Retirement Board benefits
You qualify for Medicare due to End-Stage Renal Disease (ESRD)
You live in Puerto Rico and want Part B (you'll get Part A automatically)

How to Apply

You can apply for Medicare in the following ways:

Online: Visit www.ssa.gov/benefits/medicare/
By phone: Call Social Security at 1-800-772-1213 (TTY 1-800-325-0778)
In person: Visit your local Social Security office

Insider Tip

Original Medicare FAQs

Do I need to renew my Medicare coverage every year?

No, your Original Medicare coverage (Parts A and B) automatically renews each year as long as you continue to pay your Part B premium. You don't need to take any action to maintain your coverage.

Can I have Medicare and employer health insurance at the same time?

Yes, you can have both Medicare and employer health insurance. Which one pays first depends on the size of the employer and whether your Medicare eligibility is based on age or disability. For employers with 20 or more employees, the employer plan is primary and Medicare is secondary. For employers with fewer than 20 employees, Medicare is typically primary.

Does Medicare cover care when I travel outside the U.S.?

Original Medicare generally doesn't cover healthcare services outside the United States, except in very limited circumstances (such as emergency care in Canada when you're traveling directly between Alaska and another U.S. state). Some Medicare Supplement (Medigap) plans and Medicare Advantage plans offer coverage for emergency care received outside the U.S.

What's the difference between a deductible and coinsurance?

A deductible is the amount you must pay for covered healthcare services before Medicare begins to pay. Coinsurance is the percentage of costs you pay after you've met your deductible. For example, with Part B, you pay a $257 deductible in 2025, and then you typically pay 20% of the Medicare-approved amount for services.

Can I see any doctor with Original Medicare?

With Original Medicare, you can go to any doctor, hospital, or provider that accepts Medicare and is taking new Medicare patients. You don't need referrals to see specialists. This is different from many Medicare Advantage plans, which often have network restrictions and may require referrals.

Medicare Enrollment Periods

Understanding when you can enroll in Medicare is crucial to avoid late enrollment penalties and gaps in coverage. Learn about the different enrollment periods and when you should sign up.
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Initial Enrollment Period (IEP)

Your Initial Enrollment Period is a 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65.

Your 7-Month Initial Enrollment Period

3 months before your 65th birthday month

Your 65th birthday month

3 months after your 65th birthday month

Month 1
Month 2
Month 3

Month 4

Month 5
Month 6
Month 7

When Your Coverage Begins

When your Medicare coverage starts depends on when you sign up during your Initial Enrollment Period:

If you sign up during the first 3 months of your IEP, your coverage starts the first day of the month you turn 65 (or the first day of the prior month if your birthday is on the 1st of the month).

If you sign up during the month you turn 65, your coverage starts the first day of the following month.

If you sign up during the last 3 months of your IEP, your coverage start date will be delayed:
Sign up in month 5: Coverage begins 2 months after enrollment
Sign up in month 6: Coverage begins 3 months after enrollment
Sign up in month 7: Coverage begins 3 months after enrollment

General Enrollment Period (GEP)

If you miss your Initial Enrollment Period, you can sign up for Medicare Part A and/or Part B during the General Enrollment Period, which runs from January 1 to March 31 each year.

When Your Coverage Begins

If you sign up during the General Enrollment Period, your coverage will start on the first day of the month after you sign up.

Late Enrollment Penalties

If you don't sign up for Part B when you're first eligible, you may have to pay a late enrollment penalty for as long as you have Part B. The penalty increases the longer you wait to enroll.

For 2025, the Part B late enrollment penalty is an extra 10% of the standard premium for each full 12-month period you could have had Part B but didn't sign up. This means your monthly premium could be 10%, 20%, 30% or more higher, depending on how long you delayed enrollment.

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Insider Tip

Even if you're automatically enrolled in Parts A and B, you can decline Part B if you have other health insurance (such as through an employer). However, if you don't sign up for Part B when you're first eligibleTo avoid gaps in coverage, it's best to sign up during the first 3 months of your Initial Enrollment Period. This ensures your coverage begins the month you turn 65. and don't have other qualifying coverage, you may have to pay a late enrollment penalty if you enroll later.

Enrolling After Losing Job-Based Coverage (Special Enrollment Period)

Losing job-based health coverage (from your or your spouse's current job) usually gives you an 8-month Special Enrollment Period (SEP) to sign up for Medicare Part A and/or Part B without late penalties.

Step 1: Check if You Qualify

You likely qualify if:

You had group health coverage via current employment (yours or spouse's).
That employment or coverage ended within the last 8 months.

Tip: Enroll before your old coverage ends to avoid gaps.

Step 2: Get Forms Ready

You need two forms for the Social Security Administration (SSA):

Form CMS-40B (Application for Part B): Your application. Download here.
Key parts: Personal info, check "YES" for Part B (Q6), employment dates (Q7c), state SEP reason & desired start date in Remarks (Q9), sign & date (Q10/11).
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Form CMS-L564 (Request for Employment Info): Proof of previous coverage. Download here.
You fill Section A; your employer fills Section B (coverage/employment dates).

Note: Submit BOTH forms together. If employer won't complete L564, submit it with Section A done and add other proof (pay stubs, W-2s showing deductions) & explain in CMS-40B Remarks.

Step 3: Submit Forms to SSA

Submit CMS-40B & CMS-L564 within your 8-month SEP:

Online (Recommended): Via SSA website (Medicare Benefits or SEP FAQ). Upload completed L564.
Mail/Fax: To your local SSA office (find here). Keep copies.
In-Person: At local SSA office (appointment recommended).

Coverage Start: Enroll in 1st month of SEP = coverage starts 1st of that month. Enroll later = coverage starts 1st of month *after* enrollment.

Warning: COBRA doesn't extend this SEP or prevent Part B penalties.

Step 4: Explore Plan Options

Once enrolled in Part A & B (Original Medicare), choose how to get full coverage:

Original Medicare + Add-ons: Add Part D (drugs) &/or Medigap (helps pay costs).
Medicare Advantage (Part C): Bundled plan (A, B, often D) from private insurers. May have networks (HMO/PPO) & extra benefits.

Need help comparing plans? Contact Dr. Ed's Trusted Partner, Chapter Medicare:

Phone: (352) 841-0632

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SEP Length?

8 months after job/coverage ends.

Part B Start Date?

1st of enrollment month if you enroll in month 1; 1st of month *after* enrollment if you enroll months 2-8.

Employer Won't Fill L564?

Submit with Section A done + secondary proof (pay stubs etc.) & explain on CMS-40B.

COBRA & SEP?

No, COBRA doesn't count as current employer coverage for this SEP.

Need Both Forms?

Yes, submit CMS-40B and CMS-L564 together.

Avoid Part D Penalty?

Enroll in Part D within 63 days of losing creditable drug coverage.

Apply Online?

Yes, recommended via SSA website.

Medicare Advantage and Part D Enrollment Periods

Initial Enrollment Period for Part D

Your Initial Enrollment Period for Medicare Part D (prescription drug coverage) is the same 7-month period as your Initial Enrollment Period for Parts A and B.
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Part D Late Enrollment Penalty

If you don't sign up for Part D when you're first eligible and you don't have other creditable prescription drug coverage, you may have to pay a late enrollment penalty if you join later. The penalty is calculated based on the number of months you went without creditable coverage and is added to your monthly premium for as long as you have Part D.

Annual Enrollment Period (October 15 - December 7)

During this period each year, you can:

Switch from Original Medicare to a Medicare Advantage plan
Switch from a Medicare Advantage plan to Original Medicare
Switch from one Medicare Advantage plan to another
Join, switch, or drop a Medicare Part D plan

Changes made during this period take effect on January 1 of the following year.

Medicare Advantage Open Enrollment Period (January 1 - March 31)

During this period, if you're enrolled in a Medicare Advantage plan, you can:

Switch to a different Medicare Advantage plan
Drop your Medicare Advantage plan and return to Original Medicare
Sign up for a Medicare Part D plan if you return to Original Medicare

During this period, if you're enrolled in a Medicare Advantage plan, you can:

Medicare Enrollment FAQs

I'm still working and have employer coverage. Do I need to sign up for Medicare at 65?

It depends on the size of your employer. If your employer has 20 or more employees, you can usually delay enrolling in Medicare without penalty as long as you're covered by the employer plan. You'll qualify for a Special Enrollment Period when you retire or lose that coverage.

If your employer has fewer than 20 employees, Medicare generally becomes your primary insurance at age 65, and you should enroll during your Initial Enrollment Period to avoid gaps in coverage and late enrollment penalties.

Many people enroll in Part A at 65 regardless of their employment status because it's premium-free for most people. However, if you contribute to a Health Savings Account (HSA), be aware that enrolling in any part of Medicare will make you ineligible for continued HSA contributions.

What happens if I miss my Initial Enrollment Period?

If you miss your Initial Enrollment Period and don't qualify for a Special Enrollment Period, you'll have to wait until the General Enrollment Period (January 1 - March 31) to sign up. Your coverage will start the month after you enroll

.You may face late enrollment penalties for Part B and Part D, and you'll have a gap in coverage until your benefits begin. The Part B penalty is an extra 10% of the standard premium for each full 12-month period you could have had Part B but didn't sign up, and you'll pay this penalty for as long as you have Part B.

I have COBRA after retiring. Does this affect my Medicare enrollment?

Yes. COBRA coverage doesn't count as current employer coverage for Medicare enrollment purposes. If you're eligible for Medicare and take COBRA, you should still enroll in Medicare during your Initial Enrollment Period to avoid late enrollment penalties.

Once you enroll in Medicare, your COBRA might end or might continue as secondary coverage, depending on the specific terms of your COBRA plan. Check with your COBRA administrator for details.

Can I change my Medicare coverage options every year?

Yes, you can make changes to your Medicare coverage during the Annual Enrollment Period (October 15 - December 7) each year. During this time, you can switch between Original Medicare and Medicare Advantage, change Medicare Advantage plans, or join, switch, or drop a Medicare Part D plan.

If you're enrolled in a Medicare Advantage plan, you also have an opportunity to make a change during the Medicare Advantage Open Enrollment Period (January 1 - March 31).

I'm under 65 and have a disability. When can I enroll in Medicare?

If you're under 65 and receive Social Security Disability Insurance (SSDI), you'll automatically be enrolled in Medicare after you've received SSDI benefits for 24 months. Your Medicare coverage will begin on the first day of the 25th month of your disability benefits.

Medicare Advantage (Part C)

Medicare Advantage plans are an alternative to Original Medicare offered by private insurance companies. Learn about the benefits, costs, and considerations for Medicare Advantage plans.

Compare Medicare Advantage Plans
with Dr. Ed's Trusted Partner, Chapter Medicare
Or, call: 352-841-0632

What is Medicare Advantage?

Medicare Advantage (Part C) plans are offered by private insurance companies approved by Medicare. These plans provide all your Part A and Part B coverage, and most include prescription drug coverage (Part D) as well.
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Key Features of Medicare Advantage Plans
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Combines Part A (hospital) and Part B (medical) coverage

Usually includes Part D (prescription drug) coverage

May offer extra benefits not covered by Original Medicare

Often has network restrictions (HMO or PPO)

Has an annual out-of-pocket maximum for covered services

May require referrals for specialists (HMO plans)

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Important to Know

When you join a Medicare Advantage plan, you're still in the Medicare program. You must continue to pay your Part B premium in addition to any premium the plan charges.

Extra Benefits

Many Medicare Advantage plans offer additional benefits not covered by Original Medicare, which can provide significant value depending on your healthcare needs.

Common Extra Benefits

Dental care (cleanings, fillings, dentures)

Vision care (eye exams, glasses, contacts)

Hearing services (hearing tests, hearing aids)

Fitness memberships (like SilverSneakers)

Transportation to medical appointments

Over-the-counter (OTC) allowances

Meal delivery after hospitalization

Telehealth services

Wellness programs

Insider Tip

Extra benefits vary widely between plans and may change from year to year. When comparing plans, focus on the benefits that matter most to you and verify the specific coverage details.

Types of Medicare Advantage Plans

Medicare Advantage Plan Types

Health Maintenance Organization (HMO) Plans
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Network: Must use doctors, hospitals, and providers in the plan's network (except for emergency care)
Primary Care Physician: Usually required
Referrals: Usually needed to see specialists
Prescription Drugs: Most HMO plans include drug coverage
Best for: People who prefer lower premiums and are comfortable with network restrictions and getting referrals

Preferred Provider Organization (PPO) Plans
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Network: Can see any doctor or specialist, but pay less when using in-network providers
Primary Care Physician: Not required
Referrals: Not needed for specialists
Prescription Drugs: Most PPO plans include drug coverage
Best for: People who want more flexibility to see specialists and out-of-network providers

Private Fee-for-Service (PFFS) Plans
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Network: Some have networks, others allow you to see any provider who accepts the plan's payment terms
Primary Care Physician: Not required
Referrals: Not needed for specialists
Prescription Drugs: Some PFFS plans include drug coverage
Best for: People who want flexibility but should verify provider acceptance before each visit

Special Needs Plans (SNPs)

Eligibility: Limited to people with specific diseases or characteristics
Types: D-SNP: For people eligible for both Medicare and Medicaid
C-SNP: For people with specific chronic conditions
I-SNP: For people living in institutions or requiring nursing care at home
Benefits: Tailored to the specific needs of the groups they serve
Prescription Drugs: All SNPs must include drug coverage
Best for: People with specific health conditions or circumstances who need coordinated care

Medicare Medical Savings Account (MSA) Plans

Structure: Combines a high-deductible Medicare Advantage plan with a medical savings account
Funding: Medicare deposits money into your account that you can use for healthcare costs
Prescription Drugs: Don't include drug coverage (must join a separate Part D plan)
Best for: People who are generally healthy and prefer to manage their own healthcare spending

How to Enroll in Medicare Advantage

Enrolling in Medicare Advantage

Eligibility Requirements
To join a Medicare Advantage plan, you must:

Have Medicare Part A and Part B
Live in the plan's service area
Not have End-Stage Renal Disease (ESRD) in most cases (this restriction has been removed as of 2021, but some plans may still have limitations)

When You Can Enroll

Initial Enrollment Period: When you first become eligible for Medicare
Annual Enrollment Period: October 15 - December 7 each year
Medicare Advantage Open Enrollment Period: January 1 - March 31 each year (if you're already in a Medicare Advantage plan)
Special Enrollment Period: If you qualify due to certain life events

Enrollment Tip

Before enrolling, check that your doctors, hospitals, and preferred pharmacies are in the plan's network. Also, review the plan's formulary to ensure your medications are covered.

Pros and Cons of Medicare Advantage

Advantages and Disadvantages of Medicare Advantage

Other Out-of-Pocket Costs

All-in-one coverage: Combines hospital, medical, and usually drug coverage in one plan
Extra benefits: Many plans include dental, vision, hearing, and fitness benefits
Cost savings: Often lower premiums than combining Original Medicare with separate Medigap and Part D plans
Out-of-pocket maximum: Limits your annual financial risk for covered services
Coordinated care: Many plans offer care coordination and disease management programs

Disadvantages

Network restrictions: May limit your choice of doctors and hospitals
Service area limitations: Coverage typically limited to specific geographic areas
Prior authorization: May require approval before certain services are covered
Referral requirements: Some plans require referrals to see specialists
Annual changes: Benefits, networks, and costs can change each year
Variable costs: While premiums may be lower, out-of-pocket costs can be unpredictable

Who Might Prefer Medicare Advantage?

Medicare Advantage plans may be a good fit if you:
Want the convenience of a single plan for all your Medicare coverage
Value extra benefits like dental, vision, and hearing coverage
Prefer lower monthly premiums and are comfortable with copayments when you receive services
Don't mind using network providers and following plan rules
Want an annual limit on your out-of-pocket medical expenses

Frequently Asked Questions about Medicare Advantage

Medicare Advantage FAQs

Can I have both Medicare Advantage and a Medigap policy?

No, you cannot use a Medigap policy to pay for Medicare Advantage costs. Medigap policies are designed to work with Original Medicare only. If you have a Medicare Advantage plan, you cannot purchase or use a Medigap policy.

What happens to my Medicare Advantage plan if I move?

If you move outside your Medicare Advantage plan's service area, you'll qualify for a Special Enrollment Period to switch to a new Medicare Advantage plan in your new location or return to Original Medicare. This Special Enrollment Period begins the month before your move and continues for two full months after your move.

Can I switch back to Original Medicare if I don't like my Medicare Advantage plan?

Yes, you can switch back to Original Medicare during the Annual Enrollment Period (October 15 - December 7) or during the Medicare Advantage Open Enrollment Period (January 1 - March 31) if you're already in a Medicare Advantage plan. If you switch back, you should consider enrolling in a Part D plan for prescription drug coverage. You may also want to apply for a Medigap policy, but be aware that after your initial Medigap enrollment period, you may be subject to medical underwriting and could be denied coverage or charged higher premiums based on your health status.

Do Medicare Advantage plans cover emergency care when traveling?

Yes, all Medicare Advantage plans must cover emergency and urgent care services in the United States. Many plans also offer emergency coverage when traveling abroad, though the specifics vary by plan. If you travel frequently, especially internationally, check with potential plans about their emergency coverage outside your service area.

How do Medicare Advantage plans determine which services to cover?

Medicare Advantage plans must cover all services that Original Medicare covers (except hospice care, which is still covered by Original Medicare). However, plans can set their own rules for how you get these services, such as requiring prior authorization or using network providers. Plans may also offer additional benefits beyond what Original Medicare covers. Each plan has a document called an "Evidence of Coverage" that details exactly what is covered and what you pay for each service.

Medicare Supplements (Medigap)

Medicare Supplement Insurance, commonly known as Medigap, is additional insurance you can purchase from private companies to help manage healthcare costs not covered by Original Medicare (Part A and Part B).

These plans are standardized across most states, labeled Plans A through N, each offering a different set of benefits. This standardization makes it easier to compare plans from different insurance companies. Medigap plans generally do not cover long-term care, vision or dental care, hearing aids, eyeglasses, or private-duty nursing. Some plans, however, do offer coverage for emergency medical care when traveling outside the United States.

Choosing the right Medigap plan depends on your individual healthcare needs, budget, and the specific coverage gaps you want to address.

Medicare Supplement (Medigap) Plans

Navigating the world of Medicare can feel like trying to solve a Rubik's Cube in the dark, can't it? Original Medicare (Part A and Part B) covers a lot of your healthcare costs, but it doesn't cover everything. That's where Medicare Supplement Insurance, often called Medigap, steps in. Think of Medigap as a trusty sidekick to your Original Medicare, helping to fill in those financial gaps like deductibles, coinsurance, and copayments.

These policies are sold by private insurance companies but are standardized by the federal government. This means that a Plan G from one company offers the exact same basic benefits as a Plan G from another company – the main difference will be the price and the company's customer service.

It's important to remember that Medigap policies only work with Original Medicare. You can't use a Medigap policy if you have a Medicare Advantage Plan (Part C). Also, Medigap policies generally don't cover long-term care, vision or dental care, hearing aids, eyeglasses, or private-duty nursing. For prescription drug coverage, you'll typically need to enroll in a separate Medicare Part D plan.

When can I get a When can I enroll in a Medigap plan?policy?

Ah, timing is everything, isn't it? Especially with Medigap! The absolute, without-a-doubt, best-time-ever to enroll in a Medigap policy is during your Medigap Open Enrollment Period. Think of this as your six-month golden ticket. This period starts on the first day of the month in which you are both 65 or older AND enrolled in Medicare Part B. It lasts for a full six months from that start date.

During these six months, federal law says that insurance companies cannot deny you Medigap coverage, and they cannot charge you a higher premium because of any pre-existing health conditions. That's right, they have to take you, warts and all, and give you the same price as a marathon-running yoga instructor of the same age. It's a one-time deal for most people, so you don't want to let this opportunity slip through your fingers!

Now, what if you missed that golden window, or you're not 65 yet but qualify for Medicare due to a disability? There are other situations, called guaranteed issue rights (or special enrollment periods), where you can also get a Medigap policy without the insurance company prying into your medical history. These can happen if you lose other types of coverage, like employer group health coverage, or if your Medicare Advantage plan changes its coverage or service area, or even if an insurance company hasn't played by the rules.

These situations are very specific, and you usually only have a limited time (often 63 days) to act. If you try to enroll outside your Open Enrollment Period or without a guaranteed issue right, insurance companies can, and often will, use medical underwriting. This means they'll ask you a bunch of health questions, may peek at your medical records, and can then decide to deny you coverage, charge you a much higher premium, or make you wait a period (up to six months) before they cover your pre-existing conditions.

How do Medigap plans differ from Medicare Advantage?

Medigap (Medicare Supplement Insurance) and Medicare Advantage (Part C) are fundamentally different ways to supplement or receive your Medicare benefits, and you cannot have both at the same time.

‍Medigap (Medicare Supplement):

Works With: Original Medicare (Part A and Part B).

Purpose: Helps pay some of the out-of-pocket costs that Original Medicare doesn't cover, like deductibles, coinsurance, and copayments.

Coverage: Covers costs for services approved by Original Medicare. It does not typically add extra benefits like routine vision, dental, or hearing aids (though some newer plans might offer minor additions).

Provider Choice: You can use any doctor or hospital in the U.S. that accepts Medicare. No network restrictions for Original Medicare services.

Referrals: Generally, no referrals are needed to see specialists.

Drug Coverage: Medigap plans sold after 2006 do not include prescription drug coverage. You need a separate Medicare Part D plan for drug coverage.

Cost Structure: You pay a monthly premium for the Medigap policy in addition to your Part B premium. Costs for services are then largely covered (depending on the plan) after meeting Original Medicare deductibles.

Medicare Advantage (Part C):

Works As: An alternative way to receive your Medicare benefits (Part A and Part B, and usually Part D) through a private insurance company approved by Medicare.

Purpose: Provides your Medicare Part A and Part B benefits, often includes Part D drug coverage, and may offer extra benefits.

Coverage: Must cover all services Original Medicare covers. Often includes additional benefits like routine dental, vision, hearing, and fitness programs. Coverage rules (like prior authorization) may differ from Original Medicare.

Provider Choice: Most plans have provider networks (like HMOs or PPOs). You typically need to use doctors and hospitals within the plan's network and service area, especially for non-emergency care, to get the lowest costs.

Referrals: Referrals to see specialists may be required, depending on the plan type (e.g., HMOs often require referrals).

Drug Coverage: Most Medicare Advantage plans include prescription drug coverage (MAPD plans).

Cost Structure: You continue to pay your monthly Part B premium, and may also pay an additional monthly premium to the Medicare Advantage plan (though many plans have a $0 premium). You'll typically have copayments or coinsurance for services within the plan's structure, up to an annual out-of-pocket maximum.

Key Distinction: Medigap supplements Original Medicare by covering cost gaps. Medicare Advantage replaces Original Medicare, providing benefits through a private plan with its own network and cost rules.

Can I change my current Medigap plan for another one?

You can apply to switch to a different Medigap policy at any time of the year. There's no specific annual election period for changing Medigap plans like there is for Medicare Advantage or Part D drug plans.

Here's the big "but" – and it's a sizable one: unless you have a guaranteed issue right, the insurance company you're applying to for the new Medigap policy can generally use medical underwriting. This means they can look at your health history and decide whether to accept your application, what premium to charge you (it could be higher if you have health issues), or whether to impose a waiting period for pre-existing conditions. So, while you can apply to change, there's no guarantee you'll be accepted or get the best rate, especially if your health has changed since you first got a Medigap policy.

There are a few exceptions or special situations. For instance, some states have what's called a "birthday rule," which might allow you to switch Medigap plans with guaranteed acceptance for a limited time around your birthday each year, though the plans you can switch to might be restricted.

Also, if you tried a Medicare Advantage plan for the first time and decided within 12 months it wasn't for you (this is called a "trial right"), you generally have a guaranteed right to go back to a Medigap policy. The key takeaway is that while changing is possible, doing it without medical underwriting is rare outside of specific protected situations. Always check the rules in your specific state and talk to a knowledgeable, unbiased source before making any changes! Like my partners at Chapter Medicare: 352-841-0632

‍Is there a comparison chart for ALL the Medigap plans?

Medigap Plan Comparison Chart

Why Dr. Ed often recommends Medigap Plan N

Choosing a Medigap plan is a very personal decision, like picking out a new pair of comfortable shoes; what fits one person perfectly might pinch another. But, if you're looking for a solid balance between comprehensive coverage and a more manageable monthly premium, Plan N often hits that sweet spot.

So, what’s the deal with Plan N? Think of it as getting most of the robust coverage you’d find in the more comprehensive plans, like Plan G, but with a couple of clever trade-offs that help keep those monthly payments a bit lighter on the wallet. Plan N covers your Part A hospital coinsurance and hospital costs for an extra 365 days after Medicare benefits are used up – that’s a biggie. It also takes care of your Part B coinsurance for most doctor services, your first three pints of blood if needed, and Part A hospice care coinsurance. Plus, it covers the Part A deductible and skilled nursing facility care coinsurance. That’s a hefty list of important coverages that can save you from some serious out-of-pocket shocks.

Now, here’s where Plan N asks for a little participation from you, and this is key to its lower premium. With Plan N, you’ll typically have a copayment of up to $20 for some office visits. And, if you find yourself in the emergency room, there can be a copayment of up to $50, though this ER copay is waived if you're admitted to the hospital as an inpatient. For many people, these predictable, relatively small copayments are a very acceptable trade-off for a lower monthly premium compared to, say, Plan G, which covers that Part B coinsurance at 100% without these copays (after the Part B deductible is met, of course).

One other important detail about Plan N is that it does not cover Part B excess charges. But don't let that term scare you off! An excess charge is an extra amount (up to 15% above the Medicare-approved amount) that some doctors who don’t accept Medicare assignment can legally charge you. The good news is that these excess charges are not super common. Many states actually prohibit doctors from billing for excess charges, and a vast majority of doctors nationwide do accept Medicare assignment, meaning they agree to take the Medicare-approved amount as full payment and can't hit you with an excess charge. So, while it's a gap in Plan N's coverage, for many people, it's a risk they're comfortable taking, especially given the premium savings. It’s always wise to check if your regular doctors accept Medicare assignment if you're considering Plan N.

So, why does Dr. Ed often give Plan N a thumbs up? It’s that smart balance. You get very strong coverage for the big, potentially bank-breaking hospital and medical expenses. The Part A deductible is covered, which is a significant benefit. The copays for doctor and ER visits are generally manageable and predictable. And in return for taking on those small copays and the (often minimal) risk of Part B excess charges, you usually get a noticeably lower monthly premium than you would with a plan like G. For folks who are relatively healthy, want robust protection against major medical costs, but are also mindful of their monthly budget, Plan N can be a fantastic fit. It’s like getting a really good car that’s reliable and safe, but maybe without every single luxury bell and whistle – it gets you where you need to go comfortably and affordably.

Of course, Plan N isn't for everyone. If the idea of any copayments, no matter how small, makes you uneasy, or if you live in an area where Part B excess charges are more common and you want zero exposure to them, then Plan G might be a better choice, despite its higher premium. But if you're looking for that sweet spot, that intelligent compromise between comprehensive coverage and cost-effectiveness, then I’d say Plan N definitely deserves a very close look. It’s a plan that empowers you to manage your healthcare costs wisely without sacrificing peace of mind for the really big stuff. And in my book, that’s a pretty smart move!

What is a High Deductible Medigap Plan?

I hear this one a lot! You see "high deductible" and your wallet might start to sweat a little, right? Well, let's demystify it. A high deductible Medigap plan, like the High Deductible Plan G or the (now less common for new folks) High Deductible Plan F, is a bit like having a financial moat around your healthcare costs. You agree to pay all of your Medicare-covered out-of-pocket expenses – things like your deductibles, copayments, and coinsurance – up to a certain, fairly hefty amount each year. For 2025, that deductible for Plans F and G is $2,940. Once you've bravely waded through that moat and paid that amount, then your Medigap plan jumps in and covers 100% of your Medicare-covered services for the rest of the year.

The upside? Because you're taking on more of the initial financial risk, the monthly premium for these high deductible plans is usually much lower than their standard counterparts. It can be a tempting way to save on those regular payments.

However, the downside is pretty clear: if you do need a fair bit of medical care, you'll be shelling out that full deductible amount before your Medigap coverage truly kicks in. It's a bit of a gamble – you're betting on your good health.

These plans can be a decent option for folks who are generally healthy, don't anticipate a lot of medical bills, and are comfortable with the idea of potentially paying that larger sum if a health surprise pops up. You need a bit of a financial cushion and a strong stomach for that initial out-of-pocket. If the thought of facing that full deductible gives you hives, it might not be your cup of tea, or in this case, your spoonful of medicine!

Medicare Part D (Prescription Drug Coverage)

Medicare Part D helps you pay for necessary prescription medications, covering both brand-name and generic drugs. This optional coverage is offered through private insurance companies approved by Medicare and is available to everyone enrolled in Medicare Part A or Part B. You can get Part D coverage either by joining a standalone Medicare Prescription Drug Plan (PDP) alongside Original Medicare or certain other Medicare plans, or by enrolling in a Medicare Advantage Plan (MA-PD) that includes drug benefits.

Key Changes and Features for 2025:

A significant change starting in 2025 is the $2,000 annual cap on out-of-pocket costs for covered Part D drugs. Once you reach this limit (which includes your deductible and copay/coinsurance payments), you will pay $0 for your covered prescriptions for the rest of the calendar year. The traditional "coverage gap" or "donut hole" has been eliminated.

Additionally, costs for covered insulin products remain capped at $35 per month's supply (deductible doesn't apply), and recommended vaccines covered under Part D are available at $0 cost-sharing.

Choosing the right Part D coverage involves comparing plans based on their monthly premiums, annual deductibles (maximum $590 in 2025), drug formularies (lists of covered drugs and their costs/tiers), pharmacy networks, and overall quality ratings. It's crucial to enroll during specific periods, like your Initial Enrollment Period when first eligible for Medicare, or the annual Open Enrollment Period (October 15 - December 7), to avoid a potential lifetime Late Enrollment Penalty if you don't maintain other creditable drug coverage.

Assistance programs like Extra Help (Low-Income Subsidy) are available to help eligible individuals with limited income and resources cover Part D costs. A new optional Medicare Prescription Payment Plan also allows beneficiaries to spread their out-of-pocket drug costs into monthly payments throughout the year.

How do Medicare Part D plans work?

Medicare Part D plans provide prescription drug coverage through private insurance companies approved by Medicare. While plans vary, they operate under rules set by Medicare and share some common features:
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Formulary: Each plan has a list of covered drugs, called a formulary. Formularies typically organize drugs into tiers (like generic, preferred brand, non-preferred brand, specialty), with lower tiers generally having lower costs. Plans must cover at least two drugs in most therapeutic categories, and all drugs in certain protected classes (like those used to treat cancer or HIV/AIDS).
Pharmacy Network: Plans contract with a network of pharmacies. Using an in-network pharmacy usually results in lower costs than using an out-of-network pharmacy (which may only be covered in limited circumstances).
Utilization Management: Plans use tools to manage costs and ensure appropriate medication use. These include:
‍Prior Authorization: You or your prescriber must get plan approval before a specific drug is covered.
‍Quantity Limits: Limits on how much medication you can get at one time.
‍Step Therapy: Requiring you to try a less expensive drug first before the plan covers a more expensive one.

Coverage Stages in 2025: Starting in 2025, the Part D benefit has a simpler structure with three main stages based on your out-of-pocket spending for the calendar year:
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Deductible Stage: If your plan has a deductible (up to $590 in 2025, though some plans have lower or $0 deductibles), you pay the full cost of your covered drugs until the deductible amount is met.
Initial Coverage Stage: After meeting the deductible (if any), you pay a copayment or coinsurance for each covered prescription, and the plan pays the rest. You remain in this stage until your total out-of-pocket spending on covered drugs reaches $2,000.
$0 Cost Stage (Post-Cap): Once your out-of-pocket spending on covered Part D drugs reaches $2,000 for the year, you will pay $0 (no copay or coinsurance) for all your covered Part D drugs for the remainder of the calendar year. The previous "coverage gap" or "donut hole" and "catastrophic coverage" stages have been eliminated and replaced by this $2,000 cap.

When can I enroll in a Medicare Part D plan?

It's important to enroll in Medicare Part D coverage during specific times to ensure coverage and avoid potential penalties. Here are the main enrollment periods:
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Initial Enrollment Period (IEP): This is your first chance to sign up when you become eligible for Medicare.
If eligible due to age (turning 65): It's a 7-month period starting 3 months before your 65th birthday month, including your birthday month, and ending 3 months after.

If eligible due to disability (under 65): It's a 7-month period around your 25th month of receiving Social Security or Railroad Retirement Board disability benefits (starting 3 months before, ending 3 months after the 25th month).

Coverage Start: Depends on when you enroll within your IEP. Enrolling before your eligibility month means coverage starts the month you become eligible. Enrolling during or after your eligibility month means coverage starts the following month.
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Open Enrollment Period (OEP): This happens every year from October 15 to December 7.
During OEP, anyone with Medicare can join, switch, or drop a Medicare Part D plan or a Medicare Advantage plan with drug coverage.

Changes made during OEP take effect on January 1 of the next year.

This is the primary time to review your current coverage and compare it with other available plans for the upcoming year.
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Special Enrollment Periods (SEPs): These allow you to make changes outside the standard enrollment periods due to specific life events. Common reasons for an SEP include:
Losing other creditable prescription drug coverage (like from an employer plan).
Moving to a new address that isn't in your current plan's service area.
Moving into or out of a long-term care facility (like a nursing home).
Qualifying for, or losing eligibility for, Extra Help (Low-Income Subsidy).
Your current plan changing its contract with Medicare.
Having the opportunity to switch to a plan with a 5-star overall quality rating (available once between December 8 and November 30).
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If you don't enroll in Part D or have other creditable drug coverage when you're first eligible, you might have to pay a Late Enrollment Penalty if you decide to join later.

What is the Part D late enrollment penalty? (2025)

The Medicare Part D late enrollment penalty (LEP) is an amount permanently added to your monthly Part D premium. You may have to pay this penalty if, after your Initial Enrollment Period ends, you go for 63 consecutive days or more without either Medicare Part D coverage or other creditable prescription drug coverage.

‍What is Creditable Coverage? Creditable coverage is drug coverage expected to pay, on average, at least as much as Medicare's standard Part D coverage. Common examples include coverage from an employer or union, TRICARE, VA benefits, or Indian Health Service. Your current plan provider should notify you annually if your coverage is creditable. Simple discount cards or pharmacy discount programs are not considered creditable coverage.

‍How is the Penalty Calculated? The penalty is calculated based on the number of full months you were eligible for Part D but didn't have it or other creditable coverage. The calculation is:

1% of the "national base beneficiary premium" for each full month you lacked coverage.

For 2025, the national base beneficiary premium is $36.78.
The result is rounded to the nearest $0.10 and added to your monthly Part D premium.

Example: If you went without creditable coverage for 20 months after your IEP ended, your penalty would be 20% (1% x 20) of $36.78, which is $7.356. Rounded to the nearest $0.10, your monthly penalty would be $7.40, added to your plan's premium.

‍How Long Do I Pay the Penalty? Unfortunately, the Part D late enrollment penalty is generally paid for as long as you have Medicare Part D coverage. It's a lifetime penalty.

‍How to Avoid the Penalty: * Enroll in a Medicare Part D plan or a Medicare Advantage plan with drug coverage during your Initial Enrollment Period, even if you don't take many prescriptions currently. * Ensure you don't have a gap of 63 days or more without Part D or other creditable drug coverage. * Keep records of any creditable coverage you've had.

‍Exception: If you qualify for the Extra Help (Low-Income Subsidy) program, you will not have to pay the Part D late enrollment penalty.

How do I choose the right Part D plan for my needs? (2025)

Choosing the right Medicare Part D plan is a personal decision based on your specific health needs, medications, budget, and preferred pharmacies. Since plans vary significantly, careful comparison is key. Here’s a guide to help you choose:
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List Your Prescriptions: Make a complete list of all prescription drugs you currently take, including dosages and frequency. This is crucial for checking if they are covered by the plans you consider.
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Identify Preferred Pharmacies: Note the pharmacies you prefer to use (e.g., local independent pharmacy, large chain, mail-order). Check if they are in the plan's network, as using in-network pharmacies usually offers lower costs.
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Use the Medicare Plan Finder Tool: This official tool on Medicare.gov is the most comprehensive way to compare plans available in your area.
Enter your zip code, medication list, and preferred pharmacies.
The tool will estimate your total annual costs (premiums + deductibles + copays/coinsurance) for each plan based on your specific drugs.
It allows you to directly compare plan formularies (which drugs are covered and at what tier/cost), premiums, deductibles, and pharmacy networks.
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Compare Key Plan Features:
Formulary: Does the plan cover all or most of your medications? Are your most important drugs on a lower, more affordable tier? Are there restrictions like prior authorization or step therapy for your drugs?

‍Costs: Compare the monthly premium, annual deductible, and the copays/coinsurance for your specific medications at your preferred pharmacies. Look at the estimated total annual cost provided by the Plan Finder.

‍Pharmacy Network: Are your preferred pharmacies in the plan's network? Does the plan offer preferred pharmacies with potentially lower cost-sharing? Does it offer a mail-order option if that interests you?

‍Star Ratings: Check the plan's overall quality Star Rating (1 to 5 stars). Higher ratings indicate better performance in areas like customer service, member experience, and handling of appeals.
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Consider Future Needs: Even if you don't take many drugs now, consider enrolling in a low-premium plan to secure coverage and avoid the late enrollment penalty. Your health needs can change.
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Review Annually: Plans can change their formularies, costs, and networks each year. Use the Open Enrollment Period (October 15 - December 7) to review your current plan and compare it with others to ensure it still meets your needs for the following year.

By using the Medicare Plan Finder and carefully comparing these factors, you can find a Part D plan that offers the coverage you need at a cost you can manage.

What assistance programs are available to help with Part D costs? (2025)

Several programs can help make Medicare Part D prescription drug coverage more affordable for individuals with limited income and resources:
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Extra Help (Low-Income Subsidy - LIS):
What it is: A Medicare program that helps pay for Part D costs, including monthly premiums, annual deductibles, and prescription copayments/coinsurance.
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Benefits: Significantly lowers drug costs. For 2025, eligible individuals generally pay $0 premium, $0 deductible, and reduced copays (up to $4.90 generic / $12.15 brand-name) until they reach the $2,000 OOP cap, after which they pay $0. It also eliminates the Part D late enrollment penalty for those who qualify.

Eligibility: Based on income and resource limits (which may change annually). For 2025, the limits are generally $23,475 income / $17,600 resources for an individual and $31,725 income / $35,130 resources for a married couple.

Qualification: Some people qualify automatically (if receiving full Medicaid, certain Medicare Savings Programs, or SSI). Others need to apply through the Social Security Administration (SSA.gov) or get help from their State Health Insurance Assistance Program (SHIP).
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Medicare Savings Programs (MSPs):
What they are: State-run programs that help pay Medicare costs (like Part A and Part B premiums, deductibles, coinsurance). While primarily focused on Parts A & B, qualifying for certain MSPs automatically qualifies you for Extra Help with Part D costs.

How to Apply: Contact your state Medicaid office.
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Medicaid:
What it is: A joint federal and state program providing health coverage to eligible low-income individuals. If you have full Medicaid coverage, you automatically qualify for Extra Help.

How to Apply: Contact your state Medicaid office.
State Pharmaceutical Assistance Programs (SPAPs):
What they are: Programs offered by some states to help residents pay for prescription drugs, potentially covering premiums or cost-sharing. Availability and eligibility vary by state.

How to Find: Contact your state SHIP or Department of Insurance/Aging.
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Pharmaceutical Assistance Programs (PAPs):
What they are: Programs offered directly by many drug manufacturers to provide free or low-cost medications to eligible individuals who cannot afford them. Eligibility criteria vary by manufacturer and drug.

How to Find: Ask your doctor or pharmacist, or search online for the specific drug manufacturer's patient assistance program.

If you think you might qualify for assistance, it's highly recommended to apply for Extra Help through the Social Security Administration, as this is the primary federal program for Part D cost assistance.

Income-Related Monthly Adjustment Amount (IRMAA)

If your modified adjusted gross income (MAGI) as reported on your IRS tax return from two years ago is above a certain amount, you may pay an Income-Related Monthly Adjustment Amount (IRMAA) in addition to your standard Medicare Part B and Part D premiums. This surcharge applies to higher-income beneficiaries. The Social Security Administration (SSA) determines if you owe IRMAA based on your income tax data and notifies you if an adjustment applies. For 2025, the determination is based on your 2023 tax return.

What is IRMAA and who has to pay it?

IRMAA stands for Income-Related Monthly Adjustment Amount. It is an additional amount that Medicare beneficiaries with higher incomes must pay on top of their standard monthly premiums for Medicare Part B (Medical Insurance) and Medicare Part D (Prescription Drug Coverage).

The Social Security Administration (SSA) determines if you owe IRMAA based on your Modified Adjusted Gross Income (MAGI) reported on your IRS tax return from two years prior. For example, your 2025 IRMAA is determined using your 2023 MAGI. MAGI includes your adjusted gross income plus certain deductions like tax-exempt interest.

You may have to pay IRMAA in 2025 if your 2023 MAGI was above:

$106,000 if you filed an individual tax return or are married filing separately.
$212,000 if you filed a joint tax return.

SSA will notify you directly if they determine you owe IRMAA. This adjustment applies whether you have Original Medicare or a Medicare Advantage plan.

What are the 2025 IRMAA income brackets and premium adjustments?

Your IRMAA is determined based on your Modified Adjusted Gross Income (MAGI) from two years prior (2023 MAGI for 2025 IRMAA) and your tax filing status. The standard Medicare Part B premium for 2025 is $185.00 per month. If your income is above the thresholds, you will pay the standard premium plus an IRMAA surcharge, as shown below.

2025 Medicare Part B IRMAA

Income $106k-$133k: +$74 (Part B), +$13.70 (Part D)
Income $133k-$167k: +$185 (Part B), +$35.30 (Part D)
Income $167k-$200k: +$295.90 (Part B), +$57 (Part D)
Income $200k-$500k: +$406.90 (Part B), +$78.60 (Part D)
Income $500k+: +$443.90 (Part B), +$85.80 (Part D)

(Amounts are added to the standard Part B premium of $185 and your Part D plan premium.)

How do I pay the IRMAA surcharge?

How you pay your IRMAA surcharge depends on whether it's for Part B or Part D.

‍Paying Part B IRMAA:

‍The Part B IRMAA surcharge is typically added directly to your monthly Medicare Part B premium bill. If you receive Social Security benefits, your total Part B premium (standard premium + IRMAA) is usually deducted automatically from your benefit payment. If you don't receive Social Security benefits, or if your benefit isn't large enough to cover the premium, you'll receive a bill from Medicare. You can pay this bill in several ways:
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Through your secure Medicare account online.
Using your bank's online bill payment service.
By signing up for Medicare Easy Pay, which automatically deducts the premium from your bank account each month.
By mailing a check, money order, or credit/debit card payment to Medicare.

Paying Part D IRMAA:

‍The Part D IRMAA surcharge is handled differently. You must pay the Part D IRMAA directly to Medicare, not to your Part D plan provider. You will receive a separate bill from Medicare specifically for the Part D IRMAA. This is true even if your regular Part D plan premium is paid by an employer, union, or deducted from your Social Security benefits. You can pay the Part D IRMAA bill using the same methods listed above for paying Part B premiums (Medicare account, bank bill pay, Easy Pay, mail).

‍Source: Medicare.gov, Humana

What if my income has changed since my tax return from two years ago?

Since your IRMAA is based on your income from two years prior, it might not reflect your current financial situation if your income has decreased significantly. You can ask the Social Security Administration (SSA) to reconsider your IRMAA determination if you have experienced a specific "life-changing event" that caused your income to go down.

‍Qualifying Life-Changing Events include:

Marriage
Divorce or annulment
Death of your spouse
Work stoppage (e.g., retirement)
Work reduction
Loss of income-producing property (due to disaster or event beyond your control)
Loss or termination of pension
Receipt of a settlement payment from an employer due to closure, bankruptcy, or reorganization.

How to Request Reconsideration:

‍If you believe your IRMAA should be lowered due to one of these events, you need to:

Complete Form SSA-44: Download and fill out the Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event form (SSA-44).
Provide Evidence: Gather proof of the life-changing event (e.g., death certificate, marriage certificate, letter from employer about retirement/work reduction, documentation of pension loss) and evidence of your income reduction (e.g., pay stubs, letter estimating future earnings).
Submit to SSA: Fax or mail the completed Form SSA-44 and your supporting documents to your local Social Security office. You can also call SSA at 1-800-772-1213 (TTY: 1-800-325-0778) for assistance or to discuss your situation.

What if I filed an amended tax return?

‍If SSA used outdated information because you filed an amended tax return for the relevant year (e.g., 2023 for 2025 IRMAA), you should contact SSA directly by phone to request they use the updated information.

Medicaid and Medicare

Some people qualify for both Medicare and Medicaid. Learn about the differences between these programs, how they work together, and what benefits are available to dual-eligible individuals.

Ready to Choose? Get Free Expert Medicare Guidance from Chapter Medicare

Speak to a Chapter Advisor: 352-841-0632

What is Medicaid?

Medicaid is a government program that helps people with low income pay for healthcare. Think of it like health insurance, but run by the government (both the federal government and your state government work together on it).

It helps millions of people in the U.S., including kids, pregnant women, older adults (seniors), and people with disabilities, get the medical care they need. It can cover things like doctor visits, hospital stays, and sometimes even help with long-term care at home or in a nursing home. Each state has its own Medicaid program with its own rules, but the goal is the same: to help people who can't afford healthcare get the services they need to stay healthy.

What is Medicaid and how is it different from Medicare?

What's the main difference?

The biggest difference is who they help:
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Medicaid is mainly for people with low income (not much money).

Medicare is mainly for people age 65 or older, or younger people with certain disabilities.

Some people might have low income and be over 65 or have a disability. These people might be able to get help from both Medicaid and Medicare at the same time. This is called being "dual eligible".

Coverage Differences:

Both cover basic things like doctor visits and hospital stays.
Medicaid often covers more things, especially long-term care like help at home or in a nursing home. Medicare usually only covers short-term nursing home stays or home health care after you've been in the hospital.
Medicare has different "parts" (like Part A for hospitals, Part B for doctors). You might have to pay some costs yourself, like monthly fees (premiums) or a share of the bill (deductibles and copays).
Medicaid usually has very low costs, or might even be free, depending on your income and your state's rules.

Who can get Medicaid?

Getting Medicaid depends on a few things, and the rules can be a little different in each state. But here are the main things they look at:
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How much money you make (Income): Medicaid is for people and families who don't have a lot of money. There are specific limits on how much you can earn each month or year. These limits change depending on your state and how many people are in your family.
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1. In states that expanded Medicaid, more adults can get it based just on having low income (usually if your income is below a certain level, like around $20,000-$21,000 a year for one person in 2025, but check your state's exact number).
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2. Even if your state didn't expand Medicaid, you might still qualify based on income if you fit into certain groups.
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Who you are: Medicaid helps specific groups of people, including:
1. Children
2. Pregnant women
3. Adults with low income (especially in expansion states)
4. People aged 65 or older (seniors)People with disabilities (blind, or having serious long-term health problems that make it hard to work or care for yourself).
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How much stuff you own (Assets): For some types of Medicaid (especially for seniors needing long-term care), they also look at how much money you have saved or things you own (like bank accounts, stocks). Usually, you can only have a small amount (like $2,000 for one person), but your house and car often don't count against you. Rules about assets vary a lot by state (California doesn't have an asset limit anymore!).
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Where you live: You have to live in the state where you apply for Medicaid.
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Citizenship: You usually need to be a U.S. citizen or have a specific, qualifying immigration status.

How do you know for sure?

‍The best way to know if you can get Medicaid is to apply. You can usually apply online through your state's Medicaid website or through the Health Insurance Marketplace (HealthCare.gov). They will look at your situation and tell you if you qualify.

What does Medicaid cover?

Medicaid helps pay for a lot of different medical services to keep you healthy. What exactly is covered can be a little different in each state, but there are some main services that all states must cover. There are also extra services that states can choose to cover.

Services ALL states MUST cover (Mandatory Benefits):

Doctor visits: Seeing a doctor when you're sick or for check-ups.
Hospital stays: Care you get when you have to stay in the hospital (inpatient).
Hospital visits (outpatient): Care you get at a hospital without staying overnight.
Lab tests and X-rays: Tests your doctor orders to figure out what's wrong.
Home health services: Care you might get in your own home, like from a nurse or therapist, if you need it.
Nursing home care: Care for people who need to live in a nursing facility because they need constant medical help.
Care for kids (EPSDT): Special check-ups and treatments for children under 21 to find and treat health problems early.
Family planning: Services like birth control and counseling.
Transportation to medical care: Help getting a ride to your doctor appointments or the hospital if you don't have a way to get there.

Services SOME states CHOOSE to cover (Optional Benefits):

Many states cover these extra services too:

Prescription drugs: Help paying for the medicines your doctor prescribes.
Dental care: Check-ups and treatment for your teeth.
Vision care: Eye exams and eyeglasses.
Physical therapy: Help getting stronger or moving better after an injury or illness.
Mental health care: Counseling and treatment for mental health conditions.
Help at home (Home and Community-Based Services): Help with daily tasks like bathing, dressing, or meals so you can stay in your own home instead of a nursing home.

How do you know what your state covers?

Because each state is different, the best way to know exactly what's covered is to check with your state's Medicaid office. They can give you a list of all the services included in your state's plan.

How do I apply for Medicaid?

Applying for Medicaid is usually straightforward, and you can do it anytime during the year (there's no specific enrollment period like with some other insurance).

Here are the common ways to apply:

Online through the Health Insurance Marketplace: You can go to HealthCare.gov, create an account, and fill out an application. The application asks questions about your income and family. If it looks like you or someone in your family might qualify for Medicaid, the Marketplace will automatically send your information to your state's Medicaid office. Your state office will then contact you to finish the process.
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Directly with your state's Medicaid agency: Every state has a Medicaid office. You can usually apply directly through their website. You can also often apply:
1. By phone: Call your state's Medicaid helpline.
2. By mail: Print out an application form, fill it out, and mail it in.
3. In person: Visit your local Medicaid office or sometimes other local government offices (like the Department of Social Services).

What information will I need?

‍When you apply, they will likely ask for information like:

Your name, date of birth, and Social Security number.
Proof of how much money you make (like pay stubs or tax forms).
Information about people in your household.
Proof that you live in the state.
Proof of your citizenship or immigration status.

Your state might ask for other things too. It's a good idea to check your state's Medicaid website to see exactly what you'll need before you start.

‍How long does it take?

‍After you apply, it can take some time for the state to review your application and decide if you qualify. It might take up to 45 days, or longer if they need more information or if you're applying based on a disability.

What if I have both Medicare and Medicaid? (Dual Eligibility)

Some people qualify for both Medicare and Medicaid at the same time. This is called being "dual eligible."

‍Who might be dual eligible?
‍Usually, people who are dual eligible are:
‍

Age 65 or older, OR have a qualifying disability, AND
Have low income and limited savings/assets that meet their state's Medicaid rules.

How does it work if I have both?
‍If you have both Medicare and Medicaid, they work together to cover your healthcare costs:

Medicare pays first: For services that are covered by both programs (like doctor visits or hospital stays), Medicare will pay its share first.
Medicaid pays second: Medicaid might then pay for costs that Medicare doesn't cover, like your Medicare deductibles, coinsurance, and copayments. Medicaid might also cover services that Medicare doesn't cover at all, like long-term care at home or in a nursing home, dental care, or eyeglasses (depending on your state's Medicaid rules).

What are the benefits of being dual eligible?
‍Having both programs usually means you have very low or no out-of-pocket costs for healthcare. Medicaid can help pay for your Medicare premiums (monthly fees) and other cost-sharing. It also gives you access to a wider range of services than Medicare alone might offer, especially long-term care.

‍Medicare Savings Programs:
‍Even if you don't qualify for full Medicaid benefits, you might still qualify for a Medicare Savings Program (MSP). These are run by Medicaid and help pay for your Medicare costs (like premiums, deductibles, and copayments). See the next section for more details on MSPs.

How do Medicare Savings Programs work with Medicaid?

Even if your income or assets are slightly too high for full Medicaid, you might still get help paying for your Medicare costs through a Medicare Savings Program (MSP).

‍What are Medicare Savings Programs?
‍MSPs are programs run by your state's Medicaid office specifically to help people with Medicare pay their Medicare costs. Think of them as a way Medicaid helps make Medicare more affordable if you have limited income and savings.

‍What costs can MSPs help with?
‍Depending on the specific MSP you qualify for, it can help pay for:
‍

Medicare Part B premium: This is the monthly fee most people pay for Medicare Part B (which covers doctor visits and outpatient care). Getting help with this premium can save you over $185 each month (in 2025).
Medicare Part A premium: Most people get Part A (hospital insurance) for free, but if you have to pay a premium, some MSPs might help.
Medicare deductibles: The amount you have to pay yourself before Medicare starts paying.
Medicare coinsurance and copayments: Your share of the cost for services after you meet your deductible.

Who can qualify for an MSP?
‍Eligibility is based on your income and assets (savings), but the limits are generally higher than for full Medicaid. This means you might qualify for an MSP even if you don't qualify for regular Medicaid.

The exact income and asset limits change each year and vary slightly by state. You need to have Medicare Part A to qualify for most MSPs.

‍How do I apply for an MSP?
‍You apply for MSPs through your state's Medicaid office. Often, it's the same application you use for regular Medicaid. When you apply for Medicaid, the state should automatically check if you qualify for an MSP, even if you don't qualify for full Medicaid.

‍Key takeaway: If you have Medicare and find it hard to afford the premiums or other costs, you should definitely apply for Medicaid/MSPs through your state. You might be surprised to find you qualify for help!

Medicare

Video: Understanding Medicare

Watch: Your Complete Guide to Medicare

Understanding Medicare

Medicare Eligibility

The Four Parts of Medicare

What's the difference between Original Medicare and Medicare Advantage?

Original Medicare vs. Medicare Advantage

Original Medicare (Parts A & B)

Medicare Advantage (Part C)

Important to Know

How do I choose the right Medicare coverage?

Choosing Your Medicare Coverage

Original Medicare (Parts A & B)

Part A: Hospital Insurance

Part A Costs for 2025

Part A Premiums

Service

2025 Cost

Inpatient Hospital Deductible

Hospital Coinsurance Days 1-60

Hospital Coinsurance Days 61-90

Hospital Coinsurance Days 91+ (lifetime reserve days)

Skilled Nursing Facility Days 1-20

Skilled Nursing Facility Days 21-100

Skilled Nursing Facility Days 101+

What is a Benefit Period?

Part B: Medical Insurance

Part B Costs for 2025

Part B Premiums

Service

2025 Cost

Annual Deductible

Coinsurance for most services

Preventive services

Mental health services

Clinical laboratory services

Medicare-Approved Amount

What's NOT covered by Original Medicare?

Services Not Covered by Original Medicare

Coverage Options

How to Enroll in Original Medicare

Enrolling in Original Medicare

Manual Enrollment

How to Apply

Insider Tip

Original Medicare FAQs

Do I need to renew my Medicare coverage every year?

Can I have Medicare and employer health insurance at the same time?

Does Medicare cover care when I travel outside the U.S.?

What's the difference between a deductible and coinsurance?

Can I see any doctor with Original Medicare?

Medicare Enrollment Periods

Initial Enrollment Period (IEP)

3 months before your 65th birthday month

Your 65th birthday month

3 months after your 65th birthday month

Month 1Month 2Month 3

Month 4

When Your Coverage Begins

General Enrollment Period (GEP)

When Your Coverage Begins

Late Enrollment Penalties

Need help determining if you can change YOUR Medicare plan?

Insider Tip

Enrolling After Losing Job-Based Coverage (Special Enrollment Period)

Step 1: Check if You Qualify

Step 2: Get Forms Ready

Step 3: Submit Forms to SSA

Step 4: Explore Plan Options

SEP Length?

Part B Start Date?

Employer Won't Fill L564?

COBRA & SEP?

Need Both Forms?

Avoid Part D Penalty?

Apply Online?

Medicare Advantage and Part D Enrollment Periods

Medicare Advantage and Part D Enrollment Periods

Part D Late Enrollment Penalty

Month 1
Month 2
Month 3

Medigap (Medicare Supplement Insurance) and Medicare Advantage (Part C) are fundamentally different ways to supplement or receive your Medicare benefits, and you cannot have both at the same time.

‍Medigap (Medicare Supplement):