Medicare Frequently Asked Questions

Medicare is the federal health insurance program primarily for people age 65 and older, though some younger people with disabilities or End-Stage Renal Disease (ESRD) may also qualify. It's administered by the Centers for Medicare & Medicaid Services (CMS).

Medicare consists of different parts that cover specific services:

• Part A: Hospital insurance
• Part B: Medical insurance
• Part C: Medicare Advantage plans (alternative to Original Medicare)
• Part D: Prescription drug coverage

Most people become eligible for Medicare when they turn 65. Your Initial Enrollment Period (IEP) begins 3 months before your 65th birthday month, includes your birthday month, and extends 3 months after—giving you a 7-month window.

Important: If you're still working and covered by an employer health plan with 20+ employees, you may be able to delay enrollment without penalty. However, if you miss your enrollment window without qualifying for an exception, you may face late enrollment penalties that last for life.

You may also qualify before 65 if you've been receiving Social Security Disability Insurance (SSDI) for 24 months or have ALS or ESRD.

Original Medicare (Parts A & B) is the traditional fee-for-service program run by the federal government. You can see any doctor or hospital that accepts Medicare nationwide, with no network restrictions. You'll typically need to add Part D for prescriptions and consider Medigap for additional coverage.

Medicare Advantage (Part C) is offered by private insurance companies approved by Medicare. These plans include all Part A and B coverage, plus usually Part D. They often offer extra benefits like dental, vision, and hearing coverage.

Key differences:

• Advantage plans typically have provider networks (HMO, PPO)
• Original Medicare + Medigap offers more freedom to see any Medicare provider
• Advantage plans may have lower monthly premiums but different out-of-pocket structures
• Advantage plans can change benefits and costs annually

The best time to enroll is during your Initial Enrollment Period (IEP)—the 7-month period around your 65th birthday. This is when you have the most options and protections.

Critical timing considerations:

• If your birthday is the 1st of the month, your IEP starts 4 months before
• Coverage typically begins the first day of your birthday month (or the month after if you enroll late in your birthday month)
• If you're still working with creditable coverage, you may delay Part B without penalty
• You must enroll in Part A if you're receiving Social Security benefits

Missing your enrollment window can result in lifetime penalties and gaps in coverage.

Missing your IEP without having creditable coverage can have serious consequences:

• Late enrollment penalty for Part B: 10% increase for each 12-month period you could have had Part B but didn't enroll. This penalty continues for life.
• Late enrollment penalty for Part D: 1% of the national base premium for each month you were without coverage, also for life.
• Limited enrollment opportunities: You'll need to wait for General Enrollment Period (January 1 - March 31) with coverage starting July 1.
• No guaranteed issue rights for Medigap: Insurance companies can deny coverage or charge more based on health conditions.

This is why working with an advisor during your IEP is so valuable—we help you avoid these costly mistakes.

Yes, but the timing and options depend on what you want to change:

Annual Enrollment Period (AEP): October 15 - December 7 each year. You can:

• Switch from Original Medicare to Medicare Advantage, or vice versa
• Change Medicare Advantage plans
• Add, drop, or change Part D prescription drug plans

Medicare Advantage Open Enrollment: January 1 - March 31. You can:

• Switch from one Medicare Advantage plan to another
• Drop your Medicare Advantage plan and return to Original Medicare

Special Enrollment Periods (SEP): May be available if you move, lose other coverage, qualify for Extra Help, or meet other specific criteria.

Important: Switching from Medicare Advantage to Original Medicare may be difficult if you want Medigap—you won't have guaranteed issue rights and may face medical underwriting.

Medicare costs vary based on the parts you choose and your income. Here are the basic costs for 2025:

Part A (Hospital Insurance):

• Premium-free for most people (if you or your spouse paid Medicare taxes for at least 10 years)
• Deductible: $1,632 per benefit period

Part B (Medical Insurance):

• Standard premium: $185 per month
• Higher earners pay more through IRMAA (Income-Related Monthly Adjustment Amount)
• Annual deductible: $257
• Coinsurance: Typically 20% after deductible

Part D (Prescription Drugs): Varies by plan, averaging $40-80/month

Medicare Advantage: Often $0 monthly premium (beyond Part B), but check out-of-pocket maximums

Medigap: Varies widely by plan type, age, location, and company—typically $100-300/month

Original Medicare has significant gaps in coverage, which is why many people add supplemental insurance:

• Prescription drugs: You need Part D or Medicare Advantage with drug coverage
• Dental care: Routine dental exams, cleanings, fillings, extractions
• Vision care: Eye exams for eyeglasses, eyeglasses, contact lenses
• Hearing aids: Routine hearing exams and hearing aids
• Long-term care: Custodial care in nursing homes or at home
• Cosmetic surgery: Unless medically necessary
• Acupuncture: Except for chronic lower back pain
• Foreign travel: Emergency care outside the U.S. (with limited exceptions)

This is why considering Medicare Advantage (which often includes these benefits) or Medigap (which covers some cost-sharing) is important.

Medigap (Medicare Supplement Insurance) is private insurance that helps pay for out-of-pocket costs that Original Medicare doesn't cover, such as copayments, coinsurance, and deductibles.

Key features:

• Standardized plans (A, B, C, D, F, G, K, L, M, N) with identical benefits across companies
• Works alongside Original Medicare—not with Medicare Advantage
• Guaranteed renewable—companies can't drop you as long as you pay premiums
• You can see any doctor that accepts Medicare nationwide
• Most popular plans: Plan G and Plan N

Important timing: The best time to buy Medigap is during your 6-month Medigap Open Enrollment Period, which starts when you're 65 or older and enrolled in Part B. During this period, you have guaranteed issue rights—companies cannot deny coverage or charge more due to health conditions.

Yes, you should strongly consider enrolling in Part D even if you don't currently take medications, for two important reasons:

1. Late Enrollment Penalty: If you go 63 days or longer without creditable prescription drug coverage, you'll pay a penalty of 1% of the national base premium for each month you were without coverage. This penalty is added to your premium for as long as you have Part D.

2. Future Protection: Health needs change. If you develop a condition requiring expensive medications later, you'll already have coverage in place. Waiting until you need medications means you'll pay the penalty plus potentially face a gap in coverage.

Budget-friendly option: Many low-cost Part D plans are available (some under $10/month) that provide protection against the penalty and catastrophic drug costs.

Exception: If you have creditable prescription drug coverage through an employer, union, VA, or other source, you may safely delay Part D enrollment.

Medicare Advantage (Part C) is an alternative way to get your Medicare benefits through private insurance companies approved by Medicare. When you join a Medicare Advantage plan, you're still in Medicare, but the private company provides all your Part A and Part B coverage—and usually Part D.

How it works:

• You must have both Part A and Part B to join
• You still pay your Part B premium to Medicare
• You may pay an additional premium to the plan (many plans have $0 premium)
• Plans have provider networks—typically HMO or PPO structures
• Out-of-pocket maximum protects you from catastrophic costs
• Plans often include extras like dental, vision, hearing, fitness memberships

Important: Benefits, costs, and provider networks can change every year, so it's wise to review your plan annually during AEP.

Yes, you can switch, but the process requires careful planning:

When you can switch:

• During Annual Enrollment Period (October 15 - December 7)
• During Medicare Advantage Open Enrollment (January 1 - March 31)
• During a qualifying Special Enrollment Period

The Medigap challenge: When you return to Original Medicare, you'll likely want Medigap coverage to protect against out-of-pocket costs. However, you won't have guaranteed issue rights unless you meet specific criteria (such as your Medicare Advantage plan leaving your area). This means:

• Insurance companies can deny your Medigap application
• Companies can charge higher premiums based on your health
• Pre-existing conditions may not be covered immediately

This is one reason why choosing between Original Medicare and Medicare Advantage during your IEP is so important—switching later can be difficult.

Advantages:

• Often $0 monthly premium beyond Part B
• Out-of-pocket maximum provides financial protection
• Usually includes prescription drug coverage (Part D)
• Extra benefits: dental, vision, hearing, fitness, OTC allowances
• Simplified—one plan, one card

Disadvantages:

• Provider networks—must use in-network doctors (except PPO out-of-network coverage)
• May need referrals to see specialists (HMO plans)
• Prior authorizations may be required for certain services
• Benefits and costs can change annually
• Travel limitations—emergency coverage only outside service area
• Difficulty switching to Original Medicare later if health declines

The right choice depends on your specific situation—health status, budget, doctors, travel plans, and future flexibility needs.

Based on my experience helping clients and my own near-mistakes, here are the critical errors to avoid:

1. Missing the Initial Enrollment Period: Leads to lifetime penalties and gaps in coverage. Don't assume you can "just enroll later."

2. Not coordinating with employer coverage: Failing to understand when to drop employer coverage and enroll in Medicare can result in penalties or losing creditable coverage.

3. Choosing based on premium alone: A $0 premium Medicare Advantage plan isn't truly free—consider copays, deductibles, out-of-pocket maximums, and network restrictions.

4. Not enrolling in Part D: Even if you don't take medications now, the late enrollment penalty lasts for life and increases every year you wait.

5. Picking Medicare Advantage without checking provider networks: Your doctors may not be in-network, requiring you to switch providers or pay more.

6. Waiting to buy Medigap: Missing your 6-month Medigap Open Enrollment Period means you may be denied coverage or pay much higher premiums based on health.

7. Not reviewing plans annually: Plans change every year—benefits, costs, and formularies can all shift. Review during AEP.

8. Working with captive agents who only show one company's plans: You deserve to see all your options, not just the ones that pay the highest commission.

An independent advisor makes all the difference in finding the right Medicare coverage:

Unbiased guidance: Independent advisors work with multiple carriers and show you all available options—not just the plans from one company or the ones that pay the highest commission. I'm committed to recommending what's best for you, even if it means lower compensation for me.

No cost to you: My services are completely free. I'm compensated by the insurance carriers, never by my clients. You get expert guidance at no charge.

Expertise across all options: Whether Original Medicare with Medigap, Medicare Advantage, or a hybrid approach is best for you, I can help you navigate all the choices and understand the trade-offs.

Long-term relationship: Medicare needs change over time. I'm here for annual reviews, answering questions, and helping you adjust coverage as your situation evolves.

Personal experience: I nearly made costly Medicare mistakes myself, which drives my passion for helping others avoid the same pitfalls. I study Medicare regulations extensively to provide accurate, up-to-date guidance.

Unlike captive agents who only represent one company, or call centers focused on quick sales, I take the time to understand your unique situation and find coverage that truly fits your needs and budget.