If you find Medicare confusing, you're not alone. A recent Kaiser Family Foundation study found 30% of Medicare beneficiaries have difficulty understanding the program or comparing their coverage options. Among people with poorer health, that number jumps to 41%. It's understandable, as Medicare is a complicated system that spans both government and private sectors.
In this article, we'll talk you through the Medicare program in simple terms. You can then navigate the system and make the most of your coverage.
Medicare is a federal government health insurance program that works to reduce the costs of essential healthcare so people can access the care they need.
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Several groups of people can receive Medicare benefits, including:
Medicare consists of four different parts:
Original Medicare consists of Medicare Parts A and B. You can choose to receive Medicare benefits from Original Medicare or to receive these benefits through a Medicare Advantage plan.
Legally, Medicare Advantage plans must provide equal coverage to Original Medicare. Most Medicare Advantage plans include Part D Medicare prescription drug coverage, and some plays may offer other benefits like vision, dental, hearing and gym membership.
Understanding the differences between the two options can help you decide which is most suitable. Here are some ways that these types of Medicare insurance can vary:
Simply put, Original Medicare benefits and costs are set by the federal government. Medicare Advantage plans can be more flexible in how they’re administered. The coverage, premiums, and out-of-pocket expenses can vary between providers and plans.
Because of the variations, if you're considering a Medicare Advantage plan, it's essential to research options in your area and find the provider and plan that suits you best.
Whether you choose Original Medicare or a Medicare Advantage plan, you will typically pay some cost-sharing amounts for deductibles, coinsurance and copayments when you receive covered services.
Some things Original Medicare can cover include:
The costs and rules with Medicare Advantage plans differ, and some plans may not have a deductible. When you receive care, you’ll likely pay a copay. For example, you might be responsible for paying $20 for a doctor's appointment, depending on the rules of your plan.
Likewise, for many Medicare Part D plans, there will be a copay required for some prescriptions. These copay amounts can vary depending on your plan and the type of prescription drug, such as whether it’s a generic or band name version of the drug.
The federal government automatically enrolls many people in Medicare if they’re entitled to receive retirement benefits from the Social Security (SS) or Railroad Retirement Board (RRB) at least four months before they turn 65.
If you don't receive SS or RRB benefits, you may have to enroll in Medicare yourself. Once you do that, you may decide to also enroll in a Medicare Advantage plan and/or a Medicare Part D prescription drug plan.
Some beneficiaries choose to enroll in a Medicare Supplement Insurance (Medigap) plan to supplement their Original Medicare coverage. A Medicare Supplement plan helps pay for certain out-of-pocket Medicare costs such as deductibles, copays, coinsurance and more.
Medicare enrollment can depend on your individual circumstances, but typically you can sign up for Medicare starting three months before turning 65 or once you qualify through disability. If you’re not automatically enrolled in Medicare Part A and Part B, you'll have a seven-month enrollment window called your initial enrollment period, which starts three months before your 65th birthday and continues for three months after your birthday month.
You can sign up for Original Medicare in person at your local Social Security office or over the phone, or you can enroll in Medicare online.
Medicare may seem complicated at first, but taking time to understand it can help you secure the right coverage for your needs and make the most of your Medicare benefits.
To get more information on Medicare Advantage plans and Medicare Part D prescription drug plans and the benefits that may be available in your area, call to speak with a licensed insurance agent today.
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Zia Sherrell is a digital health journalist with over a decade of healthcare experience, a bachelor’s degree in science from the University of Leeds and a master’s degree in public health from the University of Manchester. Her work has appeared in Netdoctor, Medical News Today, Healthline, Business Insider, Cosmopolitan, Yahoo, Harper's Bazaar, Men's Health and more.
When she’s not typing madly, Zia enjoys traveling and chasing after her dogs.