Medicare Insurance - Explained

Who Qualifies for Medicare?

  • People age 65 and older
  • Certain younger people with disabilities
  • People with End-Stage Renal Disease

What's Medicare?

The different parts of Medicare:

Part A

Hospital Insurance

Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

Part B

Medical Insurance

Part B covers certain doctors’ services, outpatient care, medical supplies, and preventive services.

Part D

Prescription Drug Coverage

Part D adds prescription drug coverage specific Medicare cost plans and accounts.

These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans.
Medicare Advantage (or Medicare Part C)
This includes Part A, B, and C under one plan.
This type of plan is offered via a private company that works with Medicare to provide the benefits for Part A, B, and C. There are several types of Plans including, but not limited to HMO, PPO, Private Fee-for-Service Plans (PFFS) and Special Needs Plans (SNPs).

Medigap (Medicare Supplement Health Insurance)

A Medigap policy is health insurance sold by private insurance companies to fill the “gaps” in Original Medicare Plan coverage. Medigap policies help pay some of the health care costs that the Original Medicare Plan doesn’t cover. If you are in the Original Medicare Plan and have a Medigap policy, then Medicare and your Medigap policy will each pay its share of covered health care costs.

Generally, when you buy a Medigap policy you must have Medicare Part A and Part B. You will have to pay the monthly Medicare Part B premium. In addition, you will have to pay a premium to the Medigap insurance company. As long as you pay your premium, your Medigap policy is guaranteed renewable. This means it is automatically renewed each year. Your coverage will continue year after year as long as you pay your premium. In some states, insurance companies may refuse to renew a Medigap policy bought before 1992.

Insurance companies can only sell you a “standardized” Medigap policy. Medigap policies must follow Federal and state laws. These laws protect you. The front of a Medigap policy must clearly identify it as “Medicare Supplement Insurance.”

It’s important to compare Medigap policies, because costs can vary. The standardized Medigap policies that insurance companies offer must provide the same benefits. Generally, the only difference between Medigap policies sold by different insurance companies is the cost.

You and your spouse must buy separate Medigap policies. Your Medigap policy won’t cover any health care costs for your spouse.

Some Medigap policies also cover other extra benefits that aren’t covered by Medicare.

You are guaranteed the right to buy a Medigap policy under certain circumstances.

For more information on Medigap policies, you may call 1-800-633-4227 and ask for a free copy of the publication “Choosing a Medigap Policy: A Guide to Health Insurance for People With Medicare.” You may also call your State Health Insurance Assistance Program (SHIP) and your State Insurance Department. Phone numbers for these Departments and Programs in each State can be found in that publication.

How Original Medicare works

Original Medicare is coverage managed by the federal government. Generally, there’s a cost for each service. Here are the general rules for how it works:

Can I get my health care from any doctor, other health care provider, or hospital?

In most cases, yes. You can go to any doctor, health care provider, hospital, or facility that is enrolled in Medicare and accepting new Medicare patients.

Are prescriptions covered in Original Medicare?

With a few exceptions, most prescriptions aren’t covered in Original Medicare. You can add drug coverage by joining a Medicare Prescription Drug Plan (Part D)

Do I need to choose a primary care doctor?

No, in Original Medicare you don’t need to choose a primary care doctor

Do I have to get a referral to see a specialist?

In most cases, no. In Original Medicare, you don’t need a referral, but the specialist must be enrolled in Medicare.

Should I get a supplemental policy?

You may already have employer or union coverage that may pay costs that Original Medicare doesn’t. If not, you may want to buy a Medicare Supplement Insurance (Medigap) policy.

What else do I need to know about Original Medicare?

  • You generally pay a set amount for your health care ( deductible ) before Medicare pays its share. Then, Medicare pays its share, and you pay your share ( coinsurance / copayment ) for covered services and supplies. There’s no yearly limit for what you pay out-of-pocket.
  • You usually pay a monthly premium for Part B
  • You generally don’t need to file Medicare claims. The law requires providers and suppliers to file your claims for the covered services and supplies you get. Providers include doctors, hospitals, skilled nursing facilities, and home health agencies.

Factors that affect Original Medicare out-of-pocket costs

  • Whether you have Part A and/or Part B. Most people have both.
  • Whether your doctor, other health care provider, or supplier accepts assignment.
  • The type of health care you need and how often you need it.
  • Whether you choose to get services or supplies Medicare doesn’t cover. If you do, you pay all the costs unless you have other insurance that covers it.
  • Whether you have other health insurance that works with Medicare.
  • Whether you have Medicaid or get state help paying your Medicare costs.
  • Whether you have a Medicare Supplement Insurance (Medigap) policy.
  • Whether you and your doctor or other health care provider sign a private contract.


How much does Part A cost?

* Premium-free Part A

Most people qualify for premium-free Part A by already receiving retirement benefits from Social Security, or Railroad Retirement benefits, your eligible for these benefits, or you or your spouse had Medicare-covered government employment and you are 65 or older.


If you are under 65 and you get Social Security or Railroad Retirement benefits for 24 months or you have End-Stage Renal Disease and meet certain requirements.

* Do not qualify for Premium-free Part A

Cost is $458 each month if you paid Medicare taxes for less than 30 quarters

Cost is $252 per month if you paid Medicare taxes for 30-39 quarters


How much does Part B cost?

Part B premiums

You pay a premium each month for Part B. Your Part B premium will be automatically deducted from your benefit payment if you get benefits from one of these:

* Social Security
* Railroad Retirement Board
* Office of Personnel Management

If you don’t get these benefit payments, you’ll get a bill.

Most people will pay the standard premium amount. If your modified adjusted gross income is above a certain amount, you may pay an Income Related Monthly Adjustment Amount (IRMAA). Medicare uses the modified adjusted gross income reported on your IRS tax return from 2 years ago. This is the most recent tax return information provided to Social Security by the IRS

Medicare Part D (prescription drug coverage)
This includes adding prescription drug coverage to:

* Original Medicare
* Medicare Medical Savings Account Plans
* Some Medicare Private-Fee-for-Service Plans
* Some Medicare Cost Plans

Part D costs depend on several factors and varies more than the other Parts. This depends on the plan you choose, the medications you use, if the medications are on your plans formulary and if you utilize a pharmacy in your plants network.