Last updated: November 24th, 2022
Reviewed by
Paige Geisler
Licensed Insurance Agent
Most people don’t even pay a premium for basic Medicare, which covers inpatient care in a hospital setting and some other medical services. Find out more about Medicare below, including who is eligible, how much it might cost you, and how to get this health insurance.
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Medicare is health insurance provided by the United States federal government. The government doesn’t directly administrate the program. Instead, the Centers for Medicare & Medicaid Services contract with intermediaries, which are private companies that manage the insurance for various beneficiaries. These intermediaries are tasked with overseeing benefits, claims review, and claims payments following rules set out by CMS.
While private companies administrate the Medicare program, it isn’t quite the same as common commercial or private health insurance plans (such as those you might get from companies like Blue Cross or Cigna). Here are a few differences between Medicare and common insurance plans:
| Medicare | Private Insurance |
|---|---|
| Medicare is funded by the federal government, which gets money for the program via payroll taxes. | Private insurance companies are funded via premium payments and investments. |
| CMS manages Medicare, which sets the rules for what types of treatments are covered and how much the program will pay for those services. | Common health insurance plans are managed by private companies that can set their own rules within compliance with federal laws like the Affordable Care Act. |
| Medicare is only available to qualifying older adults or people with certain conditions or disabilities. | Private or employer-sponsored health insurance plans are typically eligible to anyone who purchases them in the health care marketplace or any covered employee who opts for benefits from their employer. |
To be eligible for Medicare, you must meet one of the following conditions:
Medicare coverage is divided into parts. When enrolling in Medicare, you can choose the parts (or plans) that best meet your needs. Read more about each of these parts, when you might need them, and what they cover below.
Medicare Part A is one component of what is sometimes referred to as Original Medicare. People can enroll in Medicare Part A when they’re 65, are diagnosed with end-stage renal disease, or have been on disability for 24 months. This part of the program is also sometimes called Medicare hospital insurance as it’s geared toward covering inpatient stays.
With a few exceptions, Medicare Part A only pays for covered services in a hospital or inpatient setting. This means you typically must be admitted to a facility for treatment to have this coverage kick in. That includes hospitals, certain types of clinics, skilled nursing facilities, and qualified nursing homes. Medicare Part A also covers some home health and hospice care services.
Medicare Part B is the second component of Original Medicare. It serves as a partner to your Medicare Part A.
If you’re eligible for free Medicare Part A, you can add Part B coverage. If you aren’t eligible for free Medicare Part A, you can buy Part B coverage without also buying Part A coverage as long as you meet the overall requirements for Medicare eligibility.
For an Employer Plan Open Enrollment, the national Open enrollment for an Affordable Care Part B helps pay for the costs of outpatient care. That includes visits to your primary care physician and specialists, ambulance services, blood transfusions, some (very limited) prescription drugs, mental health services, and some durable medical equipment such as canes, walkers, wheelchairs, and hospital beds.
Medicare Part B pays for preventative services, such as checkups with your primary care physician or an annual flu shot. All other covered services are paid on a medically necessary basis, which means your provider may need to prove that they’re medically necessary with a diagnosis and other documentation when sending a claim.
Medicare Part C refers to Medicare Advantage Plans. These are Medicare plans offered through private insurance companies that combine the benefits associated with Parts A and B. You can choose these options instead of Original Medicare, though you may have different premiums and deductibles under a Medicare Advantage Plan. You might also have to use providers in-network with your plan to ensure the best cost savings.
Medicare Advantage Plans must cover all the things Original Medicare covers, which means anything covered under Parts A and B should be covered by your Part C plan. These plans often include additional coverage, which is one reason people choose them. That might consist of coverage for some hearing, vision, or dental services, access to discounted or free fitness programs, and built-in prescription drug coverage. When you have a Medicare Advantage Plan with prescription drug benefits, you don’t have to buy a separate Part D plan.
Medicare Part D is the Medicare prescription drug benefit. If you have Medicare Part A and B, you must buy a Medicare Part D plan to get comprehensive prescription drug coverage. If you have a Medicare Advantage Plan without prescription drug benefits, you’ll also need a Part D plan if you want coverage for prescription drugs.
You can choose from a variety of Medicare Part D plans, and plans aren’t required to cover all possible drugs. Plans do have to provide formularies, which are lists of covered drugs. By looking at those formularies, you can find a plan that covers the types of prescription drugs you take regularly.
Medicare does have rules for what drugs might be covered under these plans, including:
Medigap insurance plans are designed to fill the gaps left under Medicare Part A and B. They cover some or all of your copay or coinsurance costs after Medicare Parts A or B pay. Part B coinsurance is 20% of approved charges, and Part A coinsurance can start if you are in the hospital or another facility for more than 60 days. Those expenses can add up. A Medigap plan can help you save a lot of money if you use medical services often during the year.
You can’t use a Medigap plan with a Medicare Advantage Plan. In fact, it’s illegal for someone to sell you a Medigap plan if you have a Medicare Advantage Plan unless you’re buying the Medigap plan to start when you transfer back to Original Medicare (Parts A and B).
Medigap policies are sold by private insurance companies. They aren’t funded or overseen by CMS like Medicare plans are. However, they are standardized and do follow rules. Here’s a look at the types of plans and what plans in each tier must offer:
Plan types C and F can’t be sold to anyone who became eligible for Medicare after January 1, 2020.
When considering the cost of Medicare plans, you must consider three major factors:
If you apply for Social Security benefits for your retirement or apply for benefits through the Railroad Retirement Board, you probably don’t have to apply for Medicare. Your application for retirement benefits is also your Medicare application. As long as you apply for and receive these benefits at least 4 months before your 65th birthday, you’ll automatically get Part A and Part B coverage.
You can, however, opt out of Part B coverage. You can also choose a Part C plan instead of selecting Parts A and B.
If you want to apply for Medicare online and aren’t applying for Social Security benefits, you can do so. Individuals can also apply for Medicare or Medicare Advantage Plans during special enrollment periods, which last for 8 months after employer-based group coverage ends.
The Medicare Open Enrollment period is October 15 through December 7 each year. You can enroll during these times if you miss other enrollment periods or switch plans if you want to make changes to your Medicare enrollments.
Medicare isn’t free. You pay for it throughout your life when you pay into the federal tax system via payroll taxes. You will also likely pay some premiums for the benefits, even once you retire. That being said, the premiums and deductibles are often low compared to many common private insurance plans, and the right Medicare coverage can help you manage your health expenses in retirement.
Brian is the founder and CEO of Insurist and carries Life, Health, and Property & Casualty licenses in all 50 U.S. states. Since 2013, Brian has been a member of Million Dollar Round Table, a designation for the top 1% of financial advisors worldwide. Brian has been featured in Yahoo! Finance, Money.com, Entrepreneur.com, Life Happens, Forbes, MSN, and Good Financial Cents. Brian’s goal is to show customers the best products, the quickest answers to their questions, and provide expert advice.
Paige is an assistant agent for State Farm and is licensed to sell property and casualty, health, and life insurance in Virginia. She handles all different types of insurance and financial services and is currently working on a securities and bonds license. Paige has a degree from Radford University in English and is a certified notary.
