Medicare 101: The Basics You Need to Know

So you're approaching 65 (or maybe you're already there) and suddenly everyone's talking about Medicare. Letters are showing up in your mailbox, and your friends are all sharing conflicting advice.

Let's cut through the confusion with a straightforward guide to Medicare, including the key questions you absolutely need to ask.

What Exactly Is Medicare?

At its core, Medicare is the federal health insurance program primarily for people who are:

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

Think of Medicare as having four main parts, each covering different services:

Part A: Hospital Insurance

• Covers inpatient hospital stays, skilled nursing facility care, hospice, and some home health care
• Cost: Most people don't pay a premium for Part A if they or their spouse paid Medicare taxes while working

Part B: Medical Insurance

• Covers doctor visits, outpatient care, preventive services, and some home health care
• Cost: Most people pay a standard monthly premium ($184.10 in 2025)

Part C: Medicare Advantage Plans

• An alternative to Original Medicare (Parts A & B)
• Offered by private companies approved by Medicare
• Usually includes Part D drug coverage and often covers vision, dental, and hearing
• Cost: Varies by plan (some have $0 additional premiums beyond the Part B premium)

Part D: Prescription Drug Coverage

• Helps cover prescription medication costs
• Run by private insurance companies that follow Medicare rules
• Cost: Varies by plan and income level

When Do I Sign Up?

Timing is everything with Medicare. Here's what you need to know:

Initial Enrollment Period

• 7-month period that includes:
  • 3 months before your 65th birthday
  • The month of your 65th birthday
  • 3 months after your 65th birthday

Special Enrollment Periods

If you're still working at 65 and covered by employer insurance (for a company with 20+ employees), you can sign up later during a Special Enrollment Period.

Important Note

Missing your enrollment period can mean additional costs and gaps in coverage. This is one deadline you don't want to miss!

Original Medicare vs. Medicare Advantage: The Big Decision

This is probably the biggest choice you'll make regarding your Medicare coverage:

Original Medicare (Parts A & B)

• Benefits: See any doctor that accepts Medicare (most do), no referrals needed, consistent coverage nationwide
• Considerations: No out-of-pocket maximum, no prescription drug coverage (need separate Part D), no coverage for dental, vision, or hearing

Medicare Advantage (Part C)

• Benefits: Often includes Part D drug coverage, may include dental/vision/hearing, usually has an out-of-pocket maximum
• Considerations: Network restrictions (usually need to use network providers), may need referrals for specialists, coverage can vary by location

What About Medicare Supplement Insurance?

If you choose Original Medicare, you might want to consider a Medicare Supplement policy:

• Helps pay costs that Original Medicare doesn't cover (like copayments, coinsurance, and deductibles)
• Sold by private companies
• Has its own 6-month open enrollment period (starting when you're 65+ and enrolled in Part B)
• Important: You cannot have both Medicare Advantage and Medicare Supplement coverage simultaneously

10 Essential Questions to Ask Before Choosing Your Medicare Coverage

1. "Will my current doctors accept this Medicare plan?"If keeping your doctors is important, check before enrolling.
2. "What will my total costs be?"Consider premiums, deductibles, copays, and coinsurance—not just the monthly premium.
3. "Are my prescription medications covered, and what will they cost?"Drug coverage varies significantly between plans.
4. "What is the plan's quality rating?"Medicare rates plans based on quality and performance.
5. "What is my maximum out-of-pocket expense for the year?"Original Medicare has no cap, while Medicare Advantage plans do.
6. "Does the plan cover me if I travel or spend part of the year in another state?"Medicare Advantage plans often have geographic restrictions.
7. "What happens if I develop a serious health condition? Will I have access to specialists?"Some plans require referrals or have limited specialist networks.
8. "Does the plan cover additional services I need like dental, vision, or hearing?"Original Medicare doesn't cover these, but many Medicare Advantage plans do.
9. "Will I need prior approval for certain services or medications?"This could affect how quickly you receive care.
10. "Is there a good Medicare Supplement policy available to me, and what will it cost?"If choosing Original Medicare, a Medicare Supplement policy can provide additional protection.

Common Medicare Myths Clarified

Myth: "Medicare covers everything."

Reality: Medicare doesn't cover long-term care, most dental care, eye exams for glasses, dentures, or hearing aids.

Myth: "Medicare is free."

Reality: While Part A may be premium-free for most people, Part B has a monthly premium, and all parts have deductibles and coinsurance.

Myth: "I can sign up for Medicare anytime."

Reality: Outside of specific enrollment periods, you may face additional costs and coverage gaps.

Myth: "Medicare and Medicaid are the same thing."

Reality: Medicare is primarily for people 65+ regardless of income, while Medicaid is for those with limited income and resources of any age.

Getting Help With Medicare Decisions

You don't have to figure this out alone:

• Medicare.gov: The official Medicare website
• 1-800-MEDICARE (1-800-633-4227): Medicare's helpline
• State Health Insurance Assistance Program (SHIP): Free, unbiased counseling
• Social Security Administration: For enrollment questions (1-800-772-1213)

Remember, Medicare isn't one-size-fits-all. Your health needs, budget, preferred doctors, and medications will shape what's best for you. Take the time to understand your options, ask these key questions, and make an informed choice.

The best Medicare plan is the one that fits your unique situation—not what worked for your neighbor.

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