Your Common Medicare Questions Answered

Sort through the confusion and better understand your Medicare options with answers to these important questions.

By The Editors

The ins and outs of Medicare are confusing. And even when you've got the basics down, there are still specific questions you need answered. Here is a list of common questions and the answers you're looking for. To learn about Medicare Basics, get our AGA Guide to Understanding Medicare.

Q: When can I enroll in Medicare?

A: You can sign up for Medicare Part A and/or Part B during a seven month window that includes the three months before the month you turn 65, the month of your birthday, and the three months after you turn 65. If you are receiving Social Security, you will automatically be signed up for Medicare Parts A and B starting the first day of the month you turn 65. 

Q: Do I have to be on the same plan(s) as my spouse?

A: No. All Medicare plans are issued on an individual basis.

Q: What's the difference between Original Medicare, Medicare Advantage, and Medicare Supplement insurance?

A:  Medicare has four parts:

  • Part A - Hospital Insurance
  • Part B - Medical Insurance

(Parts A & B together are known as "Original Medicare")

  • Part C - Medicare Advantage Plans
  • Part D - Prescription drug plans
  • There is also Medicare Supplement Insurance

There are two ways to get Medicare coverage: Original Medicare, which is made up of Part A & Part B, or a Medicare Advantage Plan. Original Medicare is provided by the federal government and covers doctors visits, lab tests, and hospitalization. Medicare Advantage Plansare sold by private insurance companies and give at least the same coverage as Original Medicare, but can include prescription drug coverage (Part D), vision, dental, and other services. Medicare Supplement (also known as Medigap) insurance, is sold by private insurance companies, and can help pay some of the health care costs that Original Medicare doesn't cover, like copayments, coinsurance, and deductibles. 

Q: Does Medicare cover everything?

A: No. Medicare doesn't cover routine dental visits, hearing, vision, and medical services provided outside of the U.S. For a complete list of what Medicare doesn't cover, click here.

Q: Does Medicare cover long-term care?

A: No. Most long-term care isn’t medical care, but rather help with basic personal tasks of every-day life, sometimes called “activities of daily living” or “custodial care.” Medicare does not cover long-term care, if that’s the only care you need.

Medicare does cover:

  • Care in a long-term care hospital
  • Some skilled nursing care in a skilled nursing facility • Eligible home health services
  • Hospice and respite care

Q: Does Medicare cover nursing homes?

A: Medicare Part A only covers skilled care given in a certified nursing facility for individuals who meet certain conditions. To learn more, visit Medicare.gov and search “Medicare Coverage of Skilled Nursing Care.”

Q: Why would someone opt to buy a Medicare Advantage Plan over getting Medicare Part A and Medicare Part B?

A: When it comes to Medicare, the decision is yours. However, you may want to get a Medicare Advantage Plan instead of Original Medicare if:

  • Your area has a large selection of in-network doctors and hospitals.
  • You don’t travel and your doctor is in-network for the Medicare Advantage Plan you want.
  • You’re healthy and don’t expect to need hospitalization services or medical attention beyond preventative health care.
  • You want to cap your out-of-pocket health spending. Original Medicare has no out-of-pocket maximum. You keep paying a portion of the cost of services you use, unless you have a Medicare Supplement Plan. Medicare Advantage plans, by law, have an out-of-pocket maximum of $6,700 per year, as long as you use in-network doctors. Past that limit, the plan pays for all covered expenses.
  • You want an alternative to the 20% coinsurance charged by Original Medicare Part B - remember, the 20% is unlimited (unless you have a Medicare Supplement Plan), whereas Medicare Advantage out-of-pocket is limited to $6,700 for in-network services.
  • You want coverage for vision and dental. Original Medicare doesn’t cover these routine services. Certain Medicare Advantage Plans do.
  • You take prescription drugs. With a few exceptions, most prescriptions aren’t covered in Original Medicare, so you will need to buy a Prescription Drug Plan (Part D). Some Medicare Advantage Plans include prescription drug coverage.

 

Q: What factors make a difference when deciding between a Medicare Advantage (Part C) HMO and PPO?

A: Medicare Advantage Health Maintenance Organization (HMO) plans allow you to choose from a network of contracted doctors. You’ll choose a primary care physician from the plan network and be referred to specialists within the plan network if you need additional care.

HMO highlights:

  • Lower out-of-pocket expenses
  • Must go to doctors in-network
  • May include Prescription Drug Plan

Many retirees and seniors seek out HMO coverage because of the cost savings.

Medicare Advantage Preferred Provider Organizations (PPO) plans offer care within a network of physicians and hospitals. Unlike with an HMO plan, you can also see providers outside of the network of physicians and hospitals, but you’ll pay more out of pocket.

PPO highlights:

  • Can stay in-network or go out-of-network to see doctors
  • Monthly premiums potentially higher than Medicare Advantage HMO plans • Out-of-network costs potentially higher than staying in-network
  • May include Prescription Drug Plan

 

Q: How do Prescription Drug Plans (Medicare Part D) differ?

A: Each Part D plan has its own formulary, or list of covered generic and brand-name drugs. All plans must cover certain categories of drugs, but the specific drugs covered in each category may differ by carrier. Part D Plans also set their own monthly premiums, so the costs may also differ by carrier.

Q: How do Medicare Supplement/Medigap plans differ from each other? Is it in price only?

A: There are 10 different Medicare Supplement/Medigap plans and they are referred to by letters A-N. (Not to be confused with the four parts of Medicare A-D!) Medicare Supplement Plans A-N offer different levels of coverage and vary in price from one insurance company to the other. Some of the plans cover you if you travel abroad, others do not. Some pay your Medicare Part B deductible, other’s do not. It’s best to reach out to licensed plan representatives to find out how the policies differ.

Q: Where can I find out more information?

A: You can download our AGA Guide to Understanding Medicare here, or you can visit the government's web site, Medicare.gov.

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