Medicare Introduction

Medicare is a federal health insurance program primarily for people aged 65 and older, but it also covers certain younger individuals with disabilities or specific health conditions like End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS). It helps cover hospital and medical expenses, but it doesn’t cover everything, which is where supplemental plans, like Medigap or Medicare Advantage (Part C), can come in.

Age: 

• People 65 or older, as long as they are U.S. citizens or permanent legal residents for at least 5 years and have completed the required work hours throughout their lifetime.

Disability: 

• People under 65 who have been receiving Social Security Disability Insurance (SSDI) for 24 months.

Specific Health Conditions: 

• People with End-Stage Renal Disease (ESRD) or ALS (Lou Gehrig’s disease) can qualify regardless of age.

Covers inpatient care: 

• Part A helps pay for your hospital stays, including semi-private rooms, meals, and necessary services and supplies during your stay.

Other covered services:

• Skilled nursing facility care (following a hospital stay), Hospice care, Some home health care (e.g., if you're homebound and need skilled nursing care or therapy)

Costs:

• Most people don’t pay a premium for Part A if they or their spouse paid Medicare taxes while working.
• There are deductibles and copayments (for example, a deductible for hospital stays and daily coinsurance for long stays).

Covers outpatient care: 

• Part B covers medically necessary services like doctor visits, outpatient hospital services, lab tests, preventive care (like vaccines and screenings), durable medical equipment (DME), and some home health care.

Other covered services:

• Ambulance services
• Mental health care (outpatient)
• Physical therapy

Costs:

• Part B has a monthly premium, which is based on your income. Most people pay the standard premium, which in 2025 is $185.00 per month (this can change annually).
• There’s also a deductible ($257 in 2025) and coinsurance (typically 20% of the cost for most services, after the deductible is met).

Helps with prescription drugs: 

• Part D covers prescription medications that are not covered under Part A or Part B.

Offered through private insurance companies: 

• You can get a stand-alone Part D plan if you have Original Medicare (Parts A and B), or you can get prescription drug coverage through a Medicare Advantage plan that includes drug coverage.

Costs:

• Monthly premium, which varies by plan and income.
• Deductible and copayments/coinsurance for prescriptions.

IMPORTANT NOTE: 

• There’s a penalty for late enrollment in Part D if you don’t enroll when you’re first eligible and don’t have other credible drug coverage.

Initial Enrollment Period (IEP): 

• You can enroll in Medicare during a 7-month window starting 3 months before your 65th birthday and ending 3 months after. If you’re already receiving Social Security benefits, you’ll automatically be enrolled in Part A and Part B.

General Enrollment Period: 

• If you missed your IEP, you can enroll between January 1 and March 31 each year, with coverage starting July 1.

Special Enrollment Periods (SEPs): 

• If you’re still working and have employer insurance, you can delay enrollment without penalty.

Original Medicare (Part A and Part B): 

• Covers a lot, but you still have out-of-pocket costs like deductibles and coinsurance. It also doesn’t cover prescription drugs, dental, vision, or hearing aids.

Part D: 

• Prescription drug coverage you can get with either Original Medicare or through a Medicare Advantage plan that includes drugs.

Helpful Links:

About Medicare (Medicare.gov)

Medicare Basics (CMS)