Frequently Asked Questions

WHAT YOU NEED TO KNOW 

Medicare eligibility has two requirements.

1.  You must be 65 years old OR have been receiving Social Security disability benefits for at least 24 months OR have end stage renal disease OR Lou Gehrig’s disorder (ALS)

                                                    AND 

2.  You must be a US citizen or a permanent legal resident for at least 5 consecutive years.

Alert: Undocumented immigrants are NOT eligible for Medicare.

Eligibility for Medicare Part A without premium.

For premium free Part A you (or your spouse) must have worked and paid Medicare taxes for 40 quarters in your (their) lifetime. A quarter is 3 months, so 40 quarters is 10 years. Most people are eligible for Part A with no premium.  You can pay for Part A if you have not worked enough quarters to qualify for premium free Part A.

Eligibility for Part B 

Part B has the same requirements as Part A, except there is no work history requirement. For 2025, the typical premium for part B is $185/month.  Certain income levels may require higher or lower Part B premiums.

Eligibility for Part C

If you are enrolled in Part A and Part B you are eligible for Part C.

Eligibility for Part D

If you are enrolled in Part A and/or Part B you are eligible for Part D.

Self Enrollment

Most people will enroll themselves in Medicare shortly before or after they turn 65.  If you are already receiving benefits from Social Security or Railroad Retirement you will be automatically enrolled. (See below)

You are eligible to enroll during your Initial Enrollment Period which lasts 7 months. It begins on the 1st day of the month 3 months before your birth month, includes your birthday month and ends on the last day of the 3rd month after your birth month.

Example if your birthday is in May you can enroll in Medicare between February 1st and August 31st.

To enroll you will contact the Social Security Administration, either in person at your local Social Security office, online at SSA.gov or by phone at 1-800-MEDICARE (1-800-633-4227).

Automatic Enrollment

If you are already recieving Social Security or Railroad Retirement benefits when you become eligible for Medicare you will be automatically enrolled.  Three months before you are eligible for Medicare you will receive a Medicare card and a "Welcome to Medicare" brochure.  This is NOT JUNK MAIL, do not throw it away!

When should I enroll?

Typically,  people will choose to enroll at least in Part A during their Initial Enrollment Period.  Many, but not all,  people will also choose to enroll in Part B during this period.  There are several reasons to delay enrollment.  The most common reason  is because they are still working and are covered by employer group insurance.  This decision can be complicated and if you do not enroll when you are required to enroll there could be penalties involved.  It is highly advisable that you consult a trained Medicare specialist to evaluate your specific situation.  You can get assistance from Medicare.gov, your state SHIP office or a trusted Medicare agent.  

WHAT MEDICARE PART COVERS SPECIFIC COSTS

PART A AND B ORIGINAL MEDICARE

Original Medicare is Part A and Part B, Part A covers hospital type charges and Part B covers outpatient type charges.  Generally, Part A pays all approved charges after the beneficiary pays a deductible (2025, $1,676 per benefit period).If you are in the hospital more than 60 days in a single benefit period daily copays will be assessed. Part B generally pays 80% of approved charges and the beneficiary pays 20%. There is no maximum out-of-pocket amount.

MEDICARE SUPPLEMENTS (MEDIGAP)

There are different Medicare Supplement plans but they usually pay the Part A deductible and Part B coinsurance.  Some pay additional benefits like extra hospital days, skilled nursing care insurance and some foreign travel expenses. They fill in the gaps thus are sometimes called Medigap plans.

PART D

Part D pays for prescription drugs.  Most prescription medications are not covered by Original Medicare or Medicare Supplements. Prescription Drug Plans cover your prescription drug needs.  The beneficiary usually will pay a deductible then a copay or coinsurance for each prescription up to an annual limit (2025, $2000 per year).

MEDICARE ADVANTAGE (PART C)

Part C are plans offered by private insurance companies that pay for Part A and Part B covered services, i.e., they are required to provide coverage at least as good or better than Original Medicare.  There are deductible, copays and coinsurance costs which vary from plan to plan.  They all have an out-of-pocket maximum after which the plans pays 100% of covered services.  All offer some combination of additional benefits like dental, vision, hearing, fitness and over-the-counter coverage.  Some Part C plans have a Part D component and some do not.

This is not intended as comprehensive information.  The purpose of this information is to generally explain what each different component covers and how they might meet your needs.  Original Medicare is the same for everyone.  Specific plan coverage and premiums for Medicare Supplement plans, Medicare Advantage plans and Prescription Drug plans all vary.

                                  MEDICARE CREDITABLE COVERAGE 

WHAT YOU NEED TO KNOW 

What is creditable coverage?

Medicare considers insurance creditable coverage if it “meets or exceeds” Medicare standards AND can be kept in addition to or instead of Medicare.

Examples would be: employer insurance that meets the Medicare standards and you can keep as long as you are working, Veterans coverage, Medicaid.

How do I know if my insurance is “creditable”?

You should automatically receive a notice from your employer or insurance plan each September.  You can also contact human resources, drug plan provider or benefits manager.

Why do I care?

If you are eligible for Medicare and do not have coverage that is creditable for Part B and/or Part D you will be subject to penalties.  In rare circumstances there are penalties for not having creditable coverage for Part A. 

This is not intended as comprehensive information.  The purpose of this information is to generally explain that the CMS expects everyone eligible for Medicare to enroll unless they have creditable coverage and there are penalties for not doing so.

 
Do I pay for Medicare?Part A (hospital type coverage) is free to 99% percent of eligible beneficiaries based on Medicare taxes you have paid. If you are not eligible for free part A based on Medicare taxes you have paid your monthly premium will be either $285 or $505 (2025)
Part B (outpatient type charges) is not free. For 2025 most people will pay a monthly premium of $185. There are circumstances where a beneficiary may pay more or less.
Part D (prescriptions) is not free. Prescription plans are sold by third party insurers and prices vary. In 2025 the average prescription drug plan is expected to cost 46.50 per month, they range from 0.00 to 190.80 per month.
ALERT The costs above are for premiums only. Depending on your plan or combination of plans you may also be responsible to pay deductibles, copays and/or coinsurance.