Understanding How Medicare Works for Seniors

Medicare 101: What Is It?

Medicare is a government-run health insurance program designed mainly for seniors and certain individuals with disabilities. It helps cover the cost of medical care using a combination of personal payments and funds collected through payroll taxes. The program is overseen by the Centers for Medicare & Medicaid Services (CMS).

Who Can Get Medicare?

Medicare is generally available to the following groups of people:

• Adults age 65 and older
• People of any age with End-Stage Renal Disease (ESRD)
• Some younger individuals with qualifying disabilities

Your benefits under Medicare will vary depending on which parts of the program you’re enrolled in. For a breakdown of each part and what it covers, see the section titled “Medicare Parts A, B, C and D.”

Medicare and Seniors

The majority of Medicare beneficiaries are seniors aged 65 and up. Medicare is divided into four main parts, each offering specific types of coverage:

• Part A: Hospital care
• Part B: Medical services and outpatient care
• Part C: Medicare Advantage (bundled private plans that may include additional benefits)
• Part D: Prescription drug coverage

In addition, there are Medigap plans, which are optional supplemental policies that help pay for costs not fully covered by Medicare. While Medigap isn’t part of Medicare itself, it can be added to Original Medicare to help reduce out-of-pocket expenses.

How to Get in Contact With Medicare

General Medicare Contact Information

Regional Contact Info: How to Get in Touch With Centers for Medicare & Medicaid Services (CMS)

State/Territory	Regional Office	Phone Number
Alabama	Atlanta Regional Office	(404) 562 1738
Alaska	Seattle Regional Office	(206) 615-2308
American Samoa	San Francisco Regional Office	(415) 744-3502
Arizona	San Francisco Regional Office	(415) 744-3502
Arkansas	Dallas Regional Office	(214) 767-6423
California	San Francisco Regional Office	(415) 744-3502
Colorado	Denver Regional Office	(303) 844-7118
Connecticut	Boston Regional Office	(617) 565-1185
Delaware	Philadelphia Regional Office	(215) 861-4347
District of Columbia	Philadelphia Regional Office	(215) 861-4347
Florida	Atlanta Regional Office	(404) 562 1738
Georgia	Atlanta Regional Office	(404) 562-1738
Guam	San Francisco Regional Office	(415) 744-3502
Hawaii	San Francisco Regional Office	(415) 744-3502
Idaho	Seattle Regional Office	(206) 615-2308
Illinois	Chicago Regional Office	(312) 886-5344
Indiana	Chicago Regional Office	(312) 886-5344
Iowa	Kansas City Regional Office	(816) 426-5233
Kansas	Kansas City Regional Office	(816) 426-5233
Kentucky	Atlanta Regional Office	(404) 562-1738
Louisiana	Dallas Regional Office	(214) 767-6423
Maine	Boston Regional Office	(617) 565-1185
Maryland	Philadelphia Regional Office	(215) 861-4347
Massachusetts	Boston Regional Office	(617) 565-1185
Michigan	Chicago Regional Office	(312) 886-5344
Minnesota	Chicago Regional Office	(312) 886-5344
Mississippi	Atlanta Regional Office	(404) 562-1738
Missouri	Kansas City Regional Office	(816) 426-5233
Montana	Denver Regional Office	(303) 844-7118
Nebraska	Kansas City Regional Office	(816) 426-5233
Nevada	San Francisco Regional Office	(415) 744-3502
New Hampshire	Boston Regional Office	(617) 565-1185
New Jersey	New York Regional Office	Toll Free: (877) 449-5661Local: (212) 616-2229
New Mexico	Dallas Regional Office	(214) 767-6423
New York	New York Regional Office	(212) 616-2229
North Carolina	Atlanta Regional Office	(404) 562 1738
North Dakota	Denver Regional Office	(303) 844-7118
Northern Mariana Islands	San Francisco Regional Office	(415) 744-3502
Ohio	Chicago Regional Office	(312) 886-5344
Oklahoma	Dallas Regional Office	(214) 767-6423
Oregon	Seattle Regional Office	(206) 615-2308
Pennsylvania	Philadelphia Regional Office	(215) 861-4347
Puerto Rico	New York Regional Office	(212) 616-2229
Rhode Island	Boston Regional Office	(617) 565-1185
South Carolina	Atlanta Regional Office	(404) 562-1738
South Dakota	Denver Regional Office	(303) 844-7118
Tennessee	Atlanta Regional Office	(404) 562-1738
Texas	Dallas Regional Office	(214) 767-6423
Utah	Denver Regional Office	(303) 844-7118
Vermont	Boston Regional Office	(617) 565-1185
Virginia	Philadelphia Regional Office	(215) 861-4347
U.S. Virgin Islands	New York Regional Office	(212) 616-2229
Washington	Seattle Regional Office	(206) 615-2308
West Virginia	Philadelphia Regional Office	(215) 861-4347
Wisconsin	Chicago Regional Office	(312) 886-5344
Wyoming	Denver Regional Office	(303) 844-7118

How Do Seniors Usually Qualify for Medicare?

If you’re 65 or older, you’re likely able to enroll in all parts of Medicare. Depending on your work history and other factors, you may even qualify for certain benefits at no cost.

Qualifying for Part A

Seniors age 65 and up can sign up for Medicare Part A, which covers hospital care. Most people – but not everyone – can get it for free. If you qualify for premium-free Part A, you won’t need to pay a monthly fee for this coverage.

You may receive premium-free Part A if any of the following apply:

• You’re already getting retirement benefits from Social Security or the Railroad Retirement Board
• You’re eligible for those benefits but haven’t started collecting them yet
• You or your spouse worked in a Medicare-covered job and paid Medicare taxes for at least 40 quarters (about 10 years total)
• You’re currently married and your spouse qualifies for free Medicare Part A
• You’re divorced after being married for at least 10 years, and your ex-spouse qualifies
• You’re widowed and were married for at least 9 months before your spouse passed, and they qualified for premium-free benefits

If you don’t qualify for free Part A, you’ll need to pay a monthly premium. In 2025, the costs are:

• $518 per month if you have fewer than 30 quarters of work history
• $285 per month if you have between 30 and 39 quarters

Learn more in the Medicare Part A section.

Who Qualifies for Medicare Part B?

Most seniors who get free Part A are also eligible for Medicare Part B (medical coverage) automatically when they turn 65. They’ll typically be enrolled without needing to apply, but can opt out if they choose. Be aware: delaying enrollment can lead to late penalties unless you qualify for a Special Enrollment Period.

Important: Seniors in Puerto Rico must manually apply for Part B, even if they have Part A. They can do this using the Medicare Part B enrollment form (CMS-40B).

If you need to pay for Medicare Part A, you must meet all of the following to get Part B:

• Be 65 or older
• Be a U.S. citizen or a lawful permanent resident who has lived in the U.S. for at least five continuous years
• Live in the U.S. at the time you apply

Visit the Medicare Part B section for more details.

Who Can Enroll in Medicare Part C (Medicare Advantage)?

To join a Medicare Advantage (Part C) plan, you must:

• Already have Medicare Parts A and B
• Be a U.S. citizen, national, or lawfully present resident
• Live within the plan’s service area

See the Medicare Part C section for more information.

Who Can Get Medicare Part D (Drug Coverage)?

You can sign up for a Medicare Part D plan if:

• You have Medicare Part A and/or Part B
• You don’t already have creditable drug coverage through another plan

If you’re enrolled in a Medicare Advantage (Part C) plan, your drug coverage may already be included—so double-check your plan before signing up for Part D separately.

More details are available in the Medicare Part D section.

Who’s Eligible for a Medigap Plan?

Medigap plans help cover the costs that Medicare Parts A and B don’t pay for. To be eligible, you must:

• Be enrolled in both Medicare Part A and Part B
• Not be enrolled in a Medicare Advantage (Part C) plan
• Be willing to pay a monthly premium to a private insurance company
• Purchase the plan from a provider licensed in your state

You can search for Medigap policies available in your area by ZIP code using this tool: https://www.medicare.gov/medigap-supplemental-insurance-plans/#/m?lang=en&year=2025

For more, visit the Medigap Policies section.

Medicare Parts A, B, C, and D Explained

Medicare is divided into four main parts—Parts A, B, C, and D—each covering different types of health care services. Understanding what each part offers can help you make informed choices about your health coverage. Below, you’ll find a breakdown of each Medicare part, including what it covers, how costs work, and what seniors can expect.

Medicare Part A: Hospital and Related Care

Medicare Part A is the portion of Medicare that helps cover hospital stays and related services. It’s automatically included for most people who qualify for Medicare, and it covers a wide range of inpatient and facility-based care.

What Does Part A Cover?

• Inpatient hospital care, including stays in semi-private rooms, meals, general nursing services, medications, and other hospital supplies
• Care in a skilled nursing facility (SNF), including physical therapy, occupational therapy, speech therapy, and nursing care
• Inpatient mental health care in hospitals and psychiatric facilities
• Hospice care for terminal illnesses
• Home health care services such as skilled nursing visits and therapy
• Ambulance transportation when medically necessary
• Dietary counseling and swing bed services (care in a hospital bed when acute hospital care isn’t needed but skilled care still is)

Costs and How They Work

While Medicare Part A often doesn’t require monthly premiums for most enrollees, there are other costs to be aware of:

• Deductibles: The amount you pay out of pocket before Medicare starts paying. For Part A, this deductible applies each time you have a hospital stay.
• Copayments and Coinsurance: After you meet the deductible, you may pay daily coinsurance fees depending on the length of your hospital or facility stay.

Inpatient Hospital Care Details

When you are admitted to a hospital as an inpatient, Medicare Part A covers up to 90 days of care during each “benefit period.” A benefit period begins on the day you’re admitted to the hospital and ends when you haven’t been in a hospital for 60 consecutive days.

• For days 1 through 60 of your hospital stay, you pay no coinsurance.
• For days 61 through 90, you pay a daily coinsurance fee.
• If your stay goes beyond 90 days, you have access to 60 “lifetime reserve days” at a higher coinsurance cost. You get only 60 lifetime reserve days in total, so use them wisely.
• After your lifetime reserve days are used up, you’re responsible for all costs.

Inpatient Mental Health Care

Part A also covers inpatient mental health treatment at hospitals and psychiatric facilities. Services include room and board, nursing care, medications, and therapy to address conditions such as depression and anxiety.

• There is no limit on days for inpatient mental health care in general hospitals.
• However, psychiatric facilities have a lifetime limit of 190 days.
• Costs follow a similar pattern to hospital stays, with deductibles and coinsurance based on length of stay.

Skilled Nursing Facility (SNF) Care

If you require skilled nursing care or rehabilitation after a hospital stay, Medicare Part A can cover care in a Medicare-certified SNF, but only if:

• You had a qualifying hospital stay of at least three days (not counting the day of discharge).
• You enter the SNF within 30 days after leaving the hospital.
• Your doctor certifies that skilled nursing care is needed for a condition related to your hospital stay.

Costs for SNF care include:

• Days 1–20: Covered 100% by Medicare (no cost to you)
• Days 21–100: You pay a daily coinsurance fee
• Days 101 and beyond: You pay all costs

Hospice Care

Hospice care through Medicare Part A is for individuals with terminal illnesses, focusing on comfort and quality of life rather than curative treatment.

• Hospice care itself has no premium or deductible under Part A.
• You may have small copayments for prescriptions and respite care (short-term care to give your regular caregiver a break).
• Medicare doesn’t cover room and board if hospice care is provided at home or in a long-term care facility—you’re responsible for those costs unless you are admitted for short-term inpatient care for symptom management.

Home Health Care

Medicare Part A also covers certain home health services for beneficiaries who are homebound and require skilled care. This care is intermittent (not around the clock) and includes:

• Skilled nursing visits
• Physical, occupational, and speech therapy
• Home health aide services for personal care like bathing and dressing
• Medical social services
• Injectable drugs for osteoporosis

Medicare will not cover:

• 24/7 care at home
• Meals delivered to your home
• Homemaker services (such as cleaning or cooking) when that is the only type of care you need
• Personal care if that’s the only care you need

If you need durable medical equipment (DME) like walkers, wheelchairs, or hospital beds, Medicare may cover most of the cost, but you usually pay 20% coinsurance for DME.

Medicare Part B

Medicare Part B is designed to cover medically necessary services and preventive care, as well as outpatient treatments that don’t require hospital admission. Unlike Part A, which mainly focuses on hospital stays, Part B supports ongoing healthcare needs outside of inpatient care. This coverage requires enrollees to pay monthly premiums, along with other potential costs depending on their usage.

What Does Medicare Part B Cover?

Medicare Part B includes a wide range of healthcare services and supplies essential for diagnosis, treatment, and maintaining health outside of a hospital stay. Some key categories of Part B coverage include:

• Clinical Research: Medicare supports participation in approved research studies aimed at developing new treatments and medical advancements.
• Diagnostic Tests: This includes lab work, X-rays, MRIs, and other procedures used to diagnose health conditions.
• Surgical Treatment: Medically necessary outpatient surgeries are covered under Part B.
• Medicine: Certain medications, especially those administered by a healthcare professional rather than self-administered drugs, are covered.
• New Types of Patient Care: Medicare often covers innovative care methods as they become medically accepted.
• Ambulance Services: Ground and emergency air ambulance transport for urgent medical needs.
• Durable Medical Equipment (DME): Medical devices prescribed for home use to support mobility or health maintenance.
• Mental Health Care: Both outpatient treatment and limited inpatient services related to mental health.
• Preventive Care: Annual wellness visits and screenings, including one depression screening per year.

Durable Medical Equipment (DME) Included Under Part B

Durable Medical Equipment refers to medically necessary devices prescribed by a doctor for home use. Examples include:

• Blood sugar monitors and test strips
• Canes and crutches
• Commode chairs
• CPAP (Continuous Positive Airway Pressure) devices
• Hospital beds
• Infusion pumps and supplies
• Nebulizers and related medications
• Oxygen equipment and accessories
• Walkers, wheelchairs, and scooters
• Patient lifts and pressure-reducing surfaces

Medicare only pays for DME if both the prescribing doctor and the equipment supplier participate in Medicare. This ensures that the enrollee pays only the deductible and coinsurance rather than the full cost.

Mental Health Care Under Part B

Part B covers outpatient mental health services, which are services provided outside of hospitals without an overnight stay. These include:

• Annual depression screening
• Individual and group psychotherapy (talk therapy)
• Family counseling
• Psychiatric evaluations and diagnostic testing
• Medication management for certain injectable or non-self-administered drugs
• Partial hospitalization programs (more intensive outpatient care)
• Treatment for substance abuse and alcoholism

Costs and Coverage Details for Medicare Part B

Monthly Premiums

All Medicare recipients pay a monthly premium for Part B coverage. In 2025, the standard premium is $185 per month. This amount may be higher for individuals or couples with higher incomes, based on their modified adjusted gross income (MAGI) from tax returns filed two years before applying for Medicare.

If your yearly income in 2023 (for what you pay in 2025) was			You pay each month (in 2025)
File individual tax return	File joint tax return	File married & separate tax return
$106,000 or less	$212,000 or less	$106,000 or less	$185.00
above $106,000 up to $133,000	above $212,000 up to $266,000	Not applicable	$259.00
above $133,000 up to $167,000	above $266,000 up to $334,000	Not applicable	$370.00
above $167,000 up to $200,000	above $334,000 up to $400,000	Not applicable	$480.90
above $200,000 and less than $500,000	above $400,000 and less than $750,000	above $106,000 and less than $394,000	$591.90
$500,000 or above	$750,000 or above	$394,000 or above	$628.90

Deductibles and Coinsurance

• Annual Deductible: $257 (2025)
  Enrollees pay this amount out of pocket before Medicare begins to cover costs for Part B services each year.
• Coinsurance: 20% of Medicare-approved costs after the deductible is met. This means Medicare pays 80%, and the enrollee pays 20% for most covered services.

Common services subject to coinsurance include:

• Doctor visits
• Outpatient therapy
• Durable medical equipment

Ambulance Services Coverage

Medicare Part B covers ambulance transportation to the nearest appropriate facility when other transportation would endanger your health. This includes:

• Ground ambulance
• Emergency air transport (helicopter or airplane) when ground transport is unavailable or too slow

Costs include:

• 20% coinsurance of the Medicare-approved amount
• Deductible applies if not already met

Limited Outpatient Prescription Drugs

Part B covers certain outpatient drugs typically administered in a doctor’s office or hospital outpatient setting, such as injections and infusions. Patients pay:

• 20% coinsurance on Medicare-approved amounts
• Deductible applies before coverage begins

If the hospital participates in the 340B Drug Pricing Program, patients may pay less. Drugs not covered by Part B require separate prescription drug coverage, often through Medicare Part D.

Medicare Part C

Medicare Part C, commonly known as Medicare Advantage, offers an alternative way to receive your Medicare benefits through private insurance companies approved by Medicare. These plans combine all the benefits of Medicare Parts A and B, and often include Part D prescription drug coverage as well.

Many Medicare Advantage plans provide expanded coverage beyond original Medicare, often including vision, hearing, and dental services—benefits not typically covered by standard Medicare.

How Medicare Part C Works

Medicare Part C plans operate similarly to private health insurance plans. Enrollees usually need to use a network of doctors and hospitals designated by the plan to get the full range of benefits at lower costs. Staying inside the network typically means lower copayments compared to standard Medicare. However, care received outside the network can be more expensive or not covered at all, depending on the plan type.

Types of Medicare Part C Plans

There are several kinds of Medicare Advantage plans, each with different rules and coverage options:

• Health Maintenance Organization (HMO) Plans:
  These plans require you to get care within the plan’s network, except in emergencies. Referrals from your primary care doctor are usually needed to see specialists. Going outside the network often results in higher out-of-pocket costs, and sometimes the full cost is your responsibility.
• Preferred Provider Organization (PPO) Plans:
  PPO plans encourage use of network providers but allow coverage for out-of-network care at a higher cost to you. Typically, you do not need referrals to see specialists, giving more flexibility than HMOs.
• Private Fee-For-Service (PFFS) Plans:
  PFFS plans resemble original Medicare more closely. You can visit any Medicare-approved provider who agrees to the plan’s terms. Some PFFS plans have networks with lower costs, while others do not. Prescription drug coverage may not be included, so you might need to enroll separately in Medicare Part D if your plan does not offer it.
• Special Needs Plans (SNPs):
  Designed for people with specific health conditions or limited incomes, SNPs often require care within a network and may assign a primary care provider or care coordinator. SNPs must include Part D drug coverage. You qualify if you:
  • Have a chronic illness
  • Live in a nursing facility or require nursing care at home
  • Are eligible for both Medicare and Medicaid

• Medicare Savings Account (MSA) Plans:
  MSA plans combine a high-deductible health plan with a medical savings account you can use to pay for medical expenses. If you choose an MSA, you generally must have separate Part D drug coverage unless you already have a Medigap plan with prescription benefits.

Availability of Medicare Part C Plans

The types and number of Medicare Advantage plans vary by location. Some areas may offer multiple plan types, while others have limited or no Medicare Advantage options.

To find plans available in your area, visit medicare.gov/plan-compare and enter your ZIP code.

Part C Costs and Coverage Details

Medicare Part C plans provide all Part A and Part B benefits, but costs differ depending on the plan you select:

• Monthly Premiums:
  Most Medicare Advantage plans charge a monthly premium in addition to your Part B premium. Some plans may have a $0 premium or cover your Part B premium entirely. MSA plans require you to pay your Part B premium but usually do not charge additional Part C premiums.
• Copayments and Coinsurance:
  These vary widely depending on the plan and services received. Generally, Medicare Advantage plans offer lower copayments for doctor visits and other services than standard Medicare.
• Out-of-Pocket Limits:
  All Medicare Advantage plans have a yearly maximum limit on your out-of-pocket costs for Part A and Part B services, protecting you from very high expenses. In 2025, this limit cannot exceed $9,350, though many plans set lower caps.

Medicare Part D

Medicare Part D, often called a drug coverage plan, offers prescription drug benefits to supplement Original Medicare (Parts A and B). Since Medicare Parts A and B do not cover most prescription medications, seniors can opt to enroll in a Part D plan to help pay for their prescription drug costs. Enrollment in Medicare Part D is optional—beneficiaries may choose to join a plan if they do not already have prescription drug coverage through another insurance source.

Medicare Part D plans are provided by private insurance companies approved by Medicare. Availability of specific Part D plans depends on where the enrollee lives, with different companies and plan options offered in different regions.

Each plan has its own list of covered drugs, called a formulary, which categorizes medications into different tiers based on factors like cost and specialization. Generally, generic drugs are the least expensive, followed by brand-name drugs, and then specialized medications which tend to cost the most.

Required Drug Coverage Classes

All Medicare Part D plans must cover at least two drugs from each of the following classes, ensuring that beneficiaries have access to key medications:

• Antidepressants
• Antipsychotics
• Anticonvulsants
• Cancer drugs
• HIV/AIDS drugs
• Immunosuppressants

This requirement guarantees that if one version of a drug is unavailable, the plan will cover an alternative, such as a generic or equivalent medication.

Understanding the Drug Formulary

Each insurance company offering a Part D plan designs its own formulary, which lists all the prescription drugs the plan covers. The formulary is usually organized by tiers, which help determine your copayment or coinsurance amounts. Lower tiers generally include generic drugs with the lowest copays, while higher tiers cover brand-name and specialty drugs that usually require higher out-of-pocket costs.

Costs and Coverage Details

Medicare Part D enrollees pay a monthly premium to maintain their drug coverage. Premium amounts vary widely depending on the plan and the enrollee’s location.

Income-Related Additional Costs

Seniors with higher incomes may be required to pay an extra charge called the Income-Related Monthly Adjustment Amount (IRMAA) on top of their standard Part D premium. For 2025, this surcharge applies if your income exceeds the following thresholds based on your tax return from 2 years ago:

If your filing status and yearly income in 2023 was
File individual tax return	File joint tax return	File married & separate tax return	You pay each month (in 2025)
$106,000 or less	$212,000 or less	$106,000 or less	your plan premium
above $106,000 up to $133,000	above $212,000 up to $266,000	not applicable	$13.70 + your plan premium
above $133,000 up to $167,000	above $266,000 up to $334,000	not applicable	$35.30 + your plan premium
above $167,000 up to $200,000	above $334,000 up to $400,000	not applicable	$57.00 + your plan premium
above $200,000 and less than $500,000	above $400,000 and less than $750,000	above $106,000 and less than $394,000	$78.60 + your plan premium
$500,000 or above	$750,000 or above	$394,000 or above	$85.80 + your plan premium

Medigap Policies

Medigap policies are private insurance plans designed to help cover healthcare costs that Original Medicare (Parts A and B) doesn’t fully pay for. These can include expenses like copayments, coinsurance, and deductibles. Unlike Medicare itself, Medigap plans are sold by private insurance companies, not the federal government.

Medigap policies are sold on an individual basis. There are no group, family, or spousal Medigap plans. If a married couple wants Medigap coverage, each spouse must buy their own separate policy.

Prescription Drug Coverage

Medigap plans do not include prescription drug coverage. Seniors who need drug coverage must enroll in a separate Medicare Part D plan. (Some Medigap policies sold before January 1, 2006, may include prescription drug coverage, but no policies sold after this date offer drug benefits.) For more details, see the “Medicare Part D” section.

Standardized Plans

Medigap policies are standardized, meaning plans with the same letter offer the same basic benefits no matter which insurance company sells them. This makes it easier to compare plans. However, premiums and costs can differ between companies even for identical plan letters.

Comparing Medigap Policies

Except in Massachusetts, Minnesota, and Wisconsin, Medigap plans follow a uniform standard and are categorized by letter, similar to Medicare plans.

Comparing Medigap Policies

In all states except Massachusetts, Minnesota and Wisconsin, Medigap policies are standardized the same way. Like Medicare plans, Medigap policies are also categorized by letter.

The following Medigap plans are available: 

• A
• B
• C*
• D
• F*
• G
• K
• L
• M
• N

Plan Differences

The main differences between these plans relate to:

• Deductibles
• Copayments
• Coverage of skilled nursing facility care

Insurance companies decide which Medigap plans they want to offer but must meet the following rules:

• They do not have to offer every Medigap plan.
• If they sell any Medigap plan, they must offer Plan A.
• If they offer plans beyond Plan A, they must also offer either Plan C or Plan F.

Medigap Benefits by Policy

Medigap policies are grouped into 10 different plans, each offering a unique set of benefits to Medicare recipients. The table below outlines the benefits included with each Medigap plan available in all states except Massachusetts, Minnesota, and Wisconsin. For details about Medigap policies in those three states, please see the “Medigap Policies in Massachusetts, Minnesota and Wisconsin” section of this guide.

Medigap Benefits	Medigap Plans	colspan	colspan	colspan	colspan	colspan	colspan	colspan	colspan	colspan
	A	B	C	D	F*	G*	K	L	M	N
Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Part A hospice care coinsurance or copayment	Y	Y	Y	Y	Y	Y	50%	75%	Y	Y
Part A deductible	N	Y	Y	Y	Y	Y	50%	75%	50%	Y
Part B coinsurance or copayment	Y	Y	Y	Y	Y	Y	50%	75%	Y	Y***
Part B deductible	N	N	Y	N	Y	N	N	N	N	N
Part B excess charges	N	N	N	N	Y	Y	N	N	N	N
Blood transfusions per year (first 3 pints)	Y	Y	Y	Y	Y	Y	50%	75%	Y	Y
Skilled nursing facility care coinsurance	N	N	Y	Y	Y	Y	50%	75%	Y	Y
Foreign travel exchange	N	N	80%	80%	80%	80%	N	N	80%	80%
Out-of-pocket limit for 2024**	N/A	N/A	N/A	N/A	N/A	N/A	$7,060	$3,530	N/A	N/A

Medigap Policies in Massachusetts, Minnesota, and Wisconsin

In Massachusetts, Minnesota, and Wisconsin, Medigap policies follow different standardization rules. Read on to learn more about how Medigap works in each of these states.

Medigap Policies in Massachusetts

All Medigap policies in Massachusetts must cover these basic benefits:

• Part A coinsurance
• Part A hospice cost sharing
• Gap coverage for some Medicare Part A enrollees required to pay for hospice care or services
• 365 days of additional Part A hospital coverage after Medicare coverage ends
• Part B coinsurance
• First 3 pints of blood for transfusions per year

Beneficiaries in Massachusetts can select from three Medigap plans:

• Core Plan
• Supplement 1 Plan
• Supplement 1A Plan

Core Plan
Covers basic benefits plus:

• 60 inpatient days in a mental health treatment facility per year
• State-mandated benefits such as yearly pap smears and mammograms

Supplement 1 Plan
Includes everything in the Core Plan plus:

• Part A inpatient hospital deductible
• Part A skilled nursing facility coinsurance
• Part B deductible
• Foreign travel emergency costs
• 120 inpatient days for mental health treatment per year

Supplement 1A Plan
Includes everything in the Core Plan plus:

• Part A inpatient hospital deductible
• Part A skilled nursing facility coinsurance
• Foreign travel emergency costs
• 120 inpatient days for mental health treatment per year

Medigap Policies in Minnesota

All Minnesota Medigap policies must cover the following benefits:

• Part A coinsurance
• Part B coinsurance
• Part A hospice care cost sharing
• Gap coverage for some Medicare Part A enrollees required to pay for hospice care or services
• Parts A and B home health services and supplies cost sharing
• First 3 pints of blood for transfusions per year

Minnesota offers two Medigap plans:

• Basic Plan
• Extended Basic Plan

Basic Plan
Covers:

• Basic benefits
• Part A skilled nursing facility (SNF) coinsurance covering 100 days of care
• 80% of foreign travel emergency costs
• 50% of outpatient mental health care costs
• Medicare-covered preventive care
• 20% of physical therapy costs
• State-mandated benefits including diabetic equipment and supplies, routine cancer screening, reconstructive surgery, immunizations

Extended Basic Plan
Includes everything in the Basic Plan plus:

• Part A inpatient hospital deductible
• Part A skilled nursing facility coinsurance covering 120 days of care
• Part B deductible (not available for new Medicare enrollees as of January 1, 2020)
• 80% of foreign travel emergency costs
• 50% of outpatient mental health care
• 80% of usual and customary fees
• Medicare-covered preventive services
• 20% of physical therapy
• State-mandated benefits as above

Medigap Policies in Wisconsin

Wisconsin Medigap policies must cover the following benefits:

• Part A inpatient hospital coinsurance
• Part A hospice cost-sharing
• Gap coverage for some Medicare Part A enrollees required to pay for hospice care or services
• Part B coinsurance
• First 3 pints of blood for transfusions per year

Wisconsin has one main Medigap plan called the Basic Plan, but insurers have flexibility to add extra benefits.

All Basic Plans cover:

• Basic benefits
• Part A skilled nursing facility coinsurance
• 175 days of inpatient mental health care beyond Medicare limits
• 40 home health care visits beyond Medicare limits
• State-mandated benefits

Other Medigap options in Wisconsin include 50% and 25% cost-sharing plans similar to standardized Plans K and L (see “Medigap Benefits by Policy”). Insurance companies can offer Basic Plans with a high deductible of $2,800 in 2024.

Optional benefits insurers may add include:

• 50% Part A deductible
• Part B deductible (not for newly eligible Medicare recipients since January 1, 2020)
• Part B copayment or coinsurance
• Part B excess charges
• Additional home health care (up to 365 visits, including those covered by Medicare)
• Expenses related to foreign travel emergencies

Applying for Medicare: What Information and Documents Do You Need?

When applying for Medicare, you’ll need to provide specific information and documents to verify your eligibility.

Applying for Medicare Parts A and B

You will need to provide:

• Your date and place of birth
• Your Medicaid number and start date, if applicable
• Your current health insurance information

If applying as the spouse of someone eligible for Medicare, also provide:

• Marriage and divorce details
• Name of current spouse
• Name of previous spouse (if marriage lasted over 10 years or ended by death)
• Spouse’s date(s) of birth and Social Security number(s)
• Beginning and end dates of marriage(s)
• Place(s) of marriage(s)
• Names and birthdates of children who:
  • Became disabled before age 22, or
  • Are under 18 and unmarried, or
  • Are 18 or 19 and attending school full time

U.S. Military Service History (if applicable)

• Branch served in
• Position held
• Start and end dates

Employment Information (Last 3 Years)

If not self-employed, provide:

• Employer name(s)
• Start and end dates

If self-employed, provide:

• Business type
• Total net income

Additional Information

• Bank account details for direct deposit

Applying for Medicare Parts C or D

You will need the following information from your Medicare card:

• Medicare number
• Start date(s) of Medicare Parts A and/or B coverage

Ways to Apply for Original Medicare (Parts A and B)

You can apply for Medicare Parts A or B in the following ways:

• Online
• By phone
• In person

Steps to Apply Online

Follow these steps to apply for Parts A and B online:

1. Head to the Social Security website:
   https://www.socialsecurity.gov/medicare/apply.html
2. Click “Apply for Medicare Only.”
   This link takes you to the “Apply for Benefits” portal on the Social Security website.
3. Enter your information.
   The application typically takes 10 to 30 minutes.
4. Click “Submit Now.”
   After submitting, you’ll receive a receipt and application number—keep these for your records. The Social Security Administration (SSA) will process your application and mail you their decision.

Applying by Phone

Enroll in Medicare Parts A and B by calling 1-800-772-1213. 

Applying in Person

Enroll in Medicare Parts A and B by visiting your local Social Security office. Search for an office near you using the locator tool here: https://secure.ssa.gov/ICON/main.jsp 

How to Enroll in Medicare Part C

Medicare Part C (also called Medicare Advantage) is offered through private insurance companies, so the enrollment process can vary depending on your plan. Here are some common ways you can sign up:

• Online
  Check your plan provider’s website to see if they offer an online application. This is often the quickest way to enroll.
• By phone
  You can call your insurance company directly to ask about signing up or get help with the application. If you prefer, you can also call the national Medicare helpline at 1-800-633-4227 for assistance.
• By mail or in person
  Every Medicare Part C plan must provide a paper application. Some plans let you mail it in, while others require you to drop it off at their office. Be sure to ask your provider what options they offer.

Before enrolling, it’s important to find a Medicare Advantage plan that’s available where you live. You can use the official Medicare plan finder tool here: https://www.medicare.gov/plan-compare/

Signing Up for Medicare Part D

Before you can enroll in a Medicare Part D prescription drug plan, you’ll want to make sure the plan is available where you live. You can find and compare plans using the Medicare plan finder here: https://www.medicare.gov/plan-compare/

Once you’ve chosen a plan that fits your needs, here are the main ways to sign up:

• Online
  Many plans let you apply right on their website. You can also use the official Medicare site to enroll online.
• By phone
  You can call your drug plan provider to get information or to start the enrollment process. If you need extra help, the Medicare hotline at 1-800-633-4227 is available for assistance.
• By mail or in person
  Every Part D plan is required to provide a paper application. Some plans allow you to mail it in, while others ask that you submit it in person. Be sure to check with your plan for their specific process.

What Is the Program of All-Inclusive Care for the Elderly (PACE)?

PACE is a collaborative effort between Medicare and Medicaid designed to help older adults receive comprehensive medical care while staying in their own communities instead of moving to nursing homes or long-term care facilities.

Who Can Benefit from PACE?

Older adults who join PACE gain access to a dedicated healthcare team that manages and coordinates all aspects of their care. The program covers a wide range of services approved by healthcare professionals, all aimed at meeting participants’ medical needs under Medicare and Medicaid.

Services Included in PACE

Some of the care and support services covered by PACE include:

• Primary care during adult day programs
• Regular doctor and specialist visits
• Emergency medical services
• Hospital stays and treatments
• Home health care
• Dental care
• Prescription medications
• Nutritional counseling
• Physical and occupational therapies
• Preventive care and social services
• Transportation to appointments
• Nursing home care when necessary

Availability of PACE Programs

Because PACE is managed locally and not run as a federal program, its availability varies by location. There are currently over 185 PACE programs operating across 33 states. However, even if your state has a PACE program, it might not serve your specific area.

Here are some of the states with active PACE programs:

• California, Florida, New York, Texas, and Washington
• Illinois, Ohio, Pennsylvania, Wisconsin
• And many others — 33 states in total

To check if PACE is offered near you, use the official locator tool here:
https://www.npaonline.org/pace-you/pacefinder-find-pace-program-your-neighborhood

Requirements to Participate in PACE

To qualify for PACE, individuals must:

• Be at least 55 years old
• Live within the service area of a local PACE provider
• Need a nursing home level of care, as determined by your state’s certification
• Be able to safely live in the community with support from PACE services

Applying for PACE

Since PACE programs are run independently in each state, the application process can vary. Generally, you’ll need to provide documentation such as:

• Proof of age (e.g., birth certificate)
• Proof of residence (e.g., utility bill, lease, mortgage statement)
• Medical documentation confirming the need for nursing home-level care

If you’re interested in joining PACE, start by finding out if a program operates in your area using the locator tool above. Then, contact the local PACE provider directly to get details on how to apply.

VA Health Care Benefits for Older Veterans

The U.S. Department of Veterans Affairs (VA) offers a range of health care services specifically for senior veterans. These benefits make it possible for veterans to receive medical treatment and support at VA facilities nationwide.

Who Qualifies for VA Health Care?

Senior veterans may be eligible for VA health care benefits if they meet certain service and discharge requirements.

Basic Service Requirements

To qualify, you must:

• Have served in the active military, naval, or air service
• Not have received a dishonorable discharge

Note for National Guard or Reserve Members:
You must have been called to active duty by a federal order and completed your full period of service. Simply serving for training purposes does not count toward VA health care eligibility.

Additional Service Time Rules

If you enlisted after September 7, 1980, or entered active duty after October 16, 1981, you must meet one of the following:

• Served 24 continuous months, or
• Completed the full term of your service, unless you were:
  • Discharged due to a service-connected disability
  • Discharged for hardship or under “early out” provisions
  • A veteran who served before the above dates

What Does VA Health Care Cover?

Veterans enrolled in VA health care have access to many important services, including:

• Preventive checkups and screenings
• Hospital care for inpatient treatment
• Emergency and urgent care when needed
• Mental health counseling and support
• Prescription medications
• Necessary medical tests and diagnostics
• Rehabilitation and therapy services deemed essential
• Prosthetic devices and hearing aids
• Radiation treatments
• Routine eye exams

Applying for VA Health Care: What to Know

Before you can access any specific services through the VA—like long-term or in-home care—you’ll need to start by applying for general VA health care coverage.

Four Ways to Apply

You can apply using whichever method works best for you:

• Online
• By phone
• By mail
• In person

1. Online Application

Quickest option:
Go to the official VA application page: Apply for Health Care

Before you start:

• Log in to your VA.gov account (if you have one) to save your progress.
• Make sure you’ve gathered all necessary documents—see the “Information and Documents Needed to Apply” section for what you’ll need.

After submitting:

• You’ll see a confirmation once it’s sent.
• The VA will mail your enrollment decision within a week.
• Didn’t get it? Call 877-222-8387.

2. Apply by Phone

Call the VA directly at 1-877-222-8387, Monday through Friday, 8 AM – 8 PM ET. A representative will help walk you through the process.

3. Apply by Mail

Prefer paper forms? Here’s how:

1. Download VA Form 10-10EZ:
   Get the form here
2. Complete, sign, and date the form.

Special cases:

• Using a Power of Attorney? Include the POA form: Download here
• Signing with an “X”? Two people you know must witness and also sign the form.

3. Mail everything to:

Health Eligibility Center
2957 Clairmont Road, Suite 200
Atlanta, GA 30329

4. Apply in Person

Want to drop off your paperwork instead?

1. Fill out VA Form 10-10EZ: Download here
2. Bring it to a VA location near you.
   Use this VA office locator to find one close by.

Note: If using a Power of Attorney or signing with an “X,” follow the same steps as for mail-in applications.

Geriatrics and Extended Care Services

For veterans who need more comprehensive support, VA health care also covers geriatrics and extended care (GEC). This includes services like assisted living, home health care, and residential care designed to help seniors live as independently as possible.

What You’ll Need When Applying for Medicare

If you are applying for Medicare, certain documents and information are necessary to confirm your eligibility:

For Medicare Parts A and B:

• Your date and place of birth
• Medicaid number and start date, if applicable
• Details about any current health insurance coverage

If you’re applying as the spouse of someone already eligible, additional info is required, such as:

• Marriage and divorce records
• Names and birthdates of current and previous spouses (especially if a marriage lasted 10+ years or ended due to death)
• Birthdates and Social Security numbers of your spouse(s)
• Dates and locations of your marriages
• Information about children who are disabled before age 22, or are under 18 and unmarried, or 18-19 years old attending school full time

Military service history details, including:

• Branch of service
• Positions held
• Service start and end dates

Employment info for the past three years (if not self-employed):

• Employer names
• Employment dates

If self-employed:

• Business type
• Net income during that time

Bank account info to set up direct deposit for payments

For Parts C or D

When enrolling in Medicare Parts C or D, you will need information from your Medicare card, including:

• Your Medicare number
• The start dates of your Medicare Part A and/or Part B coverage

How to Get Geriatric & Extended Care (GEC)

After you’re approved for general VA health care, you can apply for long-term or in-home care under GEC.

Here’s how to get started:

• Talk to your VA social worker, or
• Call the VA at 877-222-8387 (Weekdays, 8 AM – 8 PM ET)

What to Expect with GEC Service

The VA will review whether you qualify based on your health needs and care availability in your area. Copays for GEC services depend on:

• Your income
• VA disability rating
• The type of care you need

Note on Costs:

• No copay for hospice care
• No long-term care copays for the first 21 days
• VA may bill your non-Medicare insurance for non-service-related treatments

If your insurance pays the VA, your out-of-pocket costs may be reduced.

How to Contact VA Health Care

VA Health Care – Department of Veterans Affairs (VA)