Your Free Guide to Medicare

What is Medicare?

Medicare is a federal health insurance program primarily for older adults and certain individuals with disabilities. It’s funded through a mix of personal premiums and payroll taxes, and it’s overseen by the Centers for Medicare & Medicaid Services (CMS).

Who Qualifies for Medicare?

You may be eligible for Medicare if you fall into one of the following categories:

You’re 65 years old or older
You have end-stage renal disease (ESRD)
You’re under 65 and have a qualifying disability

The type of health services you can receive through Medicare depends on which parts of the program you’re enrolled in. To explore your options, check out the section titled “Programs in Medicare.”

If you want to know how Medicare eligibility works for people with disabilities, see the section “Defining Disability.”

How Is Medicare Different From Medicaid?

Medicare and Medicaid are two separate government programs that provide health coverage, but they serve different groups of people.

Medicare is mainly for older adults and certain people with disabilities.
Medicaid helps low-income individuals and families, including children, pregnant women, and adults.

Some people may qualify for both programs—these individuals are known as dual-eligible.

While both programs are managed at the federal level by CMS, Medicaid is also run by individual states. That means eligibility rules, benefits, and costs can vary depending on where you live.

Also, Medicare has specific enrollment periods, often tied to age or life events, while Medicaid applications are accepted year-round.

For details on when and how to sign up for Medicare, visit the section “How to Apply for Medicare.”

Contact Information for Medicare

Phone Number: 1-800-MEDICARE (1-800-633-4227)
TTY Number:1-877-486-2048

Mailing Address:
Medicare Contact Center Operations
PO Box 1270
Lawrence, KS 66044

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	(212) 616-2229
New Mexico	Dallas Regional Office	(214) 767-6423
New York	New York Regional Office	Toll-Free: (877) 449-5661 Local: (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
U.S. Virgin Islands	New York Regional Office	(212) 616-2229
Utah	Denver Regional Office	(303) 844-7118
Vermont	Boston Regional Office	(617) 565-1185
Virginia	Philadelphia Regional Office	(215) 861-4140
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

Medicare Program Options

Medicare is made up of several parts, each offering different types of coverage. Here’s a breakdown of the main components:

Part A – Covers hospital-related services
Part B – Helps pay for medical services like doctor visits
Part C – Also known as Medicare Advantage, includes additional benefits
Part D – Offers prescription drug coverage
Medigap – Private plans that help pay for out-of-pocket Medicare costs
PACE – A program providing comprehensive care to certain elderly individuals

Part A: Hospital Insurance

Medicare Part A covers services you receive in a hospital or facility, as well as some home-based and end-of-life care. Most people enrolled in Medicare have Part A automatically.

Part A covers:

Inpatient hospital care – Room, meals, general nursing, medications, and other hospital services
Skilled nursing facility (SNF) care – Must follow a qualifying hospital stay
Hospice care – End-of-life support for those with terminal illness
Home health care – Skilled nursing and therapy for homebound individuals
Mental health services – Care provided in a hospital or psychiatric facility

Who Can Get Medicare Part A?

You can typically get Part A if you are:

65 or older
Under 65 and receiving disability benefits
Diagnosed with End-Stage Renal Disease (ESRD)

Disability & Early Medicare Enrollment

If you’re under 65 and receive disability benefits from Social Security or the Railroad Retirement Board (RRB) for at least 24 months, you’ll be automatically enrolled in Medicare. Your card usually arrives about three months before your 25th month of benefits.

These benefits can qualify you for Medicare:

Retirement: Usually available after 40 work credits (~10 years) of paying into the system.
Disability: Based on medical inability to work and meeting SSA’s disability standards.

Railroad Retirement Board (RRB):

Retirement & Disability: For those with sufficient railroad work history. Disability is based on the inability to do basic work tasks.

Visit:

What Counts as a Disability?

SSA standards include:

Inability to do past work
Medical condition prevents adapting to new work
Condition expected to last at least a year or result in death

RRB criteria include:

Permanent disability that prevents basic functions like walking, lifting, understanding instructions, or adapting to workplace changes

Medicare Part A Costs

Premium-Free Part A

Most people don’t pay a premium if:

They (or a spouse) paid Medicare taxes for 40 quarters
They’re already receiving SSA or RRB retirement benefits
They’re eligible for benefits but haven’t claimed them yet
They meet spousal or survivor criteria

Younger individuals may qualify if:

They receive SSA or RRB disability benefits for 24+ months
They have ESRD

Paying for Part A

If you didn’t pay enough into Medicare:

Fewer than 30 quarters: $515/month (2025)
30–39 quarters: $285/month

Other Part A Costs

Hospital & Long-Term Care

Medicare uses “benefit periods” to determine cost:

Deductible (2025): $1,676 per benefit period
Days 1–60: $0 coinsurance
Days 61–90: $419/day
Days 91+ (using lifetime reserve days): $838/day
After using all 60 lifetime reserve days: You pay full cost

You’ll also pay 20% of Medicare-approved costs for mental health services from doctors during hospital stays.

Mental Health Inpatient Care

Medicare covers:

Room, meals, nursing, therapy, medication, lab tests

Limits:

No cap for general hospitals
Lifetime cap of 190 days in psychiatric facilities

Same cost structure as regular inpatient care applies.

Not covered:

Private rooms (unless medically necessary)
Personal items, TV/phone charges
Private duty nursing

Skilled Nursing Facility (SNF) Care

Covered only if:

You had a 3-day hospital stay
You enter a SNF within 30 days of discharge
The care is related to the hospital condition
Your benefit period hasn’t ended

Costs:

Days 1–20: $0
Days 21–100: $209.50/day
Day 101 and after: You pay full cost

Hospice Care

For terminal illnesses:

Medicare covers most hospice services at no cost
$5 copay per prescription
Up to 5% cost for respite care
Doesn’t cover room and board, except in short-term hospice stays

Home Health Services

Covered at no cost when:

A doctor certifies you’re homebound and need skilled care
You receive services from a Medicare-certified agency

Covered:

Part-time skilled nursing
Physical/occupational/speech therapy
Home health aide (for hands-on care)
Medical social services
Injectable osteoporosis drugs

Not covered:

24/7 care
Meal delivery
Housekeeping if that’s the only care needed
Basic personal care without skilled services

If you need durable medical equipment (DME) like walkers or hospital beds, you pay 20% of the Medicare-approved cost.

Medicare Part B: Medical Insurance

Medicare Part B helps cover outpatient medical services and preventive care. Unlike hospital coverage (Part A), this is optional and requires monthly premium payments. Part B includes doctor visits, diagnostic tests, mental health care, certain prescription drugs, and medical equipment used at home.

What Does Medicare Part B Cover?

Part B covers medically necessary treatments and many preventive services. These include:

Outpatient & Preventive Care

Clinical research studies
Diagnostic and lab tests
Outpatient surgery
Vaccines, injections, and IV medications
Annual “Wellness” check-ups
One-time “Welcome to Medicare” visit

Ambulance Transportation

Emergency ground and air transport
Non-emergency transport (if medically necessary)

Durable Medical Equipment (DME)

Must be prescribed for home use by a Medicare-participating provider
Examples include:
- Walkers, wheelchairs, scooters
- Hospital beds
- Oxygen supplies
- Nebulizers and infusion pumps
- CPAP devices
- Blood sugar monitors, lancets, and test strips

Mental Health Services

Outpatient care, including:
- Individual or group therapy
- Family counseling
- Medication management
- Diagnostic testing
- Partial hospitalization
Annual depression screening (covered once per year by a primary care provider)

Prescription Drugs (Limited)

Injectable and infusion medications (not self-administered)
Some drugs used with DME (e.g., infusion pumps)
Hospital outpatient prescriptions (discounted if hospital participates in 340B Drug Pricing Program)

How to Qualify for Part B

Eligibility depends on your status with Medicare Part A:

If you don’t pay premiums for Part A: You’ll be automatically enrolled in Part B when you qualify for Medicare (you can choose to keep or decline it).
If you do pay premiums for Part A, you can apply for Part B if:
- You’re at least 65 years old
- You’re a U.S. citizen or a lawfully present permanent resident who’s lived in the U.S. for 5 continuous years

Note:
If you live in Puerto Rico, you must actively enroll in Part B by submitting Form CMS-40B.

Enrollment Timing Matters

Declining Part B when first eligible may lead to:

Late enrollment penalties
Limited enrollment windows later on

See the “When to Apply for Medicare” section for more details.

Part B Costs

All Medicare Part B enrollees must pay a monthly premium.

Standard premium (2025): $185
Premiums are automatically deducted from SSA, RRB, or OPM benefits if applicable
Higher-income individuals pay more based on their Modified Adjusted Gross Income (MAGI)

Individual MAGI	Joint MAGI	Married Filing Separately	Monthly Premium
≤ $106,000	≤ $212,000	≤ $106,000	$185
$106,000.01–$133,000	$212,000.01–$266,000	N/A	$259
$133,000.01–$167,000	$266,000.01–$334,000	N/A	$370
$167,000.01–$200,000	$334,000.01–$400,000	N/A	$480.90
$200,000.01–$500,000	$400,000.01–$750,000	$106,000.01–$394,000	$591.90
$500,000.01+	$750,000.01+	$394,000.01+	$628.90

Annual deductible (2025): $257
After meeting your deductible, you pay 20% of Medicare-approved costs
No coinsurance for certain preventive services, such as:
- Lab tests
- Home health care
- Depression screenings

Costs by Service Type

Doctor Visits & Therapy

20% coinsurance after deductible

Durable Medical Equipment (DME)

Must be prescribed and obtained through a Medicare-participating provider
You pay 20% coinsurance, plus the deductible (if not yet met)
Some equipment may be rented, depending on your needs

Clinical Research Participation

Medicare covers 80% of approved trial costs
You pay 20%, and the deductible may apply

Ambulance Services

20% of the cost for:
- Ground transport to nearest suitable facility
- Emergency air transport when needed
Medicare only pays if other forms of travel would endanger your health

Outpatient Prescription Drugs

20% coinsurance for:
- Drugs used with DME
- Some injectable medications
- Antigens and certain osteoporosis drugs

If the hospital participates in the 340B Drug Program, you’ll pay 20% of the discounted rate.

Drugs not covered under Part B are your full responsibility—unless you have Part D or other drug coverage. See the “Medicare Part D” section for more.

Mental Health Coverage: Outpatient

Medicare Part B covers a range of outpatient mental health services, including:

Annual depression screening (covered in full)
Psychotherapy – Individual and group sessions with licensed professionals
Family counseling (when part of treatment)
Psychiatric evaluations and testing
Medication management
Partial hospitalization – Intensive therapy without overnight stay
Substance use treatment

You pay 20% of the cost after meeting your deductible. Care must be provided by Medicare-participating professionals or facilities.

Medicare Part C

Medicare Part C, commonly called Medicare Advantage, is an alternative way to receive your Medicare benefits through private insurance companies authorized by Medicare. These plans combine the coverage found in Medicare Part A and Part B, and often include prescription drug benefits from Part D as well.

Many Medicare Advantage plans offer additional perks beyond what traditional Medicare provides, such as coverage for vision, hearing, and dental care.

Like typical health insurance, Medicare Part C plans require members to use a network of providers for their care to be covered. In exchange, members usually benefit from more comprehensive coverage and lower copayments compared to Original Medicare.

Who qualifies for Medicare Part C?

To be eligible for a Medicare Advantage plan, you must:

Have both Medicare Part A and Part B
Be a U.S. citizen, U.S. national, or legally present in the U.S.
Reside within the service area covered by the Medicare Advantage plan you wish to join

Enrollment is limited to plans that operate in your local area.

Types of Medicare Advantage Plans

There are several varieties of Medicare Part C plans, including:

Health Maintenance Organization (HMO) Plans: These plans require members to get care from doctors and hospitals within the plan’s network, except in emergencies. Specialist visits often require referrals. Using providers outside the network typically results in higher out-of-pocket costs or no coverage at all.
Preferred Provider Organization (PPO) Plans: PPOs also encourage staying within their provider network but provide some coverage for out-of-network care at a higher cost. Generally, no referrals are needed to see specialists.
Private Fee-For-Service (PFFS) Plans: These resemble traditional Medicare by allowing members to see any Medicare-approved provider who agrees to the plan’s payment terms. Some PFFS plans have networks that offer lower costs, while others do not. Some PFFS plans may not include drug coverage, so you might need to enroll separately in Part D.
Special Needs Plans (SNPs): Designed specifically for people with certain chronic illnesses, those living in institutions or requiring nursing care at home, or individuals eligible for both Medicare and Medicaid. SNP members usually need to get care within a network and work with a primary care doctor or coordinator. These plans always include prescription drug coverage.
Medicare Savings Account (MSA) Plans: MSA plans combine a high-deductible health plan with a medical savings account to cover costs. If you choose an MSA plan, you generally must also enroll in a Part D prescription drug plan unless you already have drug coverage through another policy.

The availability of these plan types varies by location, and some areas may have multiple options within each category. You can check which plans are available in your area by visiting the official Medicare website and entering your ZIP code.

Costs Associated with Medicare Part C

The costs for Medicare Advantage plans differ widely depending on the specific plan. Most HMO, PPO, PFFS, and SNP plans require a monthly premium, though the amount varies. Additionally, copayments and coinsurance fees depend on your chosen plan.

Regardless of the Medicare Advantage plan you select, you still need to pay your Medicare Part B premium. Some Medicare Advantage plans cover this Part B premium for you or charge no additional premium themselves. If you enroll in an MSA plan, you will still pay your Part B premium but usually won’t pay extra premiums for the Medicare Advantage coverage.

Importantly, no Medicare Advantage plan can charge more than $7,550 per year out-of-pocket for covered services, excluding prescription drugs. However, many plans set a lower out-of-pocket maximum.

Special Needs Plans (SNPs)

SNPs are a type of Medicare Advantage plan tailored for specific populations and include the same benefits as other Part C plans.

Insurance companies offer SNPs in three main categories:

Chronic SNP: For beneficiaries with certain chronic or disabling health conditions. Coverage may be limited to those conditions, so it’s important to verify if your condition qualifies.
Institutional SNP: Designed for individuals living in nursing homes or those who require nursing-home level care at home.
Dual-Eligible SNP: For individuals eligible for both Medicare and Medicaid benefits.

To qualify for any SNP, you must have both Medicare Part A and B, reside within the plan’s service area, and meet the criteria for the specific SNP type.

Medicare Part D: Prescription Drug Coverage

Medicare Part D, often referred to as prescription drug coverage, helps cover the cost of medications that Original Medicare (Parts A and B) does not include. Since prescription drugs aren’t covered under Parts A or B, individuals who want medication coverage can opt to enroll in a Part D plan. This type of coverage is optional and typically chosen by beneficiaries who don’t already have prescription drug coverage through another source.

Similar to Medicare Advantage (Part C), the availability of Medicare Part D plans varies depending on where you live. These plans are offered by private insurance companies that are contracted with Medicare to provide drug benefits. As a result, premiums, covered medications, and plan structures may differ from one location to another.

What Drugs Are Covered?

Although individual plans vary, all Medicare Part D providers are required to offer coverage for drugs in certain key categories defined by Medicare. These include:

Antidepressants
Antipsychotic medications
Anticonvulsants
Cancer treatments
HIV/AIDS medications
Immunosuppressants

Each insurance provider offering a Part D plan maintains its own formulary, which is a list of covered medications. These drugs are typically grouped into tiers—such as generics, preferred brand-name drugs, non-preferred brand-name drugs, and specialty medications. Lower-tier drugs, like generics, usually come with lower out-of-pocket costs.

Medicare also mandates that every Part D plan includes at least two different drugs in each treatment category. This ensures that if one brand isn’t available, a comparable medication—often a generic—can be covered as an alternative.

Who Can Get Medicare Part D?

You can usually sign up for Medicare Part D if you are enrolled in either Medicare Part A or Part B. However, if you already have drug coverage through another source—such as an employer plan or a Medicare Advantage plan that includes Part D—you might not need to enroll separately. It’s important to check your current plan details before signing up for a standalone Part D policy.

What Does Medicare Part D Cost?

Part D plans come with a monthly premium, which varies based on the specific plan you choose. In addition to the standard premium, individuals with higher incomes are subject to an extra charge called the Part D Income-Related Monthly Adjustment Amount (IRMAA).

For 2025, you may owe this additional amount if your income exceeds:

$106,000 (if filing an individual tax return or married and filing separately)
$212,000 (if married and filing jointly)

The Social Security Administration will typically notify you if you’re required to pay this extra fee.

Medigap Policies: Supplemental Coverage for Medicare

Medigap, also known as Medicare Supplement Insurance, helps cover healthcare costs that Original Medicare (Parts A and B) doesn’t fully pay for—such as copayments, coinsurance, and deductibles. These plans are offered by private insurance companies and not the federal government.

Who Can Enroll in a Medigap Plan?

Medigap is meant to complement Original Medicare, and to enroll in a policy, you must:

Be enrolled in both Medicare Part A and Part B
Not be enrolled in a Medicare Advantage (Part C) plan
Pay a monthly premium directly to the Medigap provider (in addition to your Part B premium)
Purchase your plan from a company licensed in your state

Note: Each Medigap policy covers only one person. If both you and your spouse want coverage, you’ll need to buy separate policies.

To explore options in your area, visit: Medigap Plan Finder

Important Rules About Medigap

Medigap plans cannot be used with Medicare Advantage (Part C).
If you’re enrolled in Part C, you are not allowed to purchase a Medigap policy.
Medigap plans do not include prescription drug coverage (with the exception of certain policies sold before 2006). You’ll need a separate Medicare Part D plan for that.

Standardized Plans Make Comparison Easier

Medigap policies are standardized by federal law (except in Massachusetts, Minnesota, and Wisconsin), which means each plan type offers the same core benefits, regardless of which company you buy it from. However, premiums may vary between insurers.

Plans are labeled by letters—such as Plan A, Plan G, or Plan N—and each provides a different level of coverage. Not all companies offer every plan, but:

Any company that sells Medigap must offer Plan A
If they offer more than one plan, they must also offer Plan C or Plan F*

The table below outlines which plans cover specific benefits. You’ll see indicators like:

“Y” indicates the plan covers the benefit completely.
“N” indicates the plan does not cover the benefit.
“%” Plan covers a percentage of the cost.
“N/A” not applicable.

Additional Notes:

High-deductible options (marked with one asterisk): You pay out-of-pocket costs up to $2,800 (2024) before the plan begins paying.
Out-of-pocket limit plans (two asterisks): After reaching your yearly limit and Part B deductible, the plan covers 100% of remaining costs.
Cost-sharing limits (three asterisks): The plan pays full Part B coinsurance, but you may owe up to $20 for office visits and $50 for ER visits that don’t lead to inpatient stays.

For specific state variations in Massachusetts, Minnesota, and Wisconsin, refer to the sections below the table.

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 in Massachusetts, Minnesota, and Wisconsin

While most states follow a standard format for Medigap policies, Massachusetts, Minnesota, and Wisconsin take a different approach. In these three states, Medigap plans are structured uniquely, with different benefits and coverage levels. Here’s how it works in each state:

Massachusetts Medigap Plans

In Massachusetts, all Medigap plans are required to include certain core benefits:

Part A coinsurance
Part A hospice care cost-sharing (covers gaps for hospice care under Part A)
Up to 365 additional hospital days after Medicare benefits run out
Part B coinsurance
Coverage for the first 3 pints of blood used in a transfusion each year

Residents can choose from three Medigap options:

Core Plan
Supplement 1 Plan
Supplement 1A Plan

Core Plan Includes:

All of the required basic benefits listed above
Up to 60 inpatient mental health days annually
State-required benefits like yearly mammograms and pap smears

Supplement 1 Plan Includes:

Everything in the Core Plan
Part A inpatient hospital deductible
Skilled nursing facility coinsurance under Part A
Part B deductible
Emergency coverage while traveling abroad
120 inpatient mental health days per year

Supplement 1A Plan Includes:

All Core Plan benefits
Part A deductible
Part A skilled nursing facility coinsurance
Foreign travel emergency care
120 inpatient days for mental health care annually

Minnesota Medigap Plans

Minnesota Medigap policies also offer a unique model. Every plan in the state must provide the following core benefits:

Part A and B coinsurance
Hospice care cost-sharing under Part A
Cost-sharing for home health services and medical supplies under Parts A and B
First 3 pints of blood for annual transfusions

Two main plan types are available:

Basic Plan
Extended Basic Plan

Basic Plan Offers:

All core benefits listed above
Part A skilled nursing facility coinsurance (up to 100 days of care)
80% coverage for foreign travel emergencies
50% coverage for outpatient mental health care
Coverage for Medicare-approved preventive services
20% of physical therapy costs
State-mandated services (like diabetic supplies, immunizations, cancer screenings, and reconstructive surgery)

Extended Basic Plan Offers:

All the Basic Plan benefits
Part A hospital deductible
Skilled nursing facility coinsurance for up to 120 days
Part B deductible (except for new Medicare enrollees, who are not eligible for this coverage if they joined on or after January 1, 2020)
80% of emergency care during foreign travel**
50% coverage for outpatient mental health services
80% of “usual and customary” charges**
Medicare-covered preventive care
20% of physical therapy expenses
All state-mandated benefits

Note:

Two asterisks (**) indicates the plan will pay 100 percent of costs after the beneficiary spends $1,000 in out-of-pocket expenses in a one-year period.

Wisconsin Medigap Plans

Unlike most states, Wisconsin offers a flexible approach to Medigap policies. While all plans must include a standard set of core benefits, insurance providers have the freedom to enhance the basic coverage with additional options.

Required Basic Benefits

Every Medigap policy in Wisconsin must cover:

Part A inpatient hospital coinsurance
Part A hospice care cost-sharing
- Helps cover expenses for hospice services not fully paid for by Medicare Part A
Part B coinsurance
The first 3 pints of blood used in a transfusion each year

Wisconsin’s Basic Plan

The state offers one primary Medigap option: the Basic Plan. While it includes all of the standard benefits above, insurers may also enhance it with extra features. At minimum, the Basic Plan must also cover:

Part A skilled nursing facility (SNF) coinsurance
175 inpatient mental health care days (after Medicare’s limit is reached)
40 additional home health care visits beyond Medicare’s coverage
State-mandated benefits (such as specific preventive screenings or services)

Additional Coverage Options

In addition to the Basic Plan, Wisconsin allows for other types of Medigap coverage that can vary in both cost and scope. These include:

50% and 25% cost-sharing plans, which are similar to standard Medigap Plans K and L.
A high-deductible Basic Plan that requires policyholders to pay up to $2,800 in out-of-pocket costs in 2024 before coverage begins.

Insurance companies may also choose to include the following optional benefits in their plans:

50% coverage of the Medicare Part A deductible
Medicare Part B deductible*
Part B copayments or coinsurance
Coverage for excess charges under Part B
Additional home health care (up to 365 total visits, including those paid for by Medicare)
Foreign travel emergency medical expenses

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

PACE is a Medicare-Medicaid joint program that allows older adults to receive comprehensive medical and support services within their communities—helping them avoid institutional care in nursing homes. Participants receive personalized, coordinated care from a team of healthcare professionals.

What Services Does PACE Cover?

PACE includes all medically necessary services covered under Medicare and Medicaid, as determined by your care team. These services typically include:

Adult day primary care
Dental care
Doctor visits
Emergency services
Home-based care
Hospital care
Lab tests and X-rays
Meal services
Medical specialist visits
Nursing home care
Nutrition counseling
Occupational therapy
Physical therapy
Prescription medications
Preventive care
Social services
Counseling from licensed social workers
Transportation to medical appointments

Availability of PACE

PACE is not a nationwide program—it operates locally through approved providers. As of now, over 180 PACE programs run more than 300 centers across 33 states and Washington, D.C.

PACE programs are currently available in:

Alabama
Arkansas
California
Colorado
Delaware
Florida
Indiana
Iowa
Kansas
Louisiana
Maryland
Massachusetts
Michigan
Missouri
Nebraska
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Virginia
Washington
Wisconsin
Washington, D.C.

Even if your state offers PACE, availability depends on whether a PACE organization serves your specific area.

Use the PACE locator tool to see if you qualify locally: https://www.npaonline.org/find-a-pace-program

PACE Eligibility Requirements

To enroll in PACE, you must:

Be at least 55 years old
Live within a PACE service area
Be certified by your state as needing a nursing home level of care
Be able to live safely in the community with support from PACE services

Typical PACE Costs

Your out-of-pocket expenses under PACE depend on your eligibility for Medicare and Medicaid:

Medicare-only recipients pay premiums for long-term care services and prescription drug coverage (Part D).
Dual-eligible (Medicare and Medicaid) participants usually do not pay any monthly premium for long-term care services.
Not eligible for Medicare or Medicaid? You’ll need to pay for the full cost of PACE coverage.

PACE programs do not charge deductibles or copays for services approved by your care team, making it an affordable and coordinated option for many older adults.

How to Pay for Medicare

Medicare coverage comes with various out-of-pocket costs, including premiums, deductibles, copayments, and coinsurance. Understanding these terms can help you better plan for your healthcare expenses:

Premium: A regular payment you make to maintain your Medicare coverage.
Deductible: The amount you pay out-of-pocket before Medicare starts to cover services.
Copayment: A fixed fee paid for specific services, office visits, or prescriptions.
Coinsurance: The percentage you share with Medicare for the cost of a covered service after meeting your deductible.

Paying for Medicare Parts A and B

Most enrollees must pay a Part B premium, and Part D premiums also apply. Part C (Medicare Advantage) plans may have additional premiums, and some individuals must pay a Part A premium based on their work history. See “Who needs to pay Medicare Part A premiums?” for more information.

If you receive Social Security or Railroad Retirement Board (RRB) benefits, your Part B premium can be automatically deducted from your monthly payments.

You have several ways to pay your Medicare Parts A and B premiums:

Online Payment Through Medicare Account

Log in to your Medicare account and pay using a credit card, debit card, or bank account: https://www.medicare.gov/account/login

Bank Bill Pay

Use your bank’s online bill payment service to send payments. You’ll need:

Your Medicare number
Payee name: CMS Medicare Insurance
Address:
Medicare Premium Collection Center
P.O. Box 979098
St. Louis, MO 63197-9000

Setting up Medicare Easy Pay

You can set up automatic monthly deductions from your checking or savings account. Download and complete the Easy Pay form here: CMS-Form SF5510

Mail the completed form to:
Medicare Premium Collection Center
P.O. Box 979098
St. Louis, MO 63197-9000

Mail-In Payment

Send a check, money order, or credit/debit card information using the payment coupon that comes with your bill.
Mail to:
Medicare Premium Collection Center
P.O. Box 979098
St. Louis, MO 63197-9000

Paying for Medicare Part C

If your Part C – also called Medicare Advantage – plan includes a premium, you’ll pay your insurance provider directly. During enrollment, you can typically choose a payment method. Most providers offer the following options:

Mail a check to the provider’s billing address listed on your invoice.
Set up automatic bank debit through your financial institution.
Use a debit or credit card via your provider’s online portal.
Deduct from Social Security or RRB benefits, if your provider allows it.

Payment options can vary—check with your plan provider for exact methods and instructions.

Paying for Medicare Part D (Prescription Drug Plans)

If you enroll in a Part D plan, you can request to have your monthly premium deducted from your Social Security benefits. To do this, you must contact your Part D provider directly, not Medicare or Social Security.

In addition to benefit deductions, most Part D providers also offer:

Online payments
Auto-pay via bank account or card
Manual check or card payments

If you are required to pay a Part D Income-Related Monthly Adjustment Amount (IRMAA), that payment goes directly to Social Security. You can pay it using the same options listed above for Medicare Parts A and B.

Paying for a Medigap Plan

Medigap plan payments work similarly to Medicare Part C plans—you’ll pay your insurance provider directly if your plan requires a premium. Payment options can often include the following:

Mailed checks
Bank auto-drafts
Debit or credit card payments
Deductions from Social Security or Railroad Retirement Board benefits (if available through your provider)

Refer to the “Paying for Medicare Part C” section for more detailed information about these common payment methods. Always check with your Medigap provider for specific instructions and available payment options.

The Medicare Savings Program (MSP)

If you have limited income and resources, your state may help cover Medicare premiums and other out-of-pocket costs through the Medicare Savings Program. Assistance may include help with deductibles, coinsurance, and copayments for Medicare Parts A and B.

Below are the 2025 income and resource limits for each program:

Qualified Medicare Beneficiary (QMB) Program

Helps Pay For:

Medicare Part A premiums
Medicare Part B premiums
Deductibles, coinsurance, and copayments

Income Limits:

Individual: $1,325/month
Married couple: $1,783/month

Resource Limits:

Individual: $9,660
Married couple: $14,470

Specified Low-Income Medicare Beneficiary (SLMB) Program

Helps Pay For:

Medicare Part B premiums

Income Limits:

Individual: $1,585/month
Married couple: $2,135/month

Resource Limits:

Individual: $9,660
Married couple: $14,470

Qualifying Individual (QI) Program

First-come, first-served. Priority is given to those who received QI benefits the previous year. Not available to Medicaid recipients.

Helps Pay For:

Medicare Part B premiums

Income Limits:

Individual: $1,781/month
Married couple: $2,400/month

Resource Limits:

Individual: $9,660
Married couple: $14,470

Qualified Disabled and Working Individuals (QDWI) Program

Helps Pay For:

Medicare Part A premiums

You may be eligible if:

Are a working person under age 65 with a disability
Lost premium-free Part A after returning to work
Aren’t receiving Medicaid assistance from the state
Meet the income/resource criteria below

Income Limits:

Individual: $5,302/month
Married couple: $7,135/month

Resource Limits:

Individual: $4,000
Married couple: $6,000

Medicare Savings Program Variations by State

Alaska Income Limits (2025)
(Applies to all MSP categories)

Income Limits:

Individual: $2,137/month
Married couple: $2,894/month

Resource Limits:

Individual: $9,430
Married couple: $14,130

Hawaii Resource Limits
Income Limits:

Qualified Medicare Beneficiary (QMB):
- Individual: $1,500
- Married couple: $2,027
Specified Low Income Beneficiary (SLMB)
- Individual: $1,799
- Married couple: $2,432
QMB, SLMB, QI Resource Limits:
- Individual: $6,600 + $500 per dependent
- Married couple: $9,910 + $500 per dependent
QDWI Resource Limits:
- Individual: $4,000 + $500 per dependent
- Married couple: $6,000 + $500 per dependent

How to Apply for Medicare

When the time comes to sign up for Medicare, there are several different ways you can go about it—each suited to your situation and the type of coverage you’re pursuing. Most people enroll either online, by phone, or in person, but the method available to you may depend on your eligibility and whether you’re enrolling in Original Medicare (Parts A and B) or a Medicare Advantage or drug plan (Parts C or D).

In some cases, enrollment is automatic. For instance, if you’ve been receiving Social Security or Railroad Retirement Board (RRB) benefits for at least four months before your 65th birthday, you’ll likely be enrolled in Medicare automatically. However, if this doesn’t apply to you, or if you’re enrolling in a Medicare Advantage or prescription drug plan, you’ll need to complete the enrollment yourself.

Manual enrollment is common for individuals who:

Are turning 65 but haven’t begun claiming Social Security or RRB benefits.
Are under 65 and qualify due to a disability.
Have been diagnosed with End Stage Renal Disease (ESRD).
Have ALS (Amyotrophic Lateral Sclerosis), also known as Lou Gehrig’s Disease.

Keep reading for a detailed explanation of what information you’ll need to gather, how to begin the application process, and what to expect as you enroll.

What You’ll Need to Apply

Before starting your application for Medicare, it’s a good idea to gather all necessary information and documents. This helps prevent delays and ensures your application is processed smoothly.

If Applying for Medicare Part A and/or Part B

You should be ready to provide:

Your full date and place of birth
Your Medicaid number and Medicaid start date (if you have one)
Details about your current health insurance, if you’re covered through an employer or private plan

If You’re Applying Based on a Spouse’s Eligibility

Additional documentation may be required if you’re applying for Medicare as the spouse of someone who qualifies. Be prepared to share:

Marriage and divorce records
The full name of your current spouse
The full name of any previous spouse, particularly if the marriage lasted over 10 years or ended in death
Spouses’ birthdates and Social Security numbers
Dates and locations of each marriage and divorce
Details about any children who:
- Became disabled before age 22
- Are under 18 and unmarried
- Are 18 or 19 and still attending high school full time

Other Information That May Be Needed

A record of your U.S. military service, including branch, position, and dates served
Employment history for the last three years, including:
- Employer name(s)
- Employment start and end dates
If you were self-employed, provide:
- Type of business
- Net income totals for each of the last three years
Banking information for direct deposit of any benefits (such as routing and account numbers)

If You’re Applying for Part C or D

If you’re planning to enroll in a Medicare Advantage (Part C) or Medicare prescription drug plan (Part D), you’ll need to reference your Medicare card. Specifically, you’ll be asked to provide:

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

Having your card ready before you start the process can save time and reduce frustration.

Whether you’re enrolling for the first time or making changes during a Medicare enrollment period, preparation is key. Gather your information, choose your preferred method of applying, and take the steps to ensure you get the coverage you need—when you need it.

Ways to Apply for Medicare Parts A and B

When you’re ready to sign up for Medicare Part A (hospital insurance) or Part B (medical insurance), there are multiple ways to begin the process. You can choose the method that best fits your comfort level and access to technology—whether that’s completing your application online, speaking with someone over the phone, or visiting a local Social Security office in person.

Let’s break down each of these options so you know what to expect.

Applying Online for Medicare Parts A and B

The most convenient way to enroll in Original Medicare is by submitting your application through the Social Security Administration’s (SSA) online portal. Here’s how the process works:

Go to the Medicare application page at https://www.socialsecurity.gov/medicare/apply.html.
Scroll down until you see the button labeled “Apply for Medicare Only” and click it.
You’ll be taken to the secure “Apply for Benefits” page, where you can start filling out your application.
Complete all sections with accurate information. Refer to the “Information and Documents Needed to Apply” section for a detailed checklist of what to have on hand.
Most applicants complete the process in about 10 to 30 minutes.
Once everything is filled out, click “Submit Now.”

After submitting your application, you’ll immediately receive a receipt along with a unique application number. Keep that number in a safe place in case you need to check your status or provide documentation later. The Social Security Administration will review your application and notify you by mail once a decision has been made.

Applying by Phone

If you prefer to speak with a representative or need help navigating the process, you can apply for Medicare by calling the Social Security Administration directly at:

📞 1-800-772-1213

Representatives are available to answer your questions and assist with your application over the phone.

Applying in Person

For those who would rather handle their enrollment face-to-face, you can visit your nearest Social Security office. Staff at the local office can help you complete your Medicare application on-site.

To find an office near you, use the official Social Security office locator here: https://secure.ssa.gov/ICON/main.jsp

If you initially chose not to enroll in Medicare Part B and have since changed your mind, don’t worry—it’s still possible to apply. The method you choose will depend on your preference:

Apply Online Through mySocialSecurity

Go to https://www.ssa.gov/myaccount/ and log in to your account.
Complete the application to enroll in Part B.
Submit it online once complete.

Apply by Mail

Download the enrollment form for Part B here:
CMS-40B Form
Print, complete, and sign the form.
Mail it to your local Social Security office. You can find the correct mailing address using the SSA locator:
https://secure.ssa.gov/ICON/main.jsp

How to Enroll in a Medicare Part C Plan

Medicare Advantage, also known as Part C, is administered by private insurance providers approved by Medicare. That means your enrollment process may vary slightly depending on which provider you choose. Here are the general ways you can sign up:

Applying Online

Check your provider’s website to see if they offer a digital application process. Many insurance companies have user-friendly portals that allow you to compare plans, check availability, and enroll without ever picking up the phone.

Applying by Phone

If you’d rather speak to someone directly, call the insurance provider offering the plan you want. If you’re unsure where to start, you can also call Medicare’s national helpline at:

📞 1-800-MEDICARE (1-800-633-4227)

Applying by Mail or In Person

All Medicare Advantage providers are required to make paper applications available. Some allow you to mail in the completed form, while others may request that you return it in person. Contact the plan’s customer service department to confirm their preferred submission method.

To view available plans in your ZIP code and compare benefits, visit the Medicare Plan Finder here: https://www.medicare.gov/plan-compare/-find-pace-program-your-neighborhood.

How to Enroll in a Medicare Part D Plan

If you’re interested in joining a Medicare Part D plan for prescription drug coverage, your first step is to explore which plans are available where you live. Not every plan is offered in every location, so it’s important to review your options carefully before selecting one that fits your needs.

To get started, visit the official Medicare Plan Finder at https://www.medicare.gov/plan-compare

Once you’ve identified a plan that works for your health and budget needs, you can proceed with enrollment using one of the following methods:

Applying Online

You may enroll through the Medicare Plan Finder tool or by going directly to the website of the insurance provider offering the plan. The online process is typically straightforward and allows you to compare multiple plans side-by-side before committing.

Applying by Phone

If you prefer to speak with someone directly, you can:

Call the insurance company that offers the Part D plan you wish to join.
Or dial 1-800-MEDICARE (1-800-633-4227) to get help selecting and enrolling in a plan through the national Medicare helpline.

Applying by Mail or In Person

All Part D providers are required to offer a paper application for those who prefer not to enroll online or by phone. Some plans accept completed applications by mail, while others may require that you drop off the form in person. Contact your selected provider for specific instructions regarding how they process paper enrollments.

How to Enroll in a Medigap (Medicare Supplement) Plan

Medigap plans help cover out-of-pocket costs not fully paid by Original Medicare, such as deductibles, copayments, and coinsurance. These policies are sold by private insurance companies, and availability varies by state.

To begin the enrollment process:

Compare available plans in your area by visiting the Medigap plan search tool here: https://www.medicare.gov/medigap-supplemental-insurance-plans/
Review the details of each plan, keeping in mind that benefits are standardized by letter (e.g., Plan G, Plan N), but premiums can vary between insurers.
Once you’ve identified a plan that meets your needs, search for licensed insurance companies in your state that offer it. You can do this either through the Medicare.gov site or by conducting your own search online.
Contact the insurer directly to ask about enrollment procedures. Each provider has its own application process, which may involve filling out a form online, speaking with an agent, or mailing in documentation.

Keep in mind that the best time to enroll in a Medigap plan is during your Medigap Open Enrollment Period, which begins the month you are both 65 or older and enrolled in Part B. During this time, you have guaranteed issue rights, meaning you can’t be denied coverage based on pre-existing conditions.

Knowing Your Enrollment Period: When Can You Apply for Medicare?

Medicare enrollment doesn’t happen automatically for everyone, and you can’t sign up at just any time. Instead, you must enroll during specific windows known as Medicare enrollment periods. Missing these periods can lead to delays in coverage—or worse—costly late enrollment penalties that stick with you for life.

There are three primary types of enrollment periods to be aware of:

Initial Enrollment Period (IEP)
Special Enrollment Period (SEP)
General Enrollment Period (GEP)

Let’s break each of these down so you know when you’re eligible and what to expect.

Initial Enrollment Period (IEP)

The Initial Enrollment Period is the first time you become eligible to enroll in Medicare. This enrollment window is open to those who qualify for Medicare either due to age or disability.

If you qualify based on age, your IEP includes the seven-month period that:

Begins three months before the month you turn 65
Includes the month of your 65th birthday
Ends three months after that birthday month

If you qualify based on disability, your IEP begins three months before your 25th month of receiving Social Security or Railroad Retirement Board (RRB) disability benefits, includes that month, and ends three months afterward.

During this time, you may enroll in any of the following:

Medicare Part A (Hospital Insurance)
Medicare Part B (Medical Insurance)
Medicare Part C (Medicare Advantage)
Medicare Part D (Prescription Drug Coverage)

It’s critical to apply during this window to avoid coverage delays and future penalties.

General Enrollment Period (GEP)

If you didn’t sign up for Medicare Parts A or B when you were first eligible and you’re not eligible for a Special Enrollment Period, you’ll need to wait for the General Enrollment Period. This occurs every year from January 1 to March 31.

You can enroll in Medicare during this period if:

You missed your Initial Enrollment Period; and
You don’t qualify for a Special Enrollment Period.

Coverage for those who enroll during the GEP begins on July 1 of the same year. However, be aware that signing up during this time often comes with late enrollment penalties, especially for Part B.

Open Enrollment for Medicare Advantage (Part C) and Part D

If you didn’t enroll in a Medicare Advantage (Part C) or Part D (prescription drug) plan during your Initial Enrollment Period, you’ll need to wait for Open Enrollment, which takes place every year from October 15 to December 7.

This enrollment window is your opportunity to:

Join a Medicare Advantage or Part D plan
Switch plans if you’re already enrolled
Drop Medicare Advantage and go back to Original Medicare

If this is your first time enrolling in Part D outside of your IEP, you may incur a late enrollment penalty unless you qualify for a Special Enrollment Period.

Special Enrollment Period (SEP)

Medicare also offers Special Enrollment Periods for individuals who qualify due to specific life circumstances. SEPs allow you to apply for Medicare outside of the standard enrollment windows—often without penalty—if your situation meets certain criteria.

SEP for Current Employment

If you’re 65 or older and either you or your spouse are still working and covered by an employer’s group health plan, you can delay Medicare enrollment without penalty. When that employer coverage ends, you qualify for a SEP to enroll in Medicare.

In this case:

You may enroll at any time while the group health coverage is active.
Once the coverage ends or the job ends (whichever happens first), an eight-month SEP begins.

If you enroll while still covered under the group plan, you can choose to have your Medicare coverage begin:

On the first day of the month you apply, or
On the first day of one of the next three months

SEP After Employment Ends

If you’re no longer working (or the group coverage ends), your eight-month SEP begins immediately following:

The month after your job ends, or
The month after the group plan ends—whichever happens first

Enrolling during this time helps you avoid late penalties and ensures you don’t experience a lapse in coverage.

SEP for Volunteer Work Abroad

You may qualify for a SEP if you’ve been serving as a volunteer outside the U.S. for a qualifying organization. To be eligible:

The volunteer program must last at least 12 months
The program must be sponsored by a tax-exempt organization
You must have had health insurance during your time abroad

In this case, your SEP lasts for six months following your return.

More information is available here: SSA Policy on SEP for Volunteers

Automatic Enrollment in Medicare

In some cases, you don’t have to apply manually at all—you’ll be enrolled automatically in Medicare Parts A and B if you meet one of the following criteria:

You’re already receiving Social Security or RRB benefits at least four months before your 65th birthday
➤ You’ll get your Medicare card in the mail about three months before you turn 65.
You’ve been receiving disability benefits from Social Security or the RRB for 24 months
➤ Your Medicare card will arrive roughly three months before your 25th disability benefit month.

Automatic enrollment ensures you won’t miss your opportunity to get covered, but if you want to delay or decline Part B (and avoid premiums), you must take specific action.

When to Enroll in a Medigap Policy

If you want to purchase a Medigap (Medicare Supplement Insurance) policy, timing is everything. Your best opportunity to enroll begins when you first sign up for Medicare Part B at age 65. This six-month window is known as your Medigap Open Enrollment Period.

For example, if your Medicare Part B coverage starts in June, you have until the end of November to enroll in a Medigap plan without facing restrictions or higher costs.

During this six-month period:

You have the guaranteed right to buy any Medigap policy sold in your state.
Insurance companies cannot deny you coverage or charge higher premiums based on your health status.

Under 65? Medigap Options May Be Limited

While some people under 65 qualify for Medicare due to disability, federal law does not require insurers to offer Medigap policies to these individuals. However, many states have stepped in to ensure access.

If you’re under 65 and want Medigap coverage, your eligibility depends on where you live.

States That Require Insurers to Offer Medigap to Individuals Under 65

If you live in one of the following states, insurers must offer at least one Medigap plan to Medicare beneficiaries under 65:

Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, New Hampshire, New Jersey, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, South Dakota, Tennessee, Texas, Vermont, Virginia, Wisconsin

States That Do Not Require Medigap for Those Under 65

If you reside in one of these states, insurers are not required to sell Medigap policies to individuals under age 65:

Alabama, Alaska, Arizona, Iowa, Nebraska, Nevada, New Mexico, North Dakota, Ohio, Rhode Island, South Carolina, Utah, Washington, West Virginia, Wyoming

If you’re under 65 and live in a state that does not require Medigap coverage, you may still qualify later—especially when you turn 65 and enter a new Medigap Open Enrollment Period.

Penalties for Missing Medicare Enrollment Deadlines

Failing to enroll in Medicare on time can lead to long-term penalties, especially for Parts A, B, and D. These penalties typically take the form of higher monthly premiums, and in most cases, they last for as long as you have Medicare.

Part A Late Enrollment Penalty

You’ll only face a Part A penalty if:

You’re not eligible for premium-free Part A, and
You delay signing up during your Initial Enrollment Period (IEP)

The penalty:

10% increase in your monthly premium
Duration: You’ll pay the higher rate for twice the number of years you delayed enrollment

If you miss your IEP and don’t qualify for a Special Enrollment Period, you’ll pay:

An extra 10% on your monthly premium
For each 12-month period you delayed enrollment

This penalty applies for life, making it one of the costliest Medicare mistakes you can make.

Part C (Medicare Advantage) Late Enrollment

Good news: There is no financial penalty for enrolling late in Medicare Part C. However, if you miss your IEP, you’ll have to wait until the annual Open Enrollment Period (October 15 – December 7) to sign up.

Part D Late Enrollment Penalty

If you don’t sign up for Medicare Part D when you’re first eligible, you’ll face a penalty unless you:

Have creditable drug coverage, or
Qualify for Extra Help, a low-income subsidy for drug costs

The penalty is calculated as follows:

1% of the national base premium × number of full months you went without coverage
Rounded to the nearest $0.10 and added to your monthly premium

Making Changes to A Medicare Plan

Already enrolled in Medicare? You’re not locked in forever. You can change your coverage during specific periods each year:

General Enrollment Period – January 1 to March 31
Open Enrollment Period – October 15 to December 7

What You Can Do During the General Enrollment Period

This window is mostly for those who:

Missed their initial enrollment
Want to make changes to their Medicare Advantage plan

During this time, you can:

Switch from one Medicare Advantage (Part C) plan to another
Drop a Part C plan and return to Original Medicare (Parts A and B)
➤ You can also enroll in Part D during this switch
Switch back to Original Medicare within the first 3 months of having Medicare
➤ This only applies if you enrolled during your IEP

What You Can Do During the Open Enrollment Period

This is the main time each year to review and update your plan. You can:

Switch from Original Medicare to a Medicare Advantage (Part C) plan
Switch back from Part C to Original Medicare, with or without adding Part D
Switch from one Part C plan to another
Switch or disenroll from a Part D prescription drug plan

This is your annual chance to make sure your coverage still fits your medical needs and budget.

After Enrolling in Medicare

Once you’ve enrolled in Medicare, there are a few important things to know about your Medicare card and when your coverage officially starts. When you enroll in Medicare, you’ll receive a card in the mail confirming your coverage. If you are automatically enrolled—either by turning 65 or qualifying through a disability—you can expect to receive your card three months before your eligibility date.

You may receive different cards depending on the parts of Medicare you’re enrolled in:

Medicare Parts A and B (Original Medicare)
Medicare Part C (Medicare Advantage)
Medicare Part D (Prescription Drug Coverage)

Make sure to carry all relevant cards with you, as different providers and services may require different cards based on the type of coverage.

What’s on the Medicare Card?

Your Medicare card serves as proof of your enrollment and contains key information, including:

Your name
Your Medicare ID number
The parts of Medicare you’re enrolled in (A and/or B)
The date your coverage starts

Think of it like a traditional insurance card—providers will use it to verify your identity and coverage.

How to Use the Medicare Card

Whenever you visit a doctor, hospital, or pharmacy, present your Medicare card just like you would an insurance card. This ensures you get the benefits and services you’re entitled to without delay.

Lost or Damaged Medicare Card? Here’s What to Do

If your card is lost or damaged, don’t worry—you can replace it easily.

Log in to your Medicare account at MyMedicare.gov to print a new copy.
Medicare cards are printed on paper, so you can reprint them at home—no special materials required.
Even though healthcare providers can look up your Medicare ID online, having your card with you can prevent delays in treatment.

If your card was stolen or you suspect someone is using your Medicare ID fraudulently, call:

1-800-MEDICARE (1-800-633-4227)
TTY users can call 1-877-486-2048

When Medicare Coverage Begins

Your Medicare start date depends on when you enroll. Each part of Medicare follows its own rules:

Medicare Parts A and B

If you’re automatically enrolled in Parts A and B, your coverage typically starts one month before your 65th birthday.
For example, if you turn 65 on August 17, your coverage begins July 17.

If you enroll manually during your Initial Enrollment Period (IEP), start dates vary:

When You Enroll	Coverage Starts
3 months before your birthday month	1 month before your birthday
During your birthday month	1 month after you enroll
1 month after your birthday	2 months after you enroll
2–3 months after your birthday	3 months after you enroll
During General Enrollment (Jan 1 – Mar 31)	July 1

Medicare Part C (Medicare Advantage)

Part C coverage depends on when you sign up:

When You Enroll	Coverage Starts
3 months before turning 65 (or 25th disability month)	1st day of the month you turn 65 (or 25th month)
During your 65th birthday month (or 25th disability month)	1st day of the following month
1–3 months after turning 65 (or 25th disability month)	1st day of the following month
During Open Enrollment (Oct 15 – Dec 7)	January 1 of the next year

Medicare Part D (Prescription Drug Coverage)

Part D follows a similar schedule to Part C:

When You Enroll	Coverage Starts
3 months before turning 65 (or 25th disability month)	1st day of the month you turn 65 (or 25th month)
During your 65th birthday month (or 25th disability month)	1st day of the following month
1–3 months after turning 65 (or 25th disability month)	1st day of the following month

Finding Approved Medicare Providers

To use your Medicare benefits, you must visit a provider that accepts Medicare. Unlike many private insurance plans with limited networks, Medicare is accepted by a wide range of providers across the U.S.—especially if you have Original Medicare (Parts A and B).

How to Search for Medicare-Approved Providers

If you have Original Medicare, you can find approved doctors, hospitals, and other healthcare facilities using Medicare’s official Care Compare tool here: M edicare.gov/care-compare

This tool allows you to:

Search by provider name
Filter by medical specialty
Look up providers by body part, condition, or service
Compare provider ratings and details

Be sure to confirm that the provider accepts Medicare assignment, which means they agree to the program’s payment terms and won’t charge you more than the approved amount.

How Do Medicare Claims Work?

Most of the time, your doctor or hospital will file a claim with Medicare for you. A claim is simply a request for payment for services you received.

When You Might Need to File a Claim
You only need to file a claim yourself if your provider hasn’t done so—and time is running out. Claims must be filed within 12 months of the service date.

To file a claim, you’ll need:

A completed claim form: Download here (PDF)
An itemized bill from your provider
A short letter explaining why you’re filing
Any other helpful documents

Where to send it:
Check your Medicare Summary Notice (MSN) or sign in to https://www.medicare.gov/account/login to find the correct address.

What Is a Medicare Summary Notice (MSN)?
If you have Medicare Part A and/or B, you’ll get an MSN every 3 months. It shows:

What services or items were billed to Medicare
What Medicare paid
What you may owe

This is not a bill. If you owe anything, your doctor will send you a separate bill.

Want to get your MSN online?
Sign into your Medicare account here: https://www.medicare.gov/account/login
Under “My messages,” choose “Get your Medicare Summary Notices (MSNs) electronically.”
Follow the steps to update your preference.

Sometimes Medicare denies payment for a service. If you disagree, you can appeal the decision.

How to Appeal by Medicare Plan Type

Parts A & B (Original Medicare)

You have 120 days from the date of your MSN to appeal a decision. Here are the general steps for filing an appeal if Medicare denies a service:

Download the appeal form: Redetermination Request Form (PDF)
Fill it out and mail it to the address listed on your MSN.
Or you may choose to write a letter with the following information included:
- Your name, address, and Medicare number
- What service you’re appealing
- Why you think Medicare should pay
- Any supporting info or a representative’s name (if you have one)

You’ll usually get a decision in 60 days.

Medicare Part C (Medicare Advantage Plans)

You have 60 days from the denial letter to appeal.
Write a letter to your plan with:

Your name, Medicare number, and contact info
The denied service
Why it should be covered
Any documents that support your case

You’ll usually hear back in 14 days. If it’s urgent, ask for a faster decision within 72 hours.

Medicare Part D (Drug Coverage)

You can appeal if:

You paid for a drug and want a refund
You need a drug not covered by your plan
You haven’t received the drug but want to ask for it

To appeal:

Download and fill out the Coverage Determination Request form. You can find a link to the download here: https://www.cms.gov/medicare/appeals-grievances/prescription-drug/coverage-determinations
Mail or fax it to your plan, or write a letter with:
- Your prescriber’s name and contact info
- Your condition and needed drugs
- The reason for your request

Need a medication urgently?
You can ask for a 24-hour expedited decision. Check the corresponding box on the form and include a note from your doctor. If you don’t include a doctor’s note, your plan may still approve it if your health is at risk.

Special Needs Plans (SNP) and PACE
If you’re in a Special Needs Plan or the Program of All-Inclusive Care for the Elderly, contact your plan directly to file an appeal.

Other Health Insurance & Medicare

It’s pretty common to have Medicare and other insurance plans. Sometimes, they can work together to offer a more rounded coverage for you; other times, it might make more sense to choose one over the other. Here’s what to know if you have Medicare and another type of insurance.

What if You Already Have Marketplace Insurance?

The Health Insurance Marketplace is a government website where you can compare health plans and prices. Knowing how

If you get Medicare Part A, you should cancel your Marketplace plan unless:

You have to pay for Part A, or
You decide not to enroll in Medicare.

You can keep your Marketplace coverage and still have Medicare Part A—but you’ll lose any discounts or tax credits, and your costs may go up.

Health Savings Account (HSA) Rules

Once you enroll in Medicare, you can’t put more money into your HSA. However, you can still use the money that is already in your account to pay medical bills.

Can You Lose Medicare?

Yes, but it’s rare. You may lose coverage if you:

Don’t pay your Part A (if required) or Part B premiums
Fall more than 90 days behind on payments
Return to work and had Medicare due to a disability
(You’ll keep it for 8.5 years after going back to work)
Don’t pay premiums or fees for Part C, Part D, or Medigap

Can You Get Medicare Back After Losing It?

Yes. You’ll need to wait until the General Enrollment Period.
Late penalties may apply.

If you lost coverage after going back to work, you can get Medicare again if:

You become eligible for disability again
You turn 65

Limits on Medicare Coverage

Most Medicare benefits don’t have a limit. You can visit doctors as often as needed.
But some services do have limits.

Coverage That Has Limits

✅ Inpatient Hospital Care

90 days per benefit period
60 extra “lifetime reserve” days
No limit to the number of benefit periods

✅ Skilled Nursing Facility (SNF) Care

100 days per benefit period
No lifetime reserve days

If You Go Over the Limit
If you stay in the hospital more than 90 days and have used up your lifetime reserve days, you must pay the full cost.

What You Can Do
Consider a Medigap plan. It can cover up to 365 extra days in the hospital once Medicare runs out.

Learn more in the “Medigap Policies” section of this guide.

By Admin – June 2025