Frequently Asked Medicare Questions

Who's Eligible for Medicare?

If you already get retirement benefits from Social Security or the Railroad Retirement Board, you are automatically eligible for Medicare starting the first day of the month you turn 65.

If you're not yet receiving retirement benefits, you can apply for Medicare starting three months before the month you turn 65, with coverage available as of the month you turn 65.

If you're under 65, you're eligible to receive Part A benefits if:

• You've received Social Security Disability Insurance for more than 24 months
• You have permanent kidney failure (end-stage renal disease requiring ongoing dialysis or a kidney transplant)
• You're diagnosed with amyotrophic lateral sclerosis (ALS) 

What's Medicare Part A?

Medicare Part A, also known as the Hospital Insurance program, helps cover the costs of inpatient care in:

• Hospitals
• Skilled nursing facilities (assuming you had at least a three-day inpatient stay in the hospital prior to the skilled nursing facility stay)
• Rehabilitation facilities
• Mental health and psychiatric care facilities

It'll also cover:

• Hospice care services
• Some home healthcare services

What are Premiums for Part A?

If you're eligible for Medicare, you will not have to pay a monthly premium for Part A if you or your spouse paid Medicare payroll taxes while working for at least 10 years (40 quarters).

If you or your spouse did not work or did not pay enough Medicare payroll taxes, you may not be eligible for premium-free Part A.

However, you may be able to purchase Part A by paying a monthly premium. The premiums for 2021 cost:

• $259 if you/your spouse paid taxes for between 30 and 39 quarters
• $471 if you/your spouse paid taxes for fewer than 30 quarters

Contact your local Social Security office three months before your 65th birthday to sign up.

What is Medicare Part B?

Medicare Part B is also known as the Medical Insurance program. In general, Part B covers two types of services:

• Medical services: This includes health care that you may need to diagnose and treat a medical condition. Medicare will only pay for services they define as being medically necessary.
• Preventive services: This covers care to prevent illness (such as a flu shot) or help detect an illness in an early stage so it can be managed before getting worse (such as screening for colon cancer).
• Durable medical equipment: This includes oxygen equipment, wheelchairs, walkers, and other medically necessary equipment that your doctor prescribes for use in your home.

What's the Part D Coverage Gap?

When the Medicare Part D (drug coverage) program debuted in 2006, it was designed with a coverage gap, also known as the “donut hole.”

The donut hole begins after you and your drug plan have spent a certain amount of money for covered medications, and continues until another spending threshold is reached.

Before the Affordable Care Act (ACA) was implemented, Medicare beneficiaries had to pay the full cost of their medications while they were in the donut hole. Then the ACA started closing the gap in 2011, and it was fully closed as of 2020.

Enrollees in standard drug plans now pay 25% of the cost of their medications both before and during the donut hole (after meeting their deductible, which is a maximum of $445 in2021).

However, the donut hole still exists in terms of how drug spending is counted before and during the donut hole.

To determine when you enter the donut hole, the total amount that you and your drug plan pay for your medications is combined until it reaches the initial donut hole threshold ($4,130 in 2021).

Then you have to reach another spending level before you exit the donut hole and enter the catastrophic coverage level, when your drug costs will be greatly reduced, but still not fully covered.

That amount is based on what you pay plus the manufacturer discount, which covers the majority of the cost of your medications while in the donut hole.

What's a Medigap Policy?

Original Medicare (Part A and Part B) pays for the majority of your health-related services and medical supplies. As is the case with most insurance plans, though, you will have out-of-pocket costs.

Unlike with other types of health insurance, Original Medicare puts no cap on how high your out-of-pocket costs can be.

You can purchase a Medigap insurance policy to cover the "gaps" left by Original Medicare, including:

• Copayments
• Coinsurance
• Deductibles
• Excess charges when you see a doctor who doesn't "accept assignment" with Medicare

Without a Medigap policy, these can amount to substantial out-of-pocket expenses. 

Some Medigap policies also will pay for certain health services outside the United States, which are generally not covered under Original Medicare at all.

Medigap insurance (also known as Medicare Supplement Insurance) is voluntary and you are responsible for the monthly or quarterly premiums. Medicare will not pay any of your costs to purchase a Medigap policy.

Medigap plans are offered by private health insurance companies. The prices vary from one insurer to another, but the plans themselves are standardized.

Federal rules do not require Medigap insurers to offer coverage to Medicare beneficiaries under age 65, but the majority of states have rules in place to ensure people in this group have at least some access to Medigap plans.

The federal government sets minimum standards in terms of the rules that apply to Medigap plans, but states have varying additional rules and regulations.

What's the Medicare Advantage Plan?

Medicare Part C, also known as the Medicare Advantage program, allows you to choose a Medicare-approved health plan offered by a private insurance company.

Most Medicare Advantage plans are managed care organizations (such as a PPO or HMO), but private fee-for-service plans are available in some areas that don't have provider network requirements.

Medicare Advantage plans receive payments from Medicare to provide you with the benefits covered by Original Medicare, including Part A and Part B. Most Medicare Advantage plans include Part D drug coverage, and many offer extra coverage, such as:

• Vision coverage
• Hearing care
• Dental services
• Gym memberships
• Wellness programs

More than a third of Medicare beneficiaries receive their coverage through a Medicare Advantage plan.

Although Medicare Advantage plans are not available in a few areas of the country, the average Medicare beneficiary can choose from about 30 Advantage plans, including some that are new for 2021.

How Has the ACA Changed Medicare?

The ACA made several changes to Medicare that have improved benefits and access to preventive care for millions of people. Some changes also improved the long-term financial health of the Medicare program.

Some significant changes that directly affect Medicare beneficiaries include:

• Coverage gap savings: Starting in 2011, those who reached the coverage gap began receiving a discount on their medications while in the gap. The discounts increased each year until the coverage gap was completely eliminated in 2020.
• Preventive care: Medicare now pays for an annual checkup, including a physical examination, and has eliminated all cost-sharing for various recommended preventive services and screenings.

What Are My Medicare Choices at 65?

You have two main choices for how you get your Medicare.

• Original Medicare
• Medicare Advantage Plan

Choosing Original Medicare means:

• You get Part A Hospital Insurance coverage.
• You get Part B Medical Insurance coverage.
• You have the option of enrolling in a Part D Prescription Plan.
• You may want to consider Medicare Supplement Insurance (Medigap) to pay for the out-of-pocket costs that go along with Parts A and B.

Choosing a Medicare Advantage plan means:

• You get the benefits of Part A and Part B in one private plan.
• It'll likely include Part D prescription drug coverage (in 2020, 90% of Medicare Advantage plans included Part D).
• You'll have to pay the premium for Part B plus the premium for your Advantage plan (although about half of the Advantage plans have no premium).
• You don't need Medigap coverage.

It's important to understand there's no annual window for Medigap enrollment. If you enroll in Medicare Advantage and later switch to Original Medicare, you'll likely have to go through medical underwriting in order to get a Medigap plan (the rules vary by state).

That means your price and/or eligibility for coverage will depend on your medical history. Keep in mind that without a Medigap supplement (or supplemental coverage from an employer-sponsored plan or Medicaid), your out-of-pocket exposure with just Original Medicare is unlimited.

What Does "Medically Necessary" Mean?

Medicare will only pay for services that are deemed medically necessary. According to Medicare, services or supplies are considered medically necessary if they:

• Are proper and needed for diagnosis or treatment of your medical condition
• Are provided for the diagnosis, direct care, and treatment of your medical condition
• Meet the standards of good medical practice in the medical community of your local area
• Are not mainly for the convenience of you or your doctor

What Preventive Services are Covered?

Medicare pays for certain healthcare services to prevent illness (like flu shots) or help detect an illness in an early stage so it can be managed before getting worse (such as colon cancer screening). Your doctor can tell you what tests you need and how often you need them.

As a result of the ACA, Medicare enrollees get a "Welcome to Medicare" checkup and a free annual wellness visit, along with a variety of free preventive care.

What Diabetic Supplies are Covered?

Medicare Part B covers some diabetes supplies, including:

• Blood glucose test strips
• Blood glucose monitor
• Lancet devices and lancets
• Glucose control solutions for checking the accuracy of test strips and monitors

Medicare may limit how much or how often you get these supplies.

Regular Medicare (ie, Part B) does not cover insulin unless you use an insulin pump. You'll have to pay 100% for other types of insulin, syringes, and needles, unless:

• You enroll in a Medicare Part D prescription drug plan
• OR have a Medicare Advantage plan with integrated Part D drug coverage

In 2021, the government is rolling out a pilot program in which participating Medicare Part D and Medicare Advantage insurers are offering insulin with $35 monthly copays. That's expected to save people in the program several hundred dollars a year in insulin costs.

Does Medicare Cover Dental Care?

Original Medicare does not cover routine dental care or most dental procedures such as:

• Cleanings
• Fillings
• Tooth extractions
• Dentures

Medicare Part A may pay for some dental services that you get while you're hospitalized, including emergency dental surgery performed in an inpatient setting. Most Medicare Advantage plans include at least basic dental benefits—88% did so in 2020.

However, the specific dental benefits provided will vary by plan, since this is an extra benefit offered by the Medicare Advantage insurer, and not part of the Medicare program itself.

So if you're considering Medicare Advantage plans that include dental benefits, you'll want to read the fine print to see what specific services and benefits are included in the coverage.

Does Medicare Provide Vision Care?

Medicare covers services for the diagnosis and treatment of eye disease both in your doctor’s office and the hospital. This includes testing and treatment for conditions such as macular degeneration, glaucoma, and cataracts.

If you have diabetes, Medicare Part B covers the cost of an annual diabetic retinopathy screening.

Medicare does not cover the cost of:

• Routine vision tests
• Eyeglasses
• Contact lenses 

However, following cataract surgery with an intraocular lens, Medicare will help pay for cataract glasses, contact lenses, or intraocular lenses provided by an ophthalmologist.

Most Medicare Advantage plans include coverage for at least some routine vision care.

How Can I Get a New Medicare Card?

If you have Original Medicare (Part A and Part B), and you've lost your card, call Medicare at 1-800-633-4227, or visit www.socialsecurity.gov/medicarecard. When you request a replacement Medicare card online or on the phone, you will need:

• Your name as it appears on your most recent Social Security card
• Your Social Security number
• Your date of birth

You should receive your replacement Medicare card in the mail in about 30 days. You can also visit your local Social Security office. 

The government sent new Medicare cards to all beneficiaries starting in April 2018. The new cards use a unique identification number instead of Social Security numbers.

If you are enrolled in a Medicare Advantage Plan and lost your card, call your plan’s customer service number for a replacement.

What If I Need a Drug That's Not Covered?

According to Medicare, if you need a drug that is not on your Part D plan's formulary (covered drug list), or that is on the list but you think it should be covered for a lower copayment, you can do the following:

• Contact the plan and ask for an exception. You will probably have to provide information from your doctor about why you need the drug your plan won’t cover.
• If your plan denies the exception, you can appeal. Your Part D plan must give you information on how to appeal.

Keep in mind that you have an opportunity to switch to a different Part D plan each year during the annual open enrollment period (October 15 to December 7).

During that window, you can use Medicare's plan finder tool to compare each of the Part D plans available in your area, and see how much your specific drugs would cost under each plan.

It's important to understand that a plan can change its coverage specifics from one year to the next, so it's worth your while to actively compare all of the available options each year.

What is a Drug Formulary With Tiers?

Drugs on a Part D formulary are usually grouped into tiers, and your copayment or coinsurance is determined by the tier that your medication is on. A typical Part D drug formulary includes three to five tiers.

• Tier 1 has the lowest copayment and usually includes generic medications.
• Tier 2 has a higher copayment than tier 1 and usually includes preferred brand name medications.
• Tiers 3, 4, and 5 include drugs with higher out-of-pocket costs, and can include non-preferred brand name medications as well as specialty drugs.

Drugs in the highest tiers are more likely to have coinsurance (a percentage of the cost) rather than a copay (a flat out-of-pocket amount). 

Often, a drug is in a higher tier because a similar but less expensive drug is available.

Am I Covered Outside the U.S.?

With very limited exceptions, Original Medicare (Parts A and B) generally doesn’t cover health care while you're traveling outside the U.S. and its territories. Some Medigap policies provide Foreign Travel Emergency coverage when you're out of the country.

Some Medicare Advantage plans may provide worldwide coverage benefits for emergency healthcare needs. Before traveling outside the country, check with your Medicare Advantage plan regarding travel benefits.

If you know you won't have Medicare-related coverage when you travel, you may want to consider purchasing a temporary travel health insurance policy.

What If I Can't Afford Medicare Premiums?

If you need help with medical and drug costs, including premiums, deductibles, and other out-of-pocket expenses, you have several options:

• Medicaid
• Medicare Savings Program
• Extra Help and Low-Income Subsidy
• State Pharmaceutical Assistance Program
• Pharmaceutical Assistance Program

Contact your State Health Insurance Assistance Program or your state Medicaid office for help determining whether you qualify for programs that could help you afford your coverage and out-of-pocket costs.

Where Can I Get Answers to Medicare Questions?

If you have questions about Medicare or have a problem with Medicare coverage or a Medicare claim, start by calling the Medicare Support Center at 1-800-MEDICARE.

Additionally, the website Medicare Questions and Problems: Where to Get Help will show you the six best resources for answering your Medicare questions and resolving your Medicare problems.