Medicare FAQ 2025

Medicare is a federal health insurance program for people 65 and older, younger individuals with certain disabilities (after 24 months of SSDI), and those with End-Stage Renal Disease (ESRD) or ALS.

Medicare has four main parts: • Part A: Hospital stays, hospice care, skilled nursing (post-hospital), limited home health care. • Part B: Outpatient care, preventive services, mental health, ambulance services, durable medical equipment. • Part C (Medicare Advantage): Private alternative bundling Parts A & B, usually Part D, and additional benefits like dental, vision, hearing. • Part D: Prescription drug coverage through standalone plans or bundled with Medicare Advantage.

The official CMS handbook, updated annually, detailing benefits, coverage, rights, enrollment dates, and more.

During your Initial Enrollment Period: 3 months before, during, and 3 months after your 65th birthday month.

If covered by a large employer's 'creditable' plan, you can delay Part B without penalty and enroll later via a Special Enrollment Period.

There are several important enrollment periods: • Annual Enrollment Period (AEP): Oct 15–Dec 7. Switch between Original Medicare and Advantage or update drug coverage. • General Enrollment Period (GEP): Jan 1–Mar 31 for those who missed Initial Enrollment. Penalties may apply. • Medicare Advantage Open Enrollment Period (MA-OEP): Jan 1–Mar 31 allows one Advantage plan change or return to Original Medicare. • Special Enrollment Period (SEP): Triggered by events like moving, loss of employer coverage, or Medicaid eligibility.

Costs vary by part and location: • Part A: Free for most; otherwise up to $505/month. Deductible: $1,632 per benefit period. • Part B: Approximately $185/month premium; $257 annual deductible. • Part D: Varies by plan. • Medigap: Typically $100–$250/month, varies by plan/location.

• Part B: 10% premium increase per full 12-month delay, lifelong. • Part D: 1% penalty per month delayed, lifelong premium surcharge.

After spending $2,000 out-of-pocket in 2025, drug costs are covered fully for the year.

Yes, several programs can help: • Extra Help: Assists low-income individuals with Part D costs. • Medicare Savings Programs: State programs that help with Part A/B premiums and costs.

Original Medicare (Parts A & B) allows nationwide provider access, pairs with Medigap, has no network restrictions. Medicare Advantage (Part C) is network-based (HMO/PPO), often with lower premiums and extra benefits, but with network and referral limitations.

Yes, but outside guaranteed-issue periods, switching can involve medical underwriting—potentially higher premiums or denial.

Supplemental insurance covering deductibles, copays, coinsurance for Original Medicare users.

• Plan G: Most comprehensive for new enrollees, covers all except the Part B deductible. • Plan N: Lower premiums but includes small copays for visits.

Yes. Plans C, D, F, G, M, and N cover 80% emergency costs abroad, after a $257 deductible, up to $50,000 lifetime limit.

• Part B premium: ~$185/month • Insulin costs capped at $35/month under Part D • Catastrophic drug coverage begins after $2,000 out-of-pocket • Expanded behavioral health provider access • No deductible for ACIP-recommended vaccines • Medicare Advantage out-of-pocket maximum capped around $8,300

Most Advantage plans include basic dental/vision, hearing aid discounts, and fitness perks. Medigap does not; separate plans are required.

• Original Medicare + Medigap: Any provider nationwide who accepts Medicare. • Medicare Advantage: Usually limited to network providers.

• Original Medicare: No. • Advantage HMO plans: Usually yes, for specialists and certain procedures.

Check each plan's formulary via the Medicare Plan Finder before enrolling.

Request an exception or appeal, or wait until the next enrollment period to change plans.

Right to nondiscrimination, timely access to care, explanations, appeals, and privacy.

Follow instructions on the denial notice or Explanation of Benefits (EOB). SHIP or your plan can help.

Original Medicare + Medigap provides nationwide coverage. Medicare Advantage covers only emergencies outside your area.

Original Medicare + Medigap + robust Part D plan offers broad access and predictable costs.

Consider a lower-cost Medicare Advantage plan with drug coverage, ensuring your doctors are in-network.