Medicare Basics
Everything you need to know about Medicare coverage and enrollment
Medicare has four distinct parts that work together to provide comprehensive healthcare coverage. Understanding each part is essential to making informed decisions about your healthcare.
Often called "hospital insurance," Part A covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care services.
✓ Premium-Free for Most
If you or your spouse paid Medicare taxes for at least 10 years (40 quarters), you don't pay a premium for Part A.
What Part A Covers:
- Hospital stays: Inpatient care, semi-private rooms, meals, general nursing
- Skilled nursing: Up to 100 days per benefit period (after 3-day hospital stay)
- Hospice care: Pain relief, symptom management, support services
- Home health care: Part-time or intermittent skilled care
2025 Costs
• Deductible: $1,676 per benefit period
• Days 1-60: $0 coinsurance
• Days 61-90: $419/day coinsurance
• Beyond 90 days: $838/day (60 lifetime reserve days)
Part B covers medically necessary services like doctors' visits, outpatient care, preventive services, and durable medical equipment.
2025 Monthly Premium
$185
Standard amount (higher for incomes above $106,000)
What Part B Covers:
- Doctor services: Office visits, consultations, second opinions
- Outpatient care: Emergency room, observation, outpatient surgery
- Preventive services: Screenings, vaccines, annual wellness visits
- Medical equipment: Wheelchairs, walkers, hospital beds
- Ambulance: When other transportation endangers health
- Mental health: Outpatient therapy and counseling
2025 Costs
• Annual Deductible: $257
• Coinsurance: 20% of Medicare-approved amount
• No out-of-pocket maximum
Medicare Advantage is an all-in-one alternative to Original Medicare offered by private insurance companies approved by Medicare.
What's Included
Medicare Advantage plans must cover everything Original Medicare covers (Parts A & B), but they can do it with different rules, costs, and restrictions.
Typical Benefits Include:
- All Part A and Part B benefits
- Part D prescription drug coverage (most plans)
- Dental, vision, and hearing benefits
- Fitness programs (gym memberships, SilverSneakers)
- Out-of-pocket maximum protection
- Over-the-counter (OTC) allowances
Important Restrictions
Most Medicare Advantage plans require you to use network providers and may require referrals to see specialists. Coverage can vary by location.
Plan Types: HMO, PPO, PFFS, SNP, MSA
Still pay: Part B premium + plan premium (if any)
Part D helps cover the cost of prescription medications. It's optional but highly recommended, as not enrolling can result in permanent penalties.
⚠️ Late Enrollment Penalty
If you go 63 days without creditable drug coverage after becoming eligible, you'll pay a penalty calculated as 1% of the national base premium ($35 in 2025) × number of months without coverage.
This penalty lasts as long as you have Part D!
How Part D Works:
Key Considerations:
- Each plan has its own formulary (list of covered drugs)
- Different pharmacy networks offer different costs
- Formularies can change yearly
💡 Pro Tip
Even if you don't take any medications now, consider enrolling during your Initial Enrollment Period to avoid penalties. You can always choose a low-premium plan.
How the Parts Work Together
🏥 Original Medicare Route:
Part A (Hospital) + Part B (Medical) + Part D (Drugs) + Medigap (Optional gap coverage)
🛡️ Medicare Advantage Route:
Part C (Includes A, B, usually D) + Extra benefits like dental, vision, hearing
Important: You cannot have both Medigap and Medicare Advantage at the same time.
Medicare can be confusing with all its parts and options. Our experienced agents will help you understand your choices, compare plans, and find coverage that fits your healthcare needs and budget—at no cost to you.
Original Medicare vs Medicare Advantage
Understanding the key differences helps you choose the right coverage
Parts A & B
Doctor Choice
Any doctor accepting Medicare
Referrals Required
No referrals needed
Out-of-Pocket Maximum
No maximum
Prescription Coverage
Separate Part D needed
Dental Coverage
Not covered
Vision Coverage
Not covered
Hearing Coverage
Not covered
Travel Coverage
Limited outside U.S.
Plan Consistency
Standardized nationwide
Monthly Premium
Part B premium + possibly Part D
Part C
Doctor Choice
Network providers only
Referrals Required
May need referrals (HMO)
Out-of-Pocket Maximum
Annual out-of-pocket cap
Prescription Coverage
Often included
Dental Coverage
Often included
Vision Coverage
Often included
Hearing Coverage
Often included
Travel Coverage
Varies by plan
Plan Consistency
Plans vary by location
Monthly Premium
Varies (some $0 premium)
| Feature | Original Medicare Parts A & B | Medicare Advantage Part C |
|---|---|---|
| Doctor Choice | Any doctor accepting Medicare | Network providers only |
| Referrals Required | No referrals needed | May need referrals (HMO) |
| Out-of-Pocket Maximum | No maximum | Annual out-of-pocket cap |
| Prescription Coverage | Separate Part D needed | Often included |
| Dental Coverage | Not covered | Often included |
| Vision Coverage | Not covered | Often included |
| Hearing Coverage | Not covered | Often included |
| Travel Coverage | Limited outside U.S. | Varies by plan |
| Plan Consistency | Standardized nationwide | Plans vary by location |
| Monthly Premium | Part B premium + possibly Part D | Varies (some $0 premium) |
Not sure which option is right for you? Our agents can help you compare plans based on your specific needs.