Medicare

The short version

Medicare is a federal health insurance program mainly for people aged 65 or older, some younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure). It helps cover hospital stays, doctor visits, and other medical services. Understanding Medicare is important because it can significantly affect your healthcare costs and access to medical care as you age or if you have certain health conditions. It provides a safety net for many Americans.

The law this is built on

Every point below comes from the authority named next to it. Verify the current text before relying on it.

42 U.S.C. § 1395
This federal law establishes and defines the Medicare program, setting forth who is eligible and what benefits are covered. It states that the program provides health insurance for aged and disabled individuals.
Why it matters: This is the core legal basis for Medicare, outlining its purpose and scope, ensuring that the program exists and operates for eligible people.
42 U.S.C. § 1395c
This section outlines eligibility for 'Hospital Insurance benefits for the aged,' which is Medicare Part A. It generally covers people 65 or older who are entitled to Social Security benefits.
Why it matters: This tells you if you qualify for the basic hospital coverage under Medicare once you reach a certain age.
42 U.S.C. § 1395j
This section establishes the 'Supplementary Medical Insurance Benefits for the Aged and Disabled,' known as Medicare Part B. It covers medical services like doctor visits and outpatient care.
Why it matters: This explains the part of Medicare that helps pay for services outside of hospital stays, which most people also need.
42 U.S.C. § 1395w-21
This section describes the Medicare+Choice program, now known as Medicare Part C or Medicare Advantage. It allows private health plans to offer Medicare benefits.
Why it matters: This gives you the option to receive your Medicare benefits through a private insurance company, which might offer additional services not covered by original Medicare.

Words you need to know

Medicare Part A (Hospital Insurance): Covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care (42 U.S.C. § 1395c).
Medicare Part B (Medical Insurance): Covers certain doctors' services, outpatient care, medical supplies, and preventive services (42 U.S.C. § 1395j).
Medicare Part C (Medicare Advantage): An 'all-in-one' alternative to Original Medicare offered by private companies approved by Medicare. These plans must cover everything Original Medicare covers and may offer extra benefits (42 U.S.C. § 1395w-21).
Medicare Part D (Prescription Drug Coverage): Helps cover the cost of prescription drugs. It's offered by private insurance companies approved by Medicare.
Original Medicare: This refers to Medicare Part A and Part B directly from the government. You can use any doctor or hospital in the U.S. that accepts Medicare.
Medigap (Medicare Supplement Insurance): Private health insurance that helps pay some of the healthcare costs that Original Medicare doesn't cover, like copayments, coinsurance, and deductibles.

Your rights

✓The right to choose between Original Medicare and a Medicare Advantage Plan (42 U.S.C. § 1395w-21).
✓The right to get healthcare services covered by Medicare if you are eligible (42 U.S.C. § 1395).
✓The right to appeal decisions made about your Medicare coverage or payments.
✓The right to receive information about your Medicare coverage options.
✓The right to purchase Medigap policies during a specific enrollment period without being denied coverage due to pre-existing conditions (Varies by state for certain situations).

How the process actually works

1
Eligibility
Approaching age 65 or after qualifying for disability benefits.
You generally become eligible for Medicare when you turn 65, or if you have certain disabilities or End-Stage Renal Disease. You must be a U.S. citizen or a legal resident for at least 5 years.
2
Initial Enrollment Period (IEP)
Starts 3 months before your 65th birthday.
This is a 7-month period when you can first sign up for Medicare. It starts 3 months before your 65th birthday, includes your birthday month, and ends 3 months after.
3
Choose Your Path
During your Initial Enrollment Period or other enrollment periods.
You decide between Original Medicare (Parts A & B) or a Medicare Advantage Plan (Part C). You might also add a Part D plan for prescription drugs and/or a Medigap policy.
4
Enrollment and Premiums
Automatic enrollment around age 65; manual enrollment by contacting Social Security.
If you receive Social Security or Railroad Retirement Board benefits, you are usually enrolled in Part A and Part B automatically. Otherwise, you must sign up. Most people pay a monthly premium for Part B and sometimes Part D; Part A is often premium-free.
5
Receive Care
After your coverage begins.
Once enrolled, you use your Medicare card or Medicare Advantage plan ID card when you get medical services. Medicare or your private plan pays its share, and you pay your deductibles, copayments, or coinsurance.

Deadlines that can end your case

Initial Enrollment Period (IEP)
7 months (3 months before your 65th birthday, your birthday month, and 3 months after)
If you miss this, you might pay a higher Part B premium for the rest of your life and have gaps in coverage. You might also face a Part D late enrollment penalty.
General Enrollment Period (GEP)
January 1 to March 31 each year
If you missed your IEP for Part B, you can sign up during this time. Your coverage starts July 1, and you may face late enrollment penalties.
Open Enrollment Period (OEP) / Annual Enrollment Period (AEP)
October 15 to December 7 each year
During this time, you can switch from Original Medicare to a Medicare Advantage Plan, switch between Medicare Advantage Plans, or join/switch/drop a Medicare Part D plan. Changes take effect January 1.

Costly mistakes

✕Not signing up for Medicare Part B when first eligible, leading to lifelong premium penalties and gaps in coverage.
✕Not signing up for a Part D prescription drug plan when first eligible, resulting in a late enrollment penalty unless you have other creditable coverage.
✕Assuming Medicare automatically covers all medical costs, leading to unexpected out-of-pocket expenses for deductibles, copays, and services not covered.
✕Not understanding the difference between Original Medicare and Medicare Advantage Plans before choosing.
✕Missing annual enrollment periods for making changes to your plan, which might leave you in a plan that no longer suits your needs or budget.
✕Failing to disclose other health coverage (like employer plans) when signing up, which can cause payment issues.

Your checklist

Learn about Medicare basics, including Parts A, B, C, and D.
Determine your Initial Enrollment Period (IEP) based on your 65th birthday or disability start date.
If you're still working past 65, understand how your employer coverage works with Medicare to avoid penalties.
Contact Social Security (if not automatically enrolled) to sign up for Part A and/or Part B during your IEP.
Research Medicare Advantage Plans (Part C), Medigap policies, and Part D prescription drug plans in your area.
Choose the plan(s) that best fit your health and financial needs.
Enroll in your chosen plans during the appropriate enrollment periods.
Keep your Medicare card and/or plan ID card safe and understand how to use it.

Common questions

Do I have to sign up for Medicare Part B if I'm still working?

It depends on your employer's health plan. If your employer has 20 or more employees, their plan is usually your primary payer. You might be able to delay Part B enrollment without penalty until you or your spouse stops working or the coverage ends. For employers with fewer than 20 employees, Medicare is usually primary, and you should enroll in Part B to avoid penalties. Check with your employer's benefits administrator.

What's the difference between Medicare and Medicaid?

Medicare is a federal health insurance program mainly for people 65 or older, some younger people with disabilities, and people with End-Stage Renal Disease (42 U.S.C. § 1395). Medicaid is a joint federal and state program that provides health coverage to low-income individuals and families.

Does Medicare cover dental, vision, or hearing aids?

Original Medicare (Parts A and B) generally does not cover routine dental care, eye exams for glasses, eyeglasses, or hearing aids. Some Medicare Advantage Plans (Part C) may offer these extra benefits (42 U.S.C. § 1395w-21).

Can I have both Medicare and a Medigap policy?

Yes, you can have both Original Medicare (Parts A and B) and a Medigap policy. Medigap helps pay some of the out-of-pocket costs that Original Medicare doesn't cover, like copayments, coinsurance, and deductibles. However, you cannot have a Medigap policy if you are enrolled in a Medicare Advantage Plan (Part C).

How this changes by state

While Medicare is a federal program established by 42 U.S.C. § 1395, some rules and offerings can vary by state. For instance, the availability and specific benefits of Medicare Advantage plans (Part C) and Part D prescription drug plans differ depending on what private insurers offer in your area. Additionally, some states have different rules for Medigap policies, such as guaranteed issue rights or how they are priced, especially for people under 65 who qualify for Medicare due to disability. To find state-specific information, you should check your State Health Insurance Assistance Program (SHIP) or your state's Department of Insurance.

When you need a lawyer

You might need to consult a lawyer if you believe your Medicare benefits have been wrongly denied, especially after going through the formal appeals process. A lawyer can also be helpful if you suspect Medicare fraud or abuse, or if you need to understand how Medicare interacts with other complex benefits like workers' compensation or large personal injury settlements.

Do this today

→Visit Medicare.gov to explore plan options in your area.
→Contact the Social Security Administration if you need to sign up for Part A or Part B, or if you have questions about your eligibility.
→Reach out to your State Health Insurance Assistance Program (SHIP) for free, unbiased counseling on Medicare questions.

This lesson is legal information for educational purposes only, based on 42 U.S.C. § 1395. It is not legal advice and does not create an attorney-client relationship.