Medicare

The short version

Medicare is a federal health insurance program for people 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant). It helps cover hospital stays, doctor visits, prescription drugs, and other medical services. Understanding Medicare's different parts and how to enroll is crucial to ensure you have health coverage when you need it.

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 section establishes the Medicare program, creating a health insurance plan for the aged and disabled. It outlines the eligibility requirements and the general scope of covered services.
Why it matters: This is the core law that created Medicare, defining who can get it and what kind of medical care it covers.
42 U.S.C. § 1395c (Part A)
This section describes the Hospital Insurance Benefits Plan (Part A), covering inpatient hospital services, skilled nursing facility care, hospice care, and some home health care.
Why it matters: This defines what Medicare Part A covers, mainly services related to inpatient care.
42 U.S.C. § 1395j (Part B)
This section outlines the Supplementary Medical Insurance Benefits Plan (Part B), covering doctor services, outpatient care, medical supplies, and preventive services.
Why it matters: This defines what Medicare Part B covers, mainly outpatient care and doctor visits.
42 U.S.C. § 1395w-21 (Part C)
This section describes the Medicare+Choice program, now known as Medicare Advantage (Part C). It allows private insurance companies to offer Medicare benefits.
Why it matters: This allows you to choose private plans (Medicare Advantage) that combine Parts A and B, often with extra benefits.
42 U.S.C. § 1395w-101 (Part D)
This section establishes the voluntary prescription drug benefit program (Part D), allowing private plans to offer coverage for prescription medications.
Why it matters: This created the prescription drug coverage that helps pay for your medications.

Words you need to know

Medicare Part A (Hospital Insurance): Part A generally helps cover inpatient care in a hospital, skilled nursing facility care, hospice care, and home health care. Most people don't pay a monthly premium for Part A if they or their spouse paid Medicare taxes through work for a certain period.
Medicare Part B (Medical Insurance): Part B helps cover doctors' services, outpatient care, medical supplies, and preventive services. Most people pay a monthly premium for Part B, which is often deducted from Social Security benefits.
Medicare Part C (Medicare Advantage): Part C is an 'all-in-one' alternative to Original Medicare (Parts A and B) offered by private companies approved by Medicare. These plans usually include Part A, Part B, and often Part D coverage, sometimes with extra benefits like vision or dental.
Medicare Part D (Prescription Drug Coverage): Part D helps cover the cost of prescription drugs. It's offered through private insurance companies approved by Medicare, and you can get it through a stand-alone Part D plan or as part of a Medicare Advantage plan (Part C).
Initial Enrollment Period (IEP): This is your first chance to sign up for Medicare. It lasts for seven months, starting three months before you turn 65, includes the month you turn 65, and ends three months after you turn 65. (42 U.S.C. § 1395p(e))
General Enrollment Period (GEP): If you miss your Initial Enrollment Period and don't qualify for a Special Enrollment Period, you can sign up for Part B (and sometimes Part A) during the General Enrollment Period. This runs from January 1 to March 31 each year, with coverage starting July 1. (42 U.S.C. § 1395p(e))

Your rights

✓You have the right to enroll in Medicare if you are 65 or older, or if you have certain disabilities, as defined by 42 U.S.C. § 1395.
✓You have the right to choose between Original Medicare (Parts A and B) or a Medicare Advantage Plan (Part C).
✓You have the right to obtain prescription drug coverage through a Part D plan or a Medicare Advantage Plan.
✓You have the right to appeal coverage or payment decisions if you disagree with them.
✓You have the right to change your Medicare Advantage Plan or your Part D plan during specific enrollment periods.

How the process actually works

1
Eligibility Check
When you approach age 65, or upon receiving a disability determination.
Medicare eligibility is generally tied to age (65 and older) or specific health conditions (certain disabilities or End-Stage Renal Disease). You must also be a U.S. citizen or legal resident for at least five years. (42 U.S.C. § 1395c, 42 U.S.C. § 1395j)
2
Automatic Enrollment
Three months before your 65th birthday.
If you already receive Social Security or Railroad Retirement Board benefits for at least four months before turning 65, you will automatically be enrolled in Medicare Parts A and B. Your Medicare card will be mailed to you. (42 U.S.C. § 1395b-2)
3
Initial Enrollment Period (IEP)
Seven months, starting three months before your 65th birthday, including your birthday month, and ending three months after your birthday month.
If you are not automatically enrolled, you must sign up during your Initial Enrollment Period. This period is critical to avoid potential late enrollment penalties for Part B and Part D. (42 U.S.C. § 1395p(e))
4
Choosing Your Coverage
During your Initial Enrollment Period, or during annual enrollment periods.
You must decide if you want Original Medicare (Parts A and B, plus optional Part D and Medigap) or a Medicare Advantage Plan (Part C). This choice impacts your costs, provider network, and covered benefits. (42 U.S.C. § 1395w-21)
5
Signing Up for Part B and D
During your Initial Enrollment Period or Special Enrollment Period.
If you're not automatically enrolled, you'll need to actively sign up for Part B through Social Security. You'll also need to choose and enroll in a Part D plan (if you want prescription drug coverage) or a Medicare Advantage plan with drug coverage. (42 U.S.C. § 1395p(a), 42 U.S.C. § 1395w-101)

Deadlines that can end your case

Initial Enrollment Period (IEP)
Seven months (3 months before 65th birthday, the birth month, and 3 months after)
If you don't enroll in Part B (and sometimes Part A if you pay a premium) during this window and don't qualify for a Special Enrollment Period, you may face late enrollment penalties and delays in coverage. (42 U.S.C. § 1395p(e))
General Enrollment Period (GEP)
January 1 to March 31 each year
If you enroll in Part B during this period, your coverage won't start until July 1, and you may still owe a late enrollment penalty. (42 U.S.C. § 1395p(e))
Special Enrollment Periods (SEP)
Varies depending on the qualifying event (e.g., losing employer coverage, moving)
Missing an SEP when eligible can result in late enrollment penalties for Part B and Part D, and a gap in coverage. (42 U.S.C. § 1395p(b))

Costly mistakes

✕Not understanding the difference between Original Medicare and Medicare Advantage, leading to unexpected costs or network limitations.
✕Delaying enrollment in Part B or Part D when not covered by other 'creditable' insurance, resulting in lifelong late enrollment penalties.
✕Assuming Medicare automatically covers everything, leading to gaps in coverage for things like dental, vision, or long-term care.
✕Not reviewing prescription drug plans annually, which can cause you to pay more for medications than necessary.
✕Failing to understand how employer group health plans coordinate with Medicare, leading to confusion about primary and secondary payers.

Your checklist

Verify your eligibility for Medicare based on age, disability, or specific health conditions.
Determine if you will be automatically enrolled in Parts A and B, or if you need to actively sign up.
Identify your Initial Enrollment Period (IEP) and mark key dates on your calendar.
Research the differences between Original Medicare (Parts A & B) and Medicare Advantage Plans (Part C).
Compare available Part D prescription drug plans or Medicare Advantage plans with drug coverage.
Decide if you need supplemental coverage (like Medigap) if choosing Original Medicare.
Contact Social Security (if not automatically enrolled) to sign up for Part A and Part B during your IEP.
Enroll in your chosen Part D plan or Medicare Advantage plan.

Common questions

What is the difference between Original Medicare and Medicare Advantage?

Original Medicare (Parts A and B) is provided directly by the government. You can use any doctor or hospital that accepts Medicare, and you might add a separate Part D plan and a Medigap policy. Medicare Advantage (Part C) is offered by private insurance companies approved by Medicare and usually combines Parts A, B, and D, often with extra benefits. These plans typically have networks of doctors and hospitals. (42 U.S.C. § 1395w-21)

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

It depends on your employer's health coverage. If you have creditable health coverage through your job (or your spouse's job) after age 65, you might be able to delay Part B without penalty. You'll get a Special Enrollment Period when that employer coverage ends. If your employer has fewer than 20 employees, Medicare might be your primary payer, making it wise to enroll in Part B. (42 U.S.C. § 1395p(b))

What happens if I don't sign up for Part D when I first become eligible?

If you don't join a Medicare Part D plan or a Medicare Advantage plan with drug coverage when you first become eligible, and you don't have other creditable prescription drug coverage, you may have to pay a late enrollment penalty if you decide to join later. This penalty is added to your monthly premium for as long as you have Part D coverage. (42 U.S.C. § 1395w-115(b))

Does Medicare cover dental, vision, or hearing?

Original Medicare (Parts A and B) generally does not cover routine dental care, eye exams, eyeglasses, or hearing aids. Some Medicare Advantage (Part C) plans may offer these additional benefits. You would need to check specific plan details if you choose a Part C plan. (42 U.S.C. § 1395y(a)(4))

How this changes by state

Medicare is a federal program, so the core rules for eligibility and benefits for Parts A, B, C, and D are generally the same across all states, as defined by federal law (42 U.S.C. § 1395). However, some aspects can vary by location. For example, the specific private Medicare Advantage plans (Part C) and Part D prescription drug plans available to you will differ based on where you live. Also, state laws may impact how Medigap (Medicare Supplement Insurance) policies are offered or regulated, particularly for those under 65 who qualify for Medicare due to disability. To find your state's specific Medigap rules or available plans, you can contact your State Department of Insurance or your State Health Insurance Assistance Program (SHIP).

When you need a lawyer

You typically need a lawyer when you are denied Medicare benefits or coverage for a service and need to appeal the decision, or if you believe you have been subjected to Medicare fraud or abuse. If you are facing complex eligibility issues, especially related to disability or coordination with other benefits, a lawyer specializing in elder law or Medicare can provide guidance. Lawyers do not generally assist with initial enrollment choices or comparing plans.

Do this today

→Visit Medicare.gov to learn more about the different parts of Medicare and use their plan finder tools.
→Contact the Social Security Administration directly at 1-800-772-1213 to confirm your enrollment status or to sign up.
→Reach out to your State Health Insurance Assistance Program (SHIP) for free, unbiased counseling on Medicare plans.
→If you have current employer health coverage, speak with your employer's HR department to understand how it coordinates with Medicare.

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.