Medicare Made Simple
Clear answers. Simple explanations. Confidence in your Medicare choices.
Medicare does not have to be confusing. This guide explains the basics in plain language for adults age 62 and older, especially people approaching age 65.
Watch: Medicare Explained Face to Face
A friendly male presenter will walk you through Original Medicare, Medicare Advantage, provider choice, enrollment, and Social Security.
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Welcome to Willett Senior Solutions. If you're approaching age 65, you may have questions about Medicare, your doctors, and when to sign up.
Original Medicare has two parts. Part A helps cover inpatient hospital care and certain other services. Part B helps cover doctor visits, outpatient care, preventive services, and medical equipment.
With Original Medicare, you can generally visit any doctor or hospital in the United States that accepts Medicare. You usually don't need a referral to see a specialist. This freedom can be valuable if you travel or want to keep seeing a particular doctor.
Original Medicare has deductibles and other out-of-pocket costs. For many covered Part B services, you generally pay 20 percent of the Medicare-approved amount after meeting the annual deductible. Original Medicare alone has no annual out-of-pocket limit.
A Medicare Supplement policy, also called Medigap, can help pay some of those costs. For example, Plan G generally pays the Part A hospital deductible and the Part B coinsurance for covered services, but you still pay the annual Part B deductible. Plan N also helps with costs, but may have certain copayments and does not cover Part B excess charges. You pay a separate premium for Medigap, and prescription drug coverage is usually purchased separately.
Medicare Advantage, or Part C, is a different way to get your Medicare benefits through a private insurer approved by Medicare. It includes Part A and Part B benefits, and most plans include drug coverage. Some offer extra benefits. Many have networks. With an HMO, you generally use in-network doctors for non-emergency care. A PPO may cover some out-of-network care at a higher cost. Some plans require referrals. Medicare Advantage plans have an annual out-of-pocket limit for covered Part A and Part B services. Compare doctors, prescriptions, premiums, and total costs before choosing.
Now, let's talk about enrollment. Most people have a seven-month Initial Enrollment Period around age 65. It starts three months before your birthday month, includes that month, and ends three months afterward. For example, if you turn 65 in July, it usually runs from April through October. Special timing rules can apply if your birthday is on the first day of a month.
Some people receive Social Security before 65. For example, retirement benefits can begin as early as 62, and qualifying workers may receive Social Security Disability Insurance, or SSDI. People may also receive Railroad Retirement benefits. If you receive qualifying benefits at least four months before turning 65, Medicare generally enrolls you automatically in Parts A and B. Many people receiving SSDI qualify for Medicare earlier, usually after 24 months of disability benefits. If you are not receiving qualifying benefits, you generally need to sign up yourself. You can enroll in Medicare without starting Social Security retirement benefits.
Missing your enrollment window can be expensive, but penalties do not apply to everyone. If you delay Part B without a qualifying exception, your monthly premium generally increases by 10 percent for each full 12-month period you were eligible but didn't enroll. That increase usually lasts as long as you have Part B. If you go 63 days or more without Part D or other creditable drug coverage after your enrollment period, a Part D penalty may apply. Most people get premium-free Part A; a Part A late penalty can apply to people who must pay a Part A premium.
If you're still working and covered by a group health plan based on current employment, you may qualify for a Special Enrollment Period to delay Part B without penalty. Retiree coverage and COBRA generally do not count for that exception. Check with Social Security before delaying enrollment.
Here's another important deadline. Once you are age 65 or older and enrolled in Part B, you generally have a six-month Medigap Open Enrollment Period. During this time, insurers generally cannot refuse to sell you a Medigap policy offered in your state or charge more because of your health. Some pre-existing-condition waiting periods can apply. After these six months, insurers may use medical underwriting unless you have another protected right or state-law protection. This is why it is worth comparing Medigap choices early.
You can apply for Medicare or Social Security retirement benefits through the official Social Security website. Links are provided in the enrollment section of this website.
Thank you for visiting Willett Senior Solutions. Our goal is to help you understand your options and make an informed decision.
1. How Original Medicare Works
Original Medicare is the traditional Medicare program run by the federal government. It has two main parts.
Part A — Hospital Insurance
Part A generally helps pay for covered inpatient hospital care, skilled nursing facility care, hospice care, and some home health care.
Part B — Medical Insurance
Part B generally helps pay for covered doctor services, outpatient care, preventive services, and durable medical equipment.
You can choose your doctors
With Original Medicare, you can generally use any doctor or hospital that accepts Medicare. You are not normally limited to one private plan's provider network.
2. How Medicare Advantage Is Different
Medicare Advantage is also called Medicare Part C. It is an alternative way to receive your Medicare benefits through a Medicare-approved private insurance company.
A bundled alternative
Medicare Advantage plans generally combine Part A and Part B coverage in one plan. Most plans also include Part D prescription drug coverage.
Private insurance plan
The plan is offered by a private insurer. The insurer sets the plan's network, benefits, cost-sharing, and rules within Medicare's requirements.
Networks matter
Many Medicare Advantage plans use provider networks. Depending on the plan, going outside the network can cost more or may not be covered except in certain situations, such as emergencies.
Why people choose Medicare Advantage
Plans may offer extra benefits and may have predictable copays for many services. Some plans also have a $0 monthly plan premium, although other Medicare costs can still apply.
Why people choose Original Medicare
Some people prefer the broad provider choice of Original Medicare. They may also prefer to add separate Medicare Supplement and prescription drug coverage.
Why Choosing Your Own Doctor Matters
With Original Medicare, you can see any doctor or specialist in the United States who accepts Medicare. You do not have to stay inside a private insurance company's network.
Keep more choices. If you need a heart doctor, cancer specialist, or another expert, you can generally make an appointment with any provider who accepts Medicare. Original Medicare usually does not require a referral from your primary care doctor.
More freedom when you travel. If you visit family or spend part of the year in another state, you can generally get Medicare-covered care from providers there who accept Medicare.
What changes with Medicare Advantage? Many Medicare Advantage plans have a network of doctors and hospitals. An HMO usually requires you to use its network for nonemergency care, with some exceptions. A PPO may let you see out-of-network providers, but it can cost more. Some plans also require referrals for certain specialists.
Example: Suppose you want to see a specialist at a hospital in another state. With Original Medicare, you can generally go there if the specialist accepts Medicare. With Medicare Advantage, you should first check whether the specialist and hospital are in your plan's network, whether the service is covered, and whether approval is needed.
Remember: Medicare Advantage plans may include extra benefits and lower monthly plan premiums. Original Medicare offers broader provider choice, but you should also compare costs, prescription coverage, and whether supplemental insurance is right for you.
3. Enrolling in Medicare & Social Security
Turning 65 is a major Medicare milestone. You do not have to start Social Security retirement benefits just because you are enrolling in Medicare.
About 3 months before 65
Start reviewing your Medicare choices. Check whether you will be automatically enrolled in Part A and Part B or whether you need to sign up.
Decide about Social Security
You can claim Social Security retirement benefits separately from your Medicare decision. Your Social Security claiming age affects the amount of your monthly benefit.
Enroll in Medicare when appropriate
If you are not automatically enrolled, apply for Medicare through Social Security. If you are still working and have employer coverage, special enrollment rules may apply.
Compare your coverage choices
After understanding your Medicare eligibility, compare Original Medicare plus supplemental coverage with Medicare Advantage plans available in your area.
Review your prescriptions and doctors
Make sure your doctors, hospitals, pharmacies, and prescriptions fit the plan you are considering.
Who Is Automatically Enrolled?
People already receiving qualifying benefits at least four months before age 65 are generally enrolled automatically in Medicare Parts A and B. This includes people who started Social Security retirement benefits early, people receiving Social Security Disability Insurance (SSDI), and people receiving Railroad Retirement benefits. Medicare sends your card and coverage information.
Who might be collecting Social Security before 65? Some people claim retirement benefits as early as age 62. Others receive SSDI because a qualifying disability prevents them from working. These are different types of Social Security benefits.
You do not have to start Social Security retirement benefits just to get Medicare. The automatic-enrollment rule applies when you are already receiving qualifying benefits before 65.
Who Needs to Sign Up?
If you are approaching 65 and are not receiving Social Security or Railroad Retirement benefits, you generally need to actively sign up for Medicare. You can apply through Social Security during your Initial Enrollment Period.
This is especially important for people who plan to delay Social Security retirement benefits. Delaying Social Security does not mean you should automatically delay Medicare.
Under 65 With Disability
People receiving Social Security Disability Insurance (SSDI) generally become eligible for Medicare after 24 months of disability benefits, even if they are younger than 65. People with ALS can qualify for Medicare when their SSDI benefits begin, without the 24-month wait. Special rules also apply for end-stage renal disease (ESRD). Supplemental Security Income (SSI) alone does not automatically qualify someone for Medicare.
A Simple Rule to Remember
Getting Social Security retirement or SSDI benefits before 65? You may be automatically enrolled in Medicare at 65, or earlier if you qualify through disability.
Not receiving qualifying Social Security or Railroad Retirement benefits? You generally need to sign up for Medicare yourself when eligible.
Social Security
Social Security handles Medicare enrollment for many people. It also handles applications for Social Security retirement benefits.
Remember: Medicare and Social Security are related, but they are not the same program.
Do not wait until the last minute
Enrollment timing can affect when coverage begins and whether penalties can apply. If you are working past 65 and have employer coverage based on current employment, special enrollment rules may apply. COBRA and retiree coverage usually do not qualify for this delay.
Why the 6-month Medigap Open Enrollment Period Matters
If you are 65 or older, your six-month Medigap Open Enrollment Period begins when your Medicare Part B coverage starts. During this time, you generally can buy any Medigap policy sold in your state without being denied or charged more because of health problems.
After this period, insurers may ask health questions or deny an application unless another guaranteed-issue right or state protection applies. Some pre-existing-condition waiting periods can apply even during open enrollment.
Why it matters: This may be your easiest opportunity to buy a Medicare Supplement policy that helps pay deductibles, copayments, and coinsurance while keeping Original Medicare's broad choice of providers.
Could You Pay a Medicare Late Enrollment Penalty?
Your Initial Enrollment Period normally lasts seven months: three months before your 65th birthday month, your birthday month, and three months after. A special timing rule applies to birthdays on the first of a month.
Part B: If you delay without qualifying for an exception, your premium generally rises by 10% for every full 12-month period you could have had Part B but did not enroll. The increase generally lasts as long as you have Part B.
Part D: A penalty may apply if you go 63 consecutive days or more without Part D or other creditable prescription drug coverage after your enrollment period.
Part A: Most people do not pay a Part A premium. A late penalty can apply to those who must buy Part A.
Important exception: Coverage from a group health plan based on current employment may let you delay Part B without a penalty. COBRA and retiree coverage generally do not qualify for this exception. Check your situation before delaying.
Ready to Apply? Use These Official Government Links
Sign up for Medicare Parts A and B. If you need to enroll in Medicare, use the Social Security Administration's secure website.
Apply for Social Security retirement benefits. If you are ready to begin your monthly retirement benefits, use this separate application page.
Remember: You can sign up for Medicare without starting Social Security retirement benefits. If you are already automatically enrolled in Medicare, you generally do not need to apply again. If you have employer coverage, check the enrollment rules before delaying Part B.
These buttons open official U.S. Social Security Administration websites (ssa.gov). Do not enter your Social Security number on this educational website.