Getting started
What are the four parts of Medicare?
Medicare comes in four parts. Part A is hospital insurance — inpatient stays, skilled nursing, hospice. Most people pay no premium for it because they or a spouse paid Medicare taxes while working. Part B is medical insurance — doctor visits, outpatient care, preventive services, equipment — and it has a monthly premium set by the federal government each year. Part C, also called Medicare Advantage, is a private plan that takes over how your Part A and Part B benefits are delivered, usually through a network. Part D is prescription drug coverage, offered through private plans, where each plan covers a specific list of drugs.
Source: Medicare.gov — Parts of MedicareWhen can I first sign up?
Your Initial Enrollment Period is seven months long. It starts three months before the month you turn 65, includes your birthday month, and ends three months after. If you sign up during the first three months, your coverage starts on the first day of your birthday month — and if your birthday falls on the 1st, it starts the first day of the previous month. Signing up later in the window is allowed, but it pushes your start date back.
Source: Medicare.gov — When can I sign up?Will I be enrolled automatically?
If you're already receiving Social Security or Railroad Retirement Board benefits when you approach 65, you'll generally be enrolled in Part A and Part B automatically, and your card arrives in the mail. If you're not receiving those benefits yet, enrollment isn't automatic — you have to sign up yourself through Social Security.
Source: Medicare.gov — How do I sign up?How do I actually sign up?
Enrollment in Part A and Part B happens through Social Security, not through an insurance agent — you can do it online at ssa.gov, by phone, or at a Social Security office. An agent's role comes later, if and when you're choosing private coverage on top of it. We can explain how the pieces fit together, but the Part A and Part B sign-up itself is yours to do with Social Security.
Source: Social Security — Apply for MedicareCan I get Medicare before 65?
Medicare is not only for people 65 and older. People under 65 generally become eligible after receiving Social Security disability benefits for 24 months, and enrollment at that point is usually automatic. There are two exceptions to the waiting period: people diagnosed with ALS, and people with end-stage renal disease, both of which follow their own timing rules. The parts of Medicare and the enrollment windows work much the same way once you are eligible.
Source: Medicare.gov — How does Medicare work?How do I replace my Medicare card?
If your Medicare card is lost, stolen or damaged, you can get a replacement at no cost. The quickest route is a free account at Medicare.gov, where you can print an official copy immediately and order a replacement card, or you can call 1-800-MEDICARE. That same account is useful beyond the card — it shows your coverage, your claims, and the drugs on your list, which makes it a good place to check facts about your own coverage rather than working from memory.
Source: Medicare.gov — Your Medicare cardWorking past 65 and avoiding penalties
What happens if I sign up for Part B late?
If you don't sign up for Part B when you're first eligible, and you don't qualify for a Special Enrollment Period, you'll pay an extra 10% of the Part B premium for each full 12-month period you could have had Part B but didn't. In most cases you keep paying that penalty for as long as you have Part B — it doesn't expire. It's one of the few mistakes in Medicare that never stops costing, which is why the timing usually matters more than the plan choice.
Source: Medicare.gov — Avoid late enrollment penaltiesIs there a penalty for skipping drug coverage?
If you go 63 days or more in a row after your Initial Enrollment Period without Part D or other creditable prescription drug coverage, you may owe a Part D late enrollment penalty, and it's generally added to your premium for as long as you have Part D. 'Creditable' means the drug coverage you already have is expected to pay at least as much as standard Medicare drug coverage — your current plan has to tell you whether it qualifies.
Source: Medicare.gov — Part D late enrollment penaltyI'm still working at 65. Do I need Part B?
If you're still working at 65 and have health coverage through your own or your spouse's active employer, you may be able to delay Part B without a late penalty, and pick it up later through a Special Enrollment Period. Whether that works depends on the size of the employer and on whether the coverage counts as creditable — the rules genuinely differ, and getting this one wrong is expensive. It's worth confirming your specific situation with your benefits administrator or with Social Security before you decide.
Source: Medicare.gov — Working past 65Can I stay on my spouse's work plan?
Coverage through a spouse's current employer can let you delay Part B without a penalty, in the same way coverage through your own employer can — but the details matter, and the size of the employer is usually the deciding factor. What counts is that the employment is current and active. This is a case where getting it wrong is expensive and permanent, so the right move is to confirm in writing with the employer's benefits administrator how their plan works with Medicare before deciding to delay anything.
Source: Medicare.gov — Working past 65Does COBRA let me delay Part B?
This is one of the most costly mistakes people make. COBRA is generally not treated as coverage based on current employment, so having COBRA usually does not protect you from the Part B late enrollment penalty and does not give you a Special Enrollment Period later. People who take COBRA at retirement and assume they can put off Part B often find out only when the penalty is already permanent. If you are being offered COBRA around the time you turn 65 or retire, it is worth getting clear on how it interacts with Part B before you accept it.
Source: Medicare.gov — COBRA coverageHow does retiree coverage work with Medicare?
Retiree coverage is not the same thing as coverage from a current job. Because the employment is no longer active, it generally does not let you delay Part B without a penalty. Most retiree plans are built on the assumption that you have enrolled in Medicare, and once you are 65 they typically pay after Medicare rather than before it. Some will reduce or end their benefits entirely once you are Medicare-eligible. The plan's own benefits administrator is the authority on how their specific plan coordinates, and that is the conversation to have before you make any decision.
Source: Medicare.gov — Retiree insuranceWhat does 'creditable coverage' mean?
Creditable coverage means prescription drug coverage that is expected to pay, on average, at least as much as standard Medicare drug coverage. It matters because as long as you have creditable coverage, you can delay Part D without building up a late enrollment penalty. Employer plans, union plans, and some retiree and veterans coverage are often creditable, but not always. The plan is required to tell you in writing each year whether its coverage is creditable — that notice is the document to keep, because it is your evidence if the question ever comes up.
Source: Medicare.gov — Avoid late enrollment penaltiesWhat happens to my HSA when I get Medicare?
You can't contribute to a health savings account for any month you're enrolled in Medicare. The trap is the backdating: if you enroll in Part A after 65, coverage can be backdated up to six months, and contributions made during those retroactive months become excess contributions with tax consequences. So people usually plan their final HSA contribution about six months before Part A starts. You can still spend what's already in the account after you enroll — the restriction is only on putting money in.
Source: IRS Publication 969 — Health Savings AccountsHow do VA benefits work with Medicare?
VA benefits and Medicare do not coordinate the way two insurance plans do — they operate separately. VA coverage generally applies to care you receive at a VA facility, and Medicare applies to care outside it, so many veterans keep both so that they have coverage in either setting. VA drug coverage is normally creditable, which affects Part D timing. TRICARE follows its own rules, and for most military retirees enrolling in Part B when first eligible is a requirement for keeping TRICARE. Because both are federal programs with their own rules, the VA or TRICARE directly is the right place to confirm your situation.
Source: VA.gov — VA health care and other insuranceCan I drop Part B later?
You can drop Part B, but it is not something to do casually. Because it usually means giving up a guaranteed premium, dropping Part B can leave you facing a late enrollment penalty and a wait for a future enrollment window if you want it back. Social Security handles the process, and it generally requires a specific form and, in most cases, an interview rather than a phone call or a website click. The requirement to talk to someone is deliberate, because the consequences are hard to undo.
Source: Medicare.gov — How to drop Part A & Part BUnderstanding your coverage options
Advantage or Original Medicare: what's the difference?
There are two broad directions, and neither is better in the abstract. With Original Medicare you use Part A and Part B directly and can see any provider in the country that accepts Medicare; there's no annual out-of-pocket limit on its own, which is why many people add a Medicare Supplement policy, and prescriptions are covered separately through a standalone Part D plan. With Medicare Advantage, a private plan delivers your Part A and Part B benefits, usually through a network; these plans have an annual out-of-pocket maximum and often include drug coverage, but you generally need to stay in-network and referrals or prior authorization may apply. Which one fits depends on your doctors, your prescriptions and your budget — not on which one is 'best'.
Source: Medicare.gov — Your coverage optionsWhat is a Medicare Supplement?
A Medicare Supplement policy, often called Medigap, is private insurance that works alongside Original Medicare. It does not replace Part A and Part B — it helps pay some of what they leave behind, like deductibles, copayments and coinsurance. In most states these policies are standardized and sold under letters. A plan of a given letter has to offer the same set of benefits no matter which company sells it, so the differences between companies come down to price and service rather than what the policy covers. Medigap policies do not include prescription drug coverage, so people with one usually add a separate Part D plan.
Source: Medicare.gov — Medigap basicsWhen is the best time to buy a supplement?
You get a one-time Medigap Open Enrollment Period that lasts six months, starting the first month you have Part B and are 65 or older. During that window an insurer can't turn you down or charge you more because of your health history. Once it closes, your medical history can affect whether you can buy a Medicare Supplement policy at all, and that consequence is permanent. California adds something on top: state law gives you a 60-day window following your birthday each year to switch to a Medigap policy with equal or lesser benefits, without new medical underwriting.
Source: Medicare.gov — Medigap: get ready to buyCan I have a supplement and Advantage together?
No — these are two different routes and you take one or the other. A Medicare Supplement policy is designed to sit alongside Original Medicare, so it only works if that is what you have. It is against the law for someone to sell you a Medigap policy while you are in a Medicare Advantage plan, unless you are leaving that plan and returning to Original Medicare. This is one of the more consequential decisions in Medicare, because your ability to buy a Supplement later can depend on your health history and on timing.
Source: Medicare.gov — Buying a Medigap policyWhat is California's birthday rule?
California is one of a small number of states with a birthday rule. Under state law, if you already have a Medicare Supplement policy, you get a window each year that begins on your birthday and runs for 60 days. During that window you can switch to another Supplement policy with equal or lesser benefits without going through medical underwriting — meaning your health history cannot be used to turn you down or charge you more. It is a genuinely valuable protection, and it is easy to miss because nobody sends you a reminder.
Source: California Department of Insurance — Medicare Supplement noticeHow do drug lists and tiers work?
Every Part D plan publishes a formulary, which is the list of drugs it covers. Drugs are grouped into tiers, and the tier a drug sits in affects what you pay for it. Plans can also apply rules to particular drugs — requiring you to try a lower-cost drug first, requiring approval before they will cover it, or limiting the quantity. Because formularies differ from plan to plan and can change from year to year, the practical step is to check your own specific medications against a plan's list rather than comparing plans on premium alone.
Source: Medicare.gov — What drug plans coverDoes Medicare cover dental, vision or hearing?
Original Medicare generally does not cover routine dental care, routine eye exams for glasses, or hearing aids and the exams to fit them. It covers some related medical services — for example, cataract surgery and corrective lenses afterward, or dental work that is part of a covered medical procedure — but the everyday cleanings, glasses and hearing aids are not part of it. This is one of the most common surprises people run into, and it is one of the reasons some people look at Medicare Advantage plans or standalone dental and vision policies.
Source: Medicare.gov — Dental servicesDoes Medicare pay for long-term care?
This is the biggest and most costly misunderstanding in Medicare. Medicare does not pay for long-term custodial care — help with bathing, dressing, eating, or simply living somewhere safe — when that is the only care you need. What Medicare does cover is short-term skilled care: a limited stay in a skilled nursing facility after a qualifying hospital stay, or skilled care at home, when a doctor certifies you need it. Long-term custodial care is generally paid out of pocket, through long-term care insurance, or through Medicaid once someone qualifies financially.
Source: Medicare.gov — Long-term careAm I covered when I travel abroad?
In most situations Original Medicare does not cover health care outside the United States. There are a few narrow exceptions, mostly involving emergencies near the border or on the way to Alaska. Because the general rule is no coverage, people who travel internationally often look at a separate travel medical policy for those trips. Some Medicare Supplement policies include limited foreign travel emergency benefits, and some Medicare Advantage plans offer worldwide emergency coverage, but this varies and is worth checking specifically rather than assuming.
Source: Medicare.gov — Travel outside the U.S.What preventive care is included?
Medicare covers a set of preventive services, and many of them cost you nothing when you see a provider who accepts assignment. In your first year with Part B you can have a one-time Welcome to Medicare preventive visit, and after that you can have a yearly wellness visit. These are planning visits rather than physical exams — they are about reviewing your health, your medications and your risk factors, and setting up a schedule for screenings. Screenings for things like cancer, diabetes and cardiovascular disease are covered on their own schedules.
Source: Medicare.gov — Preventive & screening servicesHow do I know if my doctor takes Medicare?
Accepting assignment means a provider agrees to be paid the Medicare-approved amount and not to bill you for more than the applicable deductible and coinsurance. Most providers do. Some accept Medicare but do not accept assignment, and they can charge somewhat more. A small number opt out of Medicare entirely, in which case Medicare pays nothing toward their care. Medicare.gov has a provider search you can use to check, and it is always worth asking the office directly, since a provider's status can change.
Source: Medicare.gov — Care Compare (find providers)Costs and help paying
What does Medicare cost?
Most people pay no premium for Part A. Part B has a standard monthly premium set by the federal government each year, and people with higher incomes pay more through an income-related adjustment based on their tax return from two years earlier. Part C and Part D costs vary by plan. Because these amounts change every year, the reliable place to check the current figures is Medicare.gov rather than anything written down elsewhere.
Source: Medicare.gov — Medicare costsDo higher earners pay more?
If your income is above a certain level, you pay more for Part B and for Part D. Social Security calls this the income-related monthly adjustment amount. It is based on the tax return you filed two years earlier, so the figure that matters in a given year is usually your income from two years before that. If your income has since dropped because of a life-changing event — retirement, the death of a spouse, divorce, loss of a pension — you can ask Social Security to reconsider using your current income instead. A lot of people pay the higher amount without knowing that request exists.
Source: Medicare.gov — Medicare costsIs there help paying for Medicare?
There are programs that help with Medicare costs if your income and resources are limited — Medicare Savings Programs can help with premiums and cost sharing, and Extra Help assists with prescription drug costs. California also has HICAP, a free counseling service for people with Medicare, which costs nothing and isn't tied to any insurance company. If free counseling is the better answer for your situation, we'll say so.
Source: Medicare.gov — Get help paying costsMedicare vs. Medi-Cal: what's the difference?
They are two different programs that are easy to confuse. Medicare is federal health insurance based mainly on age or disability, and it is not based on your income. Medicaid is a joint federal and state program based on income and resources, and in California it is called Medi-Cal. Some people qualify for both, which is usually referred to as being dually eligible. When that happens, Medicare generally pays first and Medicaid can help with costs Medicare does not cover, and there are also programs that help pay Medicare premiums for people with limited income.
Source: Medicare.gov — MedicaidDoes it cost anything to work with an agent?
Working with a licensed agent does not add anything to your premium. Agents are paid by the insurance company, and for Medicare plans the amounts are capped by the federal government rather than set by the agent. The same plan costs the same whether you enroll through an agent, directly with the company, or on your own. What differs is whether someone is walking through the details with you. You should expect an agent to tell you which companies they are appointed with, since no agent represents every company available.
Source: Medicare.gov — Your coverage optionsChanging plans, moving, and problems
When can I change plans each year?
Medicare Open Enrollment, also called the Annual Election Period, runs October 15 to December 7 every year. During it you can join, switch or drop a Medicare Advantage or Part D plan, and changes take effect January 1. Separately, if you're already in a Medicare Advantage plan, the Medicare Advantage Open Enrollment Period from January 1 to March 31 gives you one change.
Source: Medicare.gov — Joining a planCan I switch out of Advantage after January 1?
There is a second window each year, running from January 1 through March 31, that applies only to people already in a Medicare Advantage plan. During it you can switch to a different Medicare Advantage plan, or drop it and return to Original Medicare, adding a Part D plan if you want drug coverage. You get one change during that window. It is not a general open season — if you are in Original Medicare on January 1, this window does not let you join a Medicare Advantage plan.
Source: Medicare.gov — Joining a planWhat if I miss my sign-up window?
Certain life events open a Special Enrollment Period that lets you enroll or change coverage outside the normal windows — losing employer coverage, moving out of your plan's service area, and several other specific circumstances. Each one has its own rules about how long the window lasts and what you can do during it, so the answer depends on which event applies to you.
Source: Medicare.gov — Special Enrollment PeriodsWhat happens if I move?
Original Medicare, Part A and Part B, travels with you anywhere in the United States. Medicare Advantage and Part D plans are different, because they are sold by service area. If you move outside your plan's service area, your current plan generally cannot follow you, and moving gives you a Special Enrollment Period to pick up coverage where you now live. The timing of that window depends on whether you tell the plan before or after you move, so it is worth handling the notification deliberately rather than after the fact.
Source: Medicare.gov — Special Enrollment PeriodsWhat if a claim is denied?
You have the right to appeal, and appeals succeed more often than people expect. If Original Medicare denies a claim, the denial appears on your Medicare Summary Notice, and the notice explains how to ask for a redetermination and the deadline for doing it. If a Medicare Advantage or Part D plan denies something, you appeal through that plan first, and there are faster timelines when waiting would put your health at risk. The single most important thing is the deadline — appeal rights expire, and the paperwork you receive tells you when.
Source: Medicare.gov — How do I file an appeal?How do I protect myself from Medicare scams?
Treat your Medicare number the way you treat your Social Security number. Medicare will not call you out of the blue to ask for it, and nobody legitimate needs it to give you a free brace, a free genetic test, or free groceries. Common signs of a scam are pressure to decide immediately, a caller claiming to be from Medicare itself, or an offer of something free in exchange for your number. Check your statements for services you did not receive. Suspected fraud can be reported to 1-800-MEDICARE.
Source: Medicare.gov — Reporting Medicare fraud & abuseYour situation isn't on this list?
Most people's questions end up being about their own doctors, prescriptions and timing. That's a conversation, and Ben Chaib, our licensed agent in San Diego, is happy to have it with you.
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