Medicare Coverage Explained: Understanding Your Benefits

Medicare can be confusing with its various parts and coverage options. This guide breaks down everything seniors and their caregivers need to know about Medicare benefits, enrollment periods, and making the most of coverage.

Medicare Basics

Medicare is a federal health insurance program primarily for:

• People 65 years of age or older
• Certain younger people with disabilities
• People with End-Stage Renal Disease

The program is divided into four parts, each covering different services:

Medicare Part A (Hospital Insurance)

Coverage Includes:

• Inpatient hospital care
• Skilled nursing facility care
• Hospice care
• Home health care

Costs:

• Premium: Most beneficiaries don’t pay a monthly premium for Part A if they or their spouse paid Medicare taxes while working
• Deductible: $1,632 (2025) for each benefit period
• Coinsurance: Varies based on length of hospital stay

Medicare Part B (Medical Insurance)

Coverage Includes:

• Doctor visits
• Outpatient care
• Preventive services
• Durable medical equipment
• Some home health services

Costs:

• Premium: Standard monthly premium is $175.10 (2025), but may be higher based on income
• Deductible: $240 annual deductible (2025)
• Coinsurance: Typically 20% of the Medicare-approved amount after meeting the deductible

Medicare Part C (Medicare Advantage)

Medicare Advantage plans are offered by private insurance companies approved by Medicare.

Coverage Includes:

• All Part A and Part B services
• Usually includes prescription drug coverage (Part D)
• May include additional benefits like vision, dental, and hearing

Costs:

• Premium: Varies by plan (may have $0 premium options)
• Deductibles, Copays, and Coinsurance: Varies by plan
• Out-of-pocket maximum: Unlike Original Medicare, Advantage plans have annual out-of-pocket limits

Medicare Part D (Prescription Drug Coverage)

Coverage Includes:

• Outpatient prescription medications

Costs:

• Premium: Varies by plan
• Deductible: Up to $545 (2025)
• Copayments/Coinsurance: Varies by plan and drug tier

Medicare Supplement Insurance (Medigap)

Medigap policies help pay some of the health care costs that Original Medicare doesn’t cover.

Coverage Includes:

• Coinsurance and deductibles
• Some plans cover emergency care during foreign travel

Costs:

• Premium: Varies by plan, location, age, and insurance company
• Must have Medicare Part A and Part B to buy a Medigap policy

Enrollment Periods

Initial Enrollment Period

• 7-month period around 65th birthday (3 months before, birthday month, 3 months after)

General Enrollment Period

• January 1 - March 31 each year
• Coverage begins July 1

Medicare Advantage Open Enrollment

• October 15 - December 7 each year
• Changes effective January 1

Special Enrollment Periods

• Available in certain situations like moving or losing other coverage

Important Medicare Considerations for Seniors

Prescription Drug Coverage

• Review your medication list annually during open enrollment
• Use Medicare’s Plan Finder tool to compare costs
• Ask about generic alternatives

Preventive Services

Medicare covers many preventive services at no cost:

• Annual wellness visits
• Cancer screenings
• Vaccines (flu, pneumonia, COVID-19)
• Diabetes screenings

Long-Term Care Limitations

• Medicare does not cover most long-term care services
• Limited coverage for skilled nursing (up to 100 days)
• No coverage for assisted living or most home care

Additional Help with Medicare Costs

Medicare Savings Programs

• Help pay premiums, deductibles, coinsurance for lower-income beneficiaries

Extra Help Program

• Assists with prescription drug costs

State Health Insurance Assistance Programs (SHIPs)

• Free counseling and assistance with Medicare questions

Conclusion

Understanding Medicare coverage options is essential for making informed healthcare decisions. Review your coverage annually during open enrollment to ensure you have the most appropriate plan for your needs and budget.

For personalized assistance navigating Medicare options or finding supplemental coverage, use our search tool to connect with insurance experts specializing in senior healthcare benefits.