When looking at coverage choices, there’s a lot to consider. You may enroll in Medicare Part A (hospital insurance), Medicare Part B (medical insurance) or both. Once you enroll in Original Medicare (Parts A & B), you may have other coverage choices, too, such as a Medicare Advantage plan (Part C), a Medicare Prescription Drug plan (Part D) or a Medicare Supplement insurance plan (Medigap).
Since the Medicare program began, the CMS (that was not always the name of the responsible bureaucracy) has contracted with private insurance companies to operate as intermediaries between the government and medical providers to administer Part A and Part B benefits. Contracted processes include claims and payment processing, call center services, clinician enrollment, and fraud investigation. Beginning in 1997 and 2005, respectively, these Part A and B administrators (whose contracts are bid out periodically), along with other insurance companies and other companies or organizations (such as integrated health delivery systems, unions and pharmacies), also began administering Part C and Part D plans. 

Most Medicare enrollees do not pay a monthly Part A premium, because they (or a spouse) have had 40 or more 3-month quarters in which they paid Federal Insurance Contributions Act taxes. The benefit is the same no matter how much or how little the beneficiary paid as long as the minimum number of quarters is reached. Medicare-eligible persons who do not have 40 or more quarters of Medicare-covered employment may buy into Part A for an annual adjusted monthly premium of:

You should be informed before buying. If you’re reading this guide, that’s a good start. And in general you should be a skeptical buyer, although Medigap insurance is heavily regulated. Still, shopping for insurance can be exhausting, but the best companies make the process as streamlined as possible. Look for a company that caters to your needs, such as a physical office for a face-to-face meeting, a helpful customer service representative on the phone, or online chat.

"I work primarily with adults on an individual, couple or family basis concerning relationship and mental health issues. Unless the focus is family therapy, I rarely see persons under 18. I am licensed as a clinical social worker(LCSW) and as a marriage and family therapist(LMFT)and a clinical member of the American Association for Marriage and Family Therapy(AAMFT). I have been in practice since 1980 in Morganton and have experience in in-patient and out-patient mental health, individual, marital therapy and developmental disabilities. I see older adults with life transition concerns."


In 1977, the Health Care Financing Administration (HCFA) was established as a federal agency responsible for the administration of Medicare and Medicaid. This would be renamed to Centers for Medicare and Medicaid Services (CMS) in 2001. By 1983, the diagnosis-related group (DRG) replaced pay for service reimbursements to hospitals for Medicare patients.

A Medicare Advantage plan (like an HMO or PPO) is another Medicare health plan choice you may have as part of Medicare. Medicare Advantage plans are offered by private companies approved by Medicare. If you join a Medicare Advantage plan, you still have Medicare. You will get your Part A (hospital insurance) and Part B (medical insurance) coverage from the Medicare Advantage plan and no Original Medicare. Medicare Advantage plans must cover all of the services that Original Medicare covers except hospice care. Original Medicare covers hospice care even if you’re in a Medicare Advantage plan. Medicare Advantage plans aren’t supplemental coverage. Medicare Advantage plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D). In most cases, you can join a Medicare Advantage plan only at certain times during the year.
Medicare is a national health insurance program in the United States, begun in 1966 under the Social Security Administration (SSA) and now administered by the Centers for Medicare and Medicaid Services (CMS). It provides health insurance for Americans aged 65 and older, younger people with some disability status as determined by the Social Security Administration, as well as people with end stage renal disease and amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease).
If you decide to sign up for a Medicare Advantage plan, you may want to shop around, because costs and coverage details are likely to vary. Our obligation-free eHealthMedicare plan finder tool on this page lets you see all available Medicare Advantage options in your area, including a list of coverage details once you click on the plan of interest.

Medicare supplement Plan F has also been the #1 seller with Baby Boomers for many years. According to a report from America’s Health Insurance professionals, about 57% of all Medigap policies in force were a premium Medicare Plan F policy. (In recent years, Plan G has been the second most popular Medicare supplement plan, and you can read more on that below.)
In states with lots of rural areas, like Minnesota, Medicare Cost plans tend to be more popular because they offer more flexibility than an HMO. If a plan member gets services inside of the network of Medicare Cost Plans, they work the same way that an HMO works. If the plan member decides to visit a non-network medical provider, Medicare Cost Plans will cover those services the same way that Original Medicare Part A and Part B do. Typically, a Medicare Advantage HMO won’t cover non-emergency services outside of the network at all.

These Medigap insurance policies are standardized by CMS, but are sold and administered by private companies. Some Medigap policies sold before 2006 may include coverage for prescription drugs. Medigap policies sold after the introduction of Medicare Part D on January 1, 2006 are prohibited from covering drugs. Medicare regulations prohibit a Medicare beneficiary from being sold both a public Part C Medicare health plan and a private Medigap Policy. As with public Part C health plans, private Medigap policies are only available to beneficiaries who are already signed up for Original Medicare Part A and Part B. These policies are regulated by state insurance departments rather than the federal government although CMS outlines what the various Medigap plans must cover at a minimum. Therefore, the types and prices of Medigap policies vary widely from state to state and the degree of underwriting, discounts for new members, open enrollment and guaranteed issue also varies widely from state to state.


People with disabilities who receive SSDI are eligible for Medicare while they continue to receive SSDI payments; they lose eligibility for Medicare based on disability if they stop receiving SSDI. The coverage does not begin until 24 month after the SSDI start date. The 24-month exclusion means that people who become disabled must wait two years before receiving government medical insurance, unless they have one of the listed diseases. The 24-month period is measured from the date that an individual is determined to be eligible for SSDI payments, not necessarily when the first payment is actually received. Many new SSDI recipients receive "back" disability pay, covering a period that usually begins six months from the start of disability and ending with the first monthly SSDI payment.
Most Medicare enrollees do not pay a monthly Part A premium, because they (or a spouse) have had 40 or more 3-month quarters in which they paid Federal Insurance Contributions Act taxes. The benefit is the same no matter how much or how little the beneficiary paid as long as the minimum number of quarters is reached. Medicare-eligible persons who do not have 40 or more quarters of Medicare-covered employment may buy into Part A for an annual adjusted monthly premium of:
Beneficiaries may enroll in a Medicare Supplement insurance plan in California during their six-month Medigap Open Enrollment Period, beginning on the first day of the month that they are 65 or older and enrolled in Medicare Part B. During this time, beneficiaries aren’t subject to medical underwriting, which means they cannot be charged higher premiums or denied coverage based solely on medical history or a current medical condition. However, if a beneficiary adds or changes a Medicare Supplement insurance plan at any other time, medical underwriting guidelines will generally apply.

The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premium and/or copayments/ coinsurance may change on January 1 of each year.
The Congressional Budget Office (CBO) wrote in 2008 that "future growth in spending per beneficiary for Medicare and Medicaid—the federal government's major health care programs—will be the most important determinant of long-term trends in federal spending. Changing those programs in ways that reduce the growth of costs—which will be difficult, in part because of the complexity of health policy choices—is ultimately the nation's central long-term challenge in setting federal fiscal policy."[84]
"I work primarily with adults on an individual, couple or family basis concerning relationship and mental health issues. Unless the focus is family therapy, I rarely see persons under 18. I am licensed as a clinical social worker(LCSW) and as a marriage and family therapist(LMFT)and a clinical member of the American Association for Marriage and Family Therapy(AAMFT). I have been in practice since 1980 in Morganton and have experience in in-patient and out-patient mental health, individual, marital therapy and developmental disabilities. I see older adults with life transition concerns."
If you decide to sign up for a Medigap policy, a good time to do so is during the Medigap Open Enrollment Period, a six-month period that typically starts the month you turn 65 and have Medicare Part B. If you enroll in a Medigap plan during this period, you can’t be turned down or charged more because of any health conditions. But if you apply for a Medigap plan later on, you may be subject to medical underwriting; your acceptance into a plan isn’t guaranteed.
Unless you choose otherwise, you will have Original Medicare. Instead of Original Medicare, you can decide to get your Medicare benefits from a Medicare Advantage Plan, also called Part C or Medicare private health plan. Remember, you still have Medicare if you enroll in a Medicare Advantage Plan. This means that you must still pay your monthly Part B premium (and your Part A premium, if you have one). Each Medicare Advantage Plan must provide all Part A and Part B services covered by Original Medicare, but they can do so with different rules, costs, and restrictions that can affect how and when you receive care.
A 2001 study by the Government Accountability Office evaluated the quality of responses given by Medicare contractor customer service representatives to provider (physician) questions. The evaluators assembled a list of questions, which they asked during a random sampling of calls to Medicare contractors. The rate of complete, accurate information provided by Medicare customer service representatives was 15%.[100] Since then, steps have been taken to improve the quality of customer service given by Medicare contractors, specifically the 1-800-MEDICARE contractor. As a result, 1-800-MEDICARE customer service representatives (CSR) have seen an increase in training, quality assurance monitoring has significantly increased, and a customer satisfaction survey is offered to random callers.
When you apply for Medicare, you can sign up for Part A (Hospital Insurance) and Part B (Medical Insurance). Because you must pay a premium for Part B coverage, you can turn it down. However, if you decide to enroll in Part B later on, you may have to pay a late enrollment penalty for as long as you have Part B coverage. Your monthly premium will go up 10 percent for each 12-month period you were eligible for Part B, but didn’t sign up for it, unless you qualify for a special enrollment period.
Special Needs Plans (SNP): Special Needs Plans are for beneficiaries with certain unique situations and meet certain eligibility criteria. These plans may limit membership to people who have certain chronic conditions, live in an institution (such as a nursing home), or are dual eligibles (receive both Medicare and Medicaid benefits). You must meet the eligibility requirements of the Special Needs Plan to enroll; for example, to enroll in a Dual-Eligible Special Needs Plan in your service area, you must have both Medicare and Medicaid coverage.
There are two ways for providers to be reimbursed in Medicare. "Participating" providers accept "assignment," which means that they accept Medicare's approved rate for their services as payment (typically 80% from Medicare and 20% from the beneficiary). Some non participating doctors do not take assignment, but they also treat Medicare enrollees and are authorized to balance bill no more than a small fixed amount above Medicare's approved rate. A minority of doctors are "private contractors" from a Medicare perspective, which means they opt out of Medicare and refuse to accept Medicare payments altogether. These doctors are required to inform patients that they will be liable for the full cost of their services out-of-pocket, often in advance of treatment.[63]
MA plans feature a network of doctors and hospitals that enrollees must use to get the maximum payment, whereas supplements tend to provide access to a broader set of health care providers, said Shawnee Christenson, an insurance agent with Crosstown Insurance in New Hope. While that might sound good to beneficiaries, supplements can come with significantly higher premiums, Christenson said.
Any stay which begins, or medical expenses you incur, during the first 3 months after your effective date will not be considered if due to a pre-existing condition. A pre-existing condition is a condition for which medical advice was given or treatment was recommended by or received from a physician within 3 months prior to your plan's effective date.
Several measures serve as indicators of the long-term financial status of Medicare. These include total Medicare spending as a share of gross domestic product (GDP), the solvency of the Medicare HI trust fund, Medicare per-capita spending growth relative to inflation and per-capita GDP growth; general fund revenue as a share of total Medicare spending; and actuarial estimates of unfunded liability over the 75-year timeframe and the infinite horizon (netting expected premium/tax revenue against expected costs). The major issue in all these indicators is comparing any future projections against current law vs. what the actuaries expect to happen. For example, current law specifies that Part A payments to hospitals and skilled nursing facilities will be cut substantially after 2028 and that doctors will get no raises after 2025. The actuaries expect that the law will change to keep these events from happening.
Generally, the different parts of Medicare help cover specific services. Most beneficiaries choose to receive their Parts A and B benefits through Original Medicare, the traditional fee-for-service program offered directly through the federal government. It is sometimes called Traditional Medicare or Fee-for-Service (FFS) Medicare. Under Original Medicare, the government pays directly for the health care services you receive. You can see any doctor and hospital that takes Medicare (and most do) anywhere in the country.
Medicare has four parts: loosely speaking Part A is Hospital Insurance. Part B is Medical Services Insurance. Medicare Part D covers many prescription drugs, though some are covered by Part B. In general, the distinction is based on whether or not the drugs are self-administered but even this distinction is not total. Public Part C Medicare health plans, the most popular of which are branded Medicare Advantage, are another way for Original Medicare (Part A and B) beneficiaries to receive their Part A, B and D benefits; simply, Part C is capitated fee and Original Medicare is fee for service. All Medicare benefits are subject to medical necessity.
The Monthly Premium for Part B for 2019 is $135.50 per month but anyone on Social Security in 2019 is "held harmless" from that amount if the increase in their SS monthly benefit does not cover the increase in their Part B premium from 2018 to 2019. This hold harmless provision is significant in years when SS does not increase but that is not the case for 2019. There are additional income-weighted surtaxes for those with incomes more than $85,000 per annum.[45]
×