Medicare 101: Everything You Need To Know.

When you are new to Medicare, you may be overwhelmed by the sheer amount of choices. Without understanding eligibility, coverage options, costs, and enrollment procedures, you may not be able to make informed healthcare decisions. At Medicare Advocates, we are dedicated to getting you the best coverage available. Let’s go over everything you need to know about preparing for Medicare coverage.

Eligibility for Medicare and When You Can Sign Up

Medicare eligibility is generally based on age, disability, or certain medical conditions. Most people qualify upon reaching the age of 65. Others under 65 may be eligible due to disabilities or specific conditions like End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS).

There are only certain times at which you can enroll in or change your coverage. These periods include:

• Initial Enrollment Period (IEP). The IEP begins three months before your 65th birthday and lasts seven months. This is the best time to enroll in Medicare coverage, as you avoid late enrollment penalties.
• Annual Enrollment Period (AEP). AEP goes from October 15th – December 7th. Anyone with Medicare coverage can make changes to their coverage for the upcoming year during AEP.
• Medicare Advantage Open Enrollment Period (OEP). This period spans from January 1st – March 31st. Only those enrolled in Medicare Advantage can make changes to their plan.
• Special Enrollment Period (SEP). The SEP allows those with qualifying life events, such as loss of employer coverage, to enroll without penalties.

The Different Parts of Medicare and What They Cover

Medicare consists of four main parts:

• Part A covers hospital stays, skilled nursing facility care, hospice care, and some home healthcare services.
• Part B covers outpatient services, preventive care, ambulance services, and some durable medical equipment.
• Part C  is what is referred to as Medicare Advantage. It includes Parts A and B, and almost always includes Part D as well. Many plans also offer additional benefits like vision and dental.
• Part D provides prescription drug coverage.

The Benefits and Costs of Original Medicare

Original Medicare offers nationwide access to any healthcare providers that accept Medicare. Part A is usually premium-free, if you have paid Medicare taxes for at least 10 years. Otherwise, premiums apply, with costs reaching up to $505 per month depending. Other Part A costs include:

• A deductible for each benefit period of $1,676
• daily copayments for extended hospital stays beyond 60 days.
• a copayment applies from days 21-100 for a Skilled Nursing Facility, but the first 20 days are no cost.

Part B has a standard monthly premium of $185 in 2025, with an annual deductible of $257. After meeting the deductible, Medicare generally covers 80% of approved services, leaving beneficiaries responsible for 20% coinsurance with no cap on out-of-pocket expenses. Higher-income beneficiaries may pay an Income-Related Monthly Adjustment Amount (IRMAA) surcharge on their Part B premiums.

Late enrollment in Part B results in a 10% penalty for each 12-month period you were eligible but did not enroll. This penalty is permanent and added to your monthly premium, making timely enrollment crucial.

The Benefits and Costs of Medicare Advantage

Medicare Advantage (Part C) plans are offered by private insurers and provide additional benefits beyond Original Medicare, such as vision, dental, hearing, and prescription drug coverage. These plans can include more benefits as well, such as wellness programs, transportation assistance, and even fitness memberships.

Costs on Medicare Advantage vary, so your expenses may be harder to predict Most Medicare Advantage plans have $0 premiums. Copayments and coinsurance vary by plan, and most plans have an annual out-of-pocket maximum, which provides financial protection that Original Medicare lacks. This cap prevents excessive medical expenses and provides peace of mind for beneficiaries. This cap, combined with extra benefits, save many Americans hundreds or even thousands each year. Medicare Advantage is especially good for individuals who require a lot of medical care.

Medicare Advantage plans, however, have network restrictions. Many require you to use in-network providers and may need referrals for specialist visits. These limitations can be a drawback for those who prefer unrestricted provider access.

How to Get Started in Medicare

To begin, create a Medicare account and enroll in Parts A and B through the Social Security Administration. Next, decide whether to remain with Original Medicare or choose a Medicare Advantage plan. If opting for Original Medicare, consider adding a Medigap (Medicare Supplement) policy to help cover out-of-pocket costs and enroll in a standalone Part D plan for prescription drug coverage.

Choosing Between Medicare Advantage or Medicare Supplement/Medigap

Medicare Advantage offers an all-in-one plan with additional benefits and an annual spending cap, but it may restrict provider choices. Medigap provides more predictable costs and flexibility in choosing healthcare providers but requires an additional premium and does not include drug coverage, requiring a separate Part D plan.

When choosing between the two, consider your healthcare needs, budget, and provider preferences to select the best option for you.

Don’t feel like you need to do this alone. We can help you get the most cost-effective coverage based off of your health needs. We are licensed in all 50 states and with many top providers to ensure you have the best options available. If you want Advocate help, get in touch. Protecting your health is our mission.