What is Medicare?
Medicare is a federal health insurance program created to support individuals aged 65 and older, along with certain people under 65 who qualify through disability or specific health conditions. It offers access to essential healthcare services and helps manage medical expenses during critical stages of life.
Over the decades, Medicare has become a cornerstone of the American healthcare system, serving tens of millions of individuals each year.
Medicare vs. Medicaid: Key Differences
Though their names are similar, Medicare and Medicaid serve different populations and purposes:
- Medicare is a federally run program primarily for seniors and those with qualifying disabilities, regardless of income.
- Medicaid is a joint state and federal program that provides healthcare assistance to people with limited income and resources.
Some individuals may qualify for both programs. This is known as dual eligibility and can provide broader coverage than either program alone.
Who is Eligible for Medicare?
Most people become eligible for Medicare at age 65. However, you may also qualify earlier if:
- You’ve been receiving Social Security Disability Insurance (SSDI) for at least 24 months.
- You’re diagnosed with End-Stage Renal Disease (ESRD) or ALS (Lou Gehrig’s Disease), conditions that allow for immediate eligibility.
The Costs of Original Medicare
Original Medicare includes Part A (hospital coverage) and Part B (medical coverage). While both parts offer important protection, they also come with financial responsibilities such as deductibles, copays, coinsurance, and potential excess charges. Many beneficiaries choose to add supplemental coverage to help manage these out-of-pocket costs.
How to Enroll in Medicare
Once you’re eligible, the next step is enrolling. There are two ways this happens
- Automatic Enrollment – If you’re already receiving Social Security benefits when you turn 65, Medicare will automatically enroll you in Parts A and B. Your Medicare card will arrive in the mail about three months before your birthday.
- Manual Enrollment – If you’re not yet drawing Social Security, you’ll need to sign up yourself during your Initial Enrollment Period (IEP). This seven-month window starts three months before your 65th birthday, includes your birth month, and continues for three months after.
Do You Have to Enroll at 65?
Not necessarily. If you're still working, and have credible health coverage through an employer (or your spouse’s employer), you may be able to delay Medicare without penalty. That said, it's important to weigh your options carefully. The size of your employer and the nature of your current insurance can impact whether a delay is advisable or risky.
How to Find Your Medicare Number
Your Medicare number is printed on your red, white, and blue Medicare card. It’s a unique identifier, no longer tied to your Social Security number, for added security. You’ll use this number when seeking care, reviewing benefits, and managing claims.
Breaking Down the Parts of Medicare
Medicare has four main parts, each serving a distinct purpose:
- Part A – Hospital Insurance
- Part B – Medical Insurance (doctor visits, preventive care, outpatient services)
- Part C – Medicare Advantage (an all-in-one alternative offered by private insurance companies)
- Part D – Prescription Drug Coverage (can be standalone or bundled with Part C)
Understanding how these parts fit together, and what’s missing from Original Medicare, can help you make more informed decisions and avoid surprise costs.
How Much Does Medicare Cost?
Medicare helps cover medical expenses, but it isn’t free. You’ll have to pay certain costs like monthly premiums, deductibles, copays, and coinsurance. Let’s break down the basics of what you might pay for Medicare Part A and Part B.
What Does Medicare Part A Cost?
Most people don’t have to pay a monthly premium for Part A (hospital insurance) if they worked and paid Medicare taxes for at least 10 years.
But even if it’s premium-free, you still have costs if you go to the hospital. In 2025:
- You’ll pay a deductible of $1,676 for each hospital stay.
- If you’re in the hospital for more than 60 days, you’ll pay coinsurance, which means you share part of the cost.
What Does Medicare Part B Cost?
Part B (medical insurance) has a monthly premium. In 2025:
- The standard premium is $185/month.
- If you make more money, your premium may be higher.
- There’s also a yearly deductible of $257.
- After you meet the deductible, you usually pay 20% of the cost for doctor visits, tests, and other services.
What Does Medicare Part A Cover?
Medicare Part A helps cover inpatient care, which means care you receive when admitted to a hospital or skilled nursing facility. It pays for:
- Hospital rooms (semi-private)
- Meals and basic nursing care
- Medications needed during your stay
- Skilled nursing facility care (after a qualifying hospital stay)
- Hospice care for those with terminal illness
- Some home health care services
What Does Medicare Part B Cover?
Medicare Part B covers outpatient care and preventive services, including:
- Doctor visits (for illness or routine check-ups)
- Lab tests and diagnostic screenings
- Flu shots, cancer screenings, and heart disease tests
- Medical equipment such as walkers or wheelchairs
- Some medications administered in a clinical setting
What Is a Medicare Supplement Plan (Medigap)?
A Medigap plan helps cover out-of-pocket costs not paid by Original Medicare, such as:
- Deductibles
- Copayments
- Coinsurance
Medigap plans are sold by private insurance companies and are standardized into different plan types (A through N), each offering various levels of coverage.
What Is a Medicare Advantage Plan?
Medicare Advantage Plans (Part C) are offered by private insurers as an alternative to Original Medicare. These plans must cover the same services as Medicare Parts A and B.
Most Medicare Advantage Plans also include:
- Prescription drug coverage
- Dental, vision, and hearing benefits
- Additional services such as fitness programs or transportation to medical appointments
These plans typically use provider networks (HMO or PPO), which may limit which doctors and hospitals you can use.
Medigap vs. Medicare Advantage
Medigap and Medicare Advantage offer two very different ways to manage your Medicare coverage, and you cannot enroll in both at the same time.
- Medigap works with Original Medicare and gives you access to any doctor who accepts Medicare. It usually requires a separate prescription drug plan.
- Medicare Advantage replaces Original Medicare with a private plan that may include drug coverage and additional benefits, but often requires using a network of providers.
What Is Medicare Part D?
Medicare Part D helps cover the cost of prescription medications. It is available through private insurers and can be added to Original Medicare or included in a Medicare Advantage Plan.
Each plan has a list of covered drugs (called a formulary) and places medications into different pricing tiers.
Does Medicare Cover Vision?
Original Medicare provides limited vision coverage. It generally does not cover routine eye exams, glasses, or contact lenses.
It does cover:
- Cataract surgery
- Eye exams related to certain medical conditions such as glaucoma or diabetes
Some Medicare Advantage plans offer additional routine vision benefits, including eye exams and eyewear.
Does Medicare Cover Dental?
Original Medicare does not cover routine dental services like cleanings, fillings, or dentures. It may only cover dental care when it is part of another covered procedure. Many Medicare Advantage plans offer dental benefits that can include both preventive and comprehensive care.
Need Help Understanding Medicare?
Understanding Medicare can be challenging. If you are new to Medicare or unsure about your options, it’s important to get guidance from someone who can help.
Instead of calling Medicare or Social Security for general information, many people prefer to speak with a licensed insurance professional.
There are two main types of agents:
- Captive agents, who represent only one insurance company
- Independent brokers, who offer plans from multiple companies and can help you compare your options
Should You Work With an Agent or Broker?
Working with a licensed agent or broker can save time and help you avoid costly mistakes. Their services are typically free, as they are paid by the insurance companies, not by you.
A good advisor will help you evaluate your medical needs, review available plans, and guide you toward a choice that fits both your health and your budget.
Learn More About Your Medicare Options
At Dalton Insurance, we are here to help you make confident and informed decisions.
- Download our Complete Medicare Guide
- Sign up for our virtual Medicare seminar led by Tyler Dalton
- Schedule a one-on-one call with a trusted Medicare advisor
Take the next step toward clarity and peace of mind with your Medicare coverage.