Medicare Frequently Asked Questions

Choosing Medicare can feel overwhelming, especially with all the different parts, plans, enrollment periods, and rules. We've compiled answers to some of the most frequently asked Medicare questions to help you better understand your options.

Don't see your question? Contact Argos Insurance Solutions for personalized assistance from a licensed Medicare agent. There is never any obligation, and we'll help you understand your options based on your specific situation.

Medicare Basics

1. What is Medicare?

Medicare is the federal health insurance program primarily for people age 65 and older. It also provides coverage for certain younger individuals with qualifying disabilities and people with End-Stage Renal Disease (ESRD) or ALS.

Medicare helps cover many healthcare costs, but it does not pay for everything. Depending on your needs, you may choose Original Medicare, a Medicare Advantage plan, a Medicare Supplement (Medigap) plan, or a standalone Part D prescription drug plan.

2. What are the different parts of Medicare?

Medicare consists of four main parts:

• Part A – Hospital Insurance

• Part B – Medical Insurance

• Part C – Medicare Advantage Plans offered by private insurance companies

• Part D – Prescription Drug Coverage

Each part covers different healthcare services and works together to provide comprehensive coverage.

3. Who is eligible for Medicare?

Most people become eligible when they turn 65.

You may also qualify before age 65 if:

• You receive Social Security Disability Insurance (SSDI) for 24 months

• You have End-Stage Renal Disease (ESRD)

• You have ALS (Lou Gehrig's Disease)

4. Is Medicare free?

Not entirely.

Many people qualify for premium-free Part A based on their work history or their spouse's work history.

However, most beneficiaries pay a monthly premium for Part B, and additional costs such as deductibles, copayments, and coinsurance may apply depending on the type of coverage you choose.

5. What does Medicare Part A cover?

Part A generally covers:

• Inpatient hospital stays

• Skilled nursing facility care (after a qualifying hospital stay)

• Hospice care

• Limited home health services

Part A does not cover long-term custodial nursing home care.

6. What does Medicare Part B cover?

Part B covers medically necessary outpatient services, including:

• Doctor visits

• Specialists

• Preventive care

• Lab work

• X-rays

• Durable medical equipment

• Physical therapy

• Mental health services

• Ambulance transportation (when medically necessary)

7. What is Original Medicare?

Original Medicare refers to Medicare Part A and Part B administered directly by the federal government.

Original Medicare allows you to see any provider nationwide who accepts Medicare.

8. What is Medicare Advantage (Part C)?

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

These plans combine Part A and Part B coverage and often include:

• Prescription drug coverage

• Dental benefits

• Vision benefits

• Hearing benefits

• Fitness memberships

• Over-the-counter allowances

• Transportation benefits (on certain plans)

Benefits vary by plan and county.

9. What is Medicare Part D?

Part D provides prescription drug coverage.

Plans are offered by private insurance companies approved by Medicare and help reduce the cost of covered prescription medications.

Every Part D plan has its own formulary (list of covered drugs).

10. What is a Medicare Supplement (Medigap) plan?

Medigap plans work alongside Original Medicare.

They help pay certain out-of-pocket costs such as:

• Deductibles

• Coinsurance

• Copayments

Medigap plans do not replace Original Medicare and generally do not include prescription drug coverage.

Enrollment

11. When should I enroll in Medicare?

Most people enroll during their Initial Enrollment Period (IEP), which begins three months before the month they turn 65, includes their birth month, and continues for three months afterward.

Enrolling on time can help you avoid lifelong late enrollment penalties.

12. How do I enroll in Medicare?

You can enroll through the Social Security Administration:

• Online through the SSA website

• By phone

• At your local Social Security office

If you're already receiving Social Security retirement benefits before age 65, you may be automatically enrolled.

13. Do I have to enroll in Medicare if I'm still working?

Not necessarily.

If you have creditable employer coverage through your or your spouse's current employer, you may be able to delay Part B without penalty.

The rules depend on the size of the employer and the type of health coverage you have.

14. What happens if I miss my enrollment period?

Missing your enrollment period could result in:

• Late enrollment penalties

• Delayed coverage

• Waiting until another enrollment period

Some individuals may qualify for a Special Enrollment Period based on certain life events.

15. Can I change my Medicare plan every year?

Yes.

Most Medicare beneficiaries can review and change their coverage during the Annual Enrollment Period (October 15 through December 7).

Coverage changes generally become effective January 1.

Coverage Questions

16. Does Medicare cover dental care?

Original Medicare generally does not cover routine dental care such as cleanings, fillings, dentures, or routine exams.

Many Medicare Advantage plans include dental benefits.

17. Does Medicare cover vision care?

Original Medicare generally does not cover routine eye exams or glasses.

Some Medicare Advantage plans include routine vision benefits.

18. Does Medicare cover hearing aids?

Original Medicare generally does not cover hearing aids or routine hearing exams.

Many Medicare Advantage plans offer hearing benefits.

19. Does Medicare cover prescriptions?

Original Medicare has limited prescription drug coverage.

Most beneficiaries obtain prescription coverage through a Medicare Part D plan or a Medicare Advantage plan that includes drug coverage.

20. Can I keep my doctor?

It depends on your coverage.

Original Medicare allows you to see any provider who accepts Medicare.

Medicare Advantage plans generally use provider networks, although PPO plans often offer greater flexibility than HMOs.

Costs

21. Will I still have out-of-pocket costs?

Yes.

Depending on your coverage, you may be responsible for deductibles, copayments, coinsurance, and premiums.

Many beneficiaries choose additional coverage to help reduce these expenses.

22. What is the Part B premium?

The Part B premium is set annually by Medicare and may be higher for individuals with higher incomes due to the Income-Related Monthly Adjustment Amount (IRMAA).

23. What is IRMAA?

IRMAA is an additional premium charged to higher-income Medicare beneficiaries for Part B and Part D coverage.

Eligibility is based on your modified adjusted gross income reported to the IRS.

24. What is the Medicare Part B deductible?

The Part B deductible is the amount you must pay before Medicare begins sharing certain outpatient healthcare costs.

The deductible amount is updated periodically.

25. What is coinsurance?

Coinsurance is your share of the cost for covered healthcare services after you've met any applicable deductible.

For many Part B services, Medicare generally pays 80%, and you are responsible for the remaining 20% unless you have additional coverage.

Prescription Drug Coverage

26. What is a formulary?

A formulary is the list of prescription medications covered by a Part D or Medicare Advantage prescription drug plan.

27. Can my prescriptions change during the year?

Yes.

Insurance companies may update their formularies according to Medicare rules, although beneficiaries receive notice of certain changes.

28. What if my medication isn't covered?

You may be able to:

• Request a formulary exception

• Switch medications

• Change plans during an eligible enrollment period
  

29. What is Extra Help?

Extra Help is a federal program that assists eligible individuals with Part D prescription drug costs, including premiums and copayments.

30. What are Medicare Savings Programs?

Medicare Savings Programs help eligible individuals with limited income and resources pay certain Medicare costs, such as Part B premiums and, in some cases, deductibles and coinsurance.

Medicare Advantage

31. What's the difference between an HMO and PPO?

An HMO generally requires you to use in-network providers except in emergencies.

A PPO offers greater flexibility to use providers outside the network, though your costs may be higher.

32. Do Medicare Advantage plans include prescription coverage?

Many do, but not all.

Always verify whether a plan includes Part D coverage before enrolling.

33. Can I switch back to Original Medicare?

Yes, during certain enrollment periods or if you qualify for a Special Enrollment Period.

34. Are emergency services covered anywhere?

Yes.

Emergency and urgently needed care is covered regardless of where you are in the United States.

35. Do Medicare Advantage plans cover out-of-state care?

Routine care usually depends on your plan's network, but emergency care is covered nationwide.

Special Situations

36. What if I move?

Moving may qualify you for a Special Enrollment Period, allowing you to change your Medicare coverage.

37. Can I have Medicare and Medicaid?

Yes.

Individuals eligible for both programs are known as dual-eligible beneficiaries and may qualify for additional benefits and reduced costs.

38. Can veterans have Medicare too?

Yes.

VA benefits and Medicare work separately, and many veterans choose to have both.

39. Can I travel with Medicare?

Original Medicare is generally accepted nationwide by providers who accept Medicare.

Coverage outside the United States is very limited.

40. Does Medicare cover care outside the United States?

Generally, no.

There are limited exceptions, and some Medicare Supplement plans may offer limited foreign travel emergency benefits.

Working With an Agent

41. Why should I work with an independent Medicare agent?

An independent agent can compare plans from multiple insurance companies, explain your options, and help you choose coverage that fits your healthcare needs and budget.

42. Does it cost anything to use an agent?

No.

There is no additional cost to you for working with a licensed Medicare agent.

43. Can you compare multiple insurance companies?

Yes.

Argos Insurance Solutions can compare plans from multiple Medicare carriers available in your area.

44. Will I lose Medicare if I choose Medicare Advantage?

No.

You remain enrolled in Medicare. A private insurance company administers your Medicare benefits under rules established by Medicare.

45. Can you help me review my current plan?

Absolutely.

Annual plan reviews can help ensure your doctors, prescriptions, and healthcare needs are still well matched to your coverage.

Common Questions

46. Does Medicare cover annual wellness visits?

Yes. Medicare covers an Annual Wellness Visit for eligible beneficiaries.

47. Does Medicare cover preventive screenings?

Yes. Medicare covers many preventive services, including screenings and vaccines, subject to Medicare rules.

48. Can Medicare deny coverage?

Yes. Certain services may require medical necessity or prior authorization depending on your coverage.

49. Can I appeal a Medicare decision?

Yes. Medicare provides several levels of appeal if coverage or payment is denied.

50. How often should I review my Medicare plan?

At least once every year, especially before the Annual Enrollment Period, to ensure your doctors, prescriptions, and benefits still meet your needs.

Still Have Questions?

Medicare rules can vary depending on your age, employment, income, location, healthcare needs, and current coverage.

If you're unsure about your options, contact Argos Insurance Solutions. We'll help you understand your Medicare choices, compare plans available in your area, and answer your questions—all at no cost or obligation.