How to Understand Medicare: Logically Explained by an Analyst - YouMeMindBody - Health & Wellness
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How to Understand Medicare: Logically Explained by an Analyst


Glenn Stok is a systems analyst and technical writer. He thoroughly studied Medicare and is skilled at explaining its features.

I have a knack for analyzing complicated topics and making sense out of them, thanks to my technical background as a systems analyst.

When I turned 65 and became eligible for Medicare, I studied the rules and regulations so that I can make the right choices.

My intention with this article is to help you avoid stress by giving you a thorough understanding of the various parts of Medicare and its commonly misunderstood rules. I always stay knowledgeable of the latest changes to keep this article accurate and up-to-date.

Once you have a good knowledge of the important issues, you’ll have an advantage in selecting the right coverage for your needs.

You'll also know how to avoid penalties. Some of my friends have these penalties because they overlooked the requirement for Medicare drug coverage. I'll get into that later.

I will not discuss premium costs because that information is available from Medicare. What I will do is give you a complete understanding of the overall makeup of Medicare.

Medicare is frequently misunderstood. My intention in this article is to explain how the program works.

Medicare is frequently misunderstood. My intention in this article is to explain how the program works.

Remaining Clueless Can Cause Irreversible Penalties

Many of my friends who are older than me just took original Medicare. They didn't know of other options that offer more benefits at less cost.

They even had unexpected doctor bills that were not covered. And they found out too late about the irreversible penalties imposed for not starting a creditable prescription drug coverage in time. I’ll get into those details in this article.

You're ahead of those who remain clueless since you are showing interest in reading this article. I won't let you down.

So, You’ll Soon Be 65

Everyone has different needs based on how healthy or unhealthy they may be, and differing financial situations as well. For that reason, I can't tell you specifics about what to do. But I will tell you what I learned through my research and decision-making to get the most out of Medicare.

That should help you understand what you need to do and how to avoid the pitfalls.

When you are close to becoming 65, you will start getting a lot of mailings offering advice. These are agents who are focused on selling you insurance. They don't lie, but they don't tell you the full story either. They will only tell you what will convince you to go with their insurance.

I also started seeing a lot of Google ads everywhere I looked on the Internet. That's how Google advertising works. They know what your interests are, and what your needs are, based on your recent web browsing activity.

All these ads direct you to websites that help compare features of various plans.

It's best to ignore all these agents and ads. Everything they tell you, you can find on one single most useful site,

Take the time to scrutinize that site. It will save you from making costly mistakes.

Are Medicare Agents Helpful?

One thing I learned by doing my research is that I kept stumbling upon agent websites that looked like they were specific insurance companies. Once I realized they are asking for personal contact information before I could gather any information from the site, I realized where I was.

Another thing I learned was that many agents I spoke with were giving me answers they knew I wanted to hear. After a while, I realized they were doing this to get me to sign up with them.

It would be more honest if they were to give me specific reasons why one thing or the other is good or bad, rather than tell me only what's good.

Whenever I asked why something was not the right choice, they beat around the bush. As an example, when I questioned an agent working for Anthem about something that didn't make sense in their proposal, she said that I’d get a full document explaining benefits after I sign up. What good is that? They lost my business for that reason.

New Medicare Cards Have More Security

By now everyone on Medicare should have received the new card. It no longer has your Social Security number on it. That helps avoid identity theft.

A sample of the old Medicare card is shown on the left below. On the right is a sample of the new version.

The Medicare number on the new card no longer is your Social Security number.

The Medicare number on the new card no longer is your Social Security number.

The Parts of Medicare

Medicare has different parts that cover different things. Original Medicare consists of Parts A and B. Then there are "plans." Notice what word I'm using as you continue reading.

The most common thing I've noticed is that many people confuse "Medicare Parts" with "Medicare Plans." This attention to detail will help you understand what many people tend to confuse.

Part A: This is the part of Medicare that helps pay the cost of inpatient hospital care, including nursing services after leaving the hospital, hospice, and some other home health services. The government pays the Part A premium unless you earn over a certain amount. For most people, it’s free.

Part B: This is the part of Medicare that pays 80% of the cost of doctor services. You pay the Part B premium, but you can have it deducted from your Social Security payments if you’re already collecting it.

Part C: This is the part that confuses people. It's an Advantage Plan. In my opinion, this should not be called a "part" letter. It’s an optional "plan" that replaces original Medicare.

The Plans of Medicare

Advantage Plans:

Advantage plans replace everything with a single insurance, although you still have to pay for Part B if you want an Advantage Plan. You carry just one Insurance card, and you can still have your Part B premium deducted from your social security benefits.

Advantage plans are provided by private insurance. They can be an HMO or a PPO. They usually include Part D (I’ll get into that later) for prescription drugs, and they may have other benefits usually not included with original Medicare. In some states, all or part of the premium is paid by Medicare.

Unlike original Medicare, doctors need to register to be in any particular Advantage Plan. One plan I looked at did not include my primary doctor. That’s a problem you need to check carefully. If you choose a PPO, you can go to any doctor that accepts Medicare, but you will pay extra if they are not in the plan.

Supplemental Plans:

If I were in charge of naming conventions, I'd say that this should be called Part E for Extra. You have the option of adding a supplemental plan to original Medicare. That is also known as Medigap insurance. All Supplemental plans cover the other 20% that Medicare doesn't cover, and you can go to any doctor that accepts Medicare.

Part D drug coverage is optional, but accumulates penalties if you don’t apply for it.

Part D Prescription Drug Coverage

Part D Prescription Drug Coverage

Prescription Drug Plans

Part D: This is prescription drug coverage. It’s optional, but accumulates penalties if you don’t take it. Medicare requires you to have creditable prescription drug coverage to avoid penalties. This is usually included with Advantage Plans (discussed above).

If you are healthy and don’t need medications, except once in a blue moon when you come down with a cold or have an injury that requires medication, you might think that you can pass up on Part D and save the cost of the monthly premium.

However, for every month you go without Part D, and you don't have any other creditable prescription drug coverage (see next section below), you'll have a 1% penalty per month added to your premium in the future when you do end up taking a Part D plan.

To be clear, that’s 1% of the national average cost of Part D for every month you delay, starting from the month you become 65.

For example, say you decide you need drug coverage when you’re 70. That’s 60 months since you were 65. So you’ll have a 60% penalty added to your premium (1% for each of 60 months you delayed coverage).

Think about that! Nobody does. Nobody complains to his or her congressmen about this either. We all vote for our politicians without realizing how we are being screwed. Politicians abide by the only people telling them what to do—the drug companies.

What is Creditable Prescription Drug Coverage?

A creditable prescription drug plan is one that qualifies for Medicare to avoid the penalties I mentioned above. Any plan that is specified as Part D by the insurance company is a creditable plan.

You may also be covered by insurance from a current or former employer, union, or even a spouse’s insurance that is considered a creditable prescription drug plan. Make sure you get a letter indicating that it is creditable coverage. You’ll need that letter to avoid penalties if you join a Part D plan later.

Original Medicare vs. Advantage Plans


Optional Add-Ons to Medicare

The Part D Prescription Drug plan is an optional add-on to Medicare, but as I discussed above, if you don’t start a Part D drug plan when you first become eligible for it at the age of 65, then you will incur a cumulative 1% penalty per month that adds up until you start this plan. At that time, the penalty will be added to the monthly premium that you pay.

Advantage Plans usually include Part D and may also include additional extra coverage.

Instead of getting an advantage plan, you could consider a supplemental plan (aka Medigap) as an add-on to regular Medicare to cover the other 20%.

Is Medicare Void of Obamacare Regulations?

Here’s an interesting note: I began my Medicare in the middle of 2015, and my rates went up 20% by January of 2016 for the Part D drug coverage.

I thought that I'd get away from Obamacare once I’m on Medicare. However, the Affordable Care Act (Obamacare) included rules that negatively affected Medicare. Obama reacted under the pressure of the pharmaceutical lobbyists and did not allow Medicare to negotiate better drug prices.

“Part of the agreement of the Affordable Care Act is that Medicare cannot negotiate lower drug prices with pharmaceuticals.”

— Dr. Sanjay Gupta

Your 20% Share That Medicare Doesn't Pay

Medicare only covers 80% of your doctor bills. And what’s worse, they don’t cover excessive charges that some doctors charge beyond Medicare-approved amounts. If you want to have insurance that pays your 20% share, you can do this with either of two methods:

1. Supplemental (Medigap) insurance. Private insurance companies provide this. You keep your Original Medicare Parts A and B. The Supplemental plan pays some of the costs not covered by Original Medicare.

2. Advantage Plans. This completely replaces Original Medicare and rolls all coverage into one plan known as Part C. A lot of research needs to be done to select the right one for your situation. The most important thing is to check if your doctors are in the plan you choose.

I like Supplemental (Medigap) plans better because any doctor who accepts Medicare will be covered. Advantage plans require you to use doctors and hospitals in their network. Supplemental Plans do not have networks, so you can use any doctor or hospital that accepts Medicare.

Based on your own needs, Advantage Plans can be a reasonable choice. You just have to compare and know what you’re getting.

Of course, you can just go with Parts A and B without additional coverage, but you have to pay the other 20% of doctor bills in that case.

Only Original Medicare Travels With You

Regular Medicare and all Supplemental Plans protect you when you travel anywhere within the U.S. You may visit any doctor or hospital that accepts Medicare patients. This includes specialists who accept Medicare with no need for referrals.

That is not true with Part C Advantage plans since private insurance companies run these. You’ll need to check their specific rules.

Video: Review of Medicare

Choosing to Just Use Parts A and B Without Extra Protection

As a healthy person, I feel I can deal with paying the 20% Medicare doesn't cover. But if I wait six months and add a Supplemental plan or Advantage Plan later, they can charge me more, refuse preexisting conditions, or turn me down altogether. Obamacare specifically left Medicare out of the preexisting condition rule. Not many people realize that.

Then there's Part D for prescription drugs. I don't need it now, but as I explained earlier, they tag on a 12% penalty every year that I wait (1% per month). And that would stay with me for the rest of my life.

Medicare is soon cruel, in my opinion. They get you coming and going, and they take advantage of the elderly who can't study complicated things and make decisions for themselves.

There Is a Medigap Supplemental Plan That’s Right For You

When you are covered by a Supplemental Plan (Medigap), there are no surprises. You’ll know what’s covered based on the plan you choose.

Don't confuse plans with parts. Medicare has Parts A, B, and D. And supplemental coverage has several plans to choose from, labeled from Plan A through Plan F. Rather than duplicate that info here, you can see a complete detailed listing of each plan at Remember, that’s the only site you need for all your questions.

By law, each plan is exactly the same no matter which insurance company you go with. Therefore, once you decide on the supplemental plan you want, the only thing you need to compare is the cost.

Medicare Part B Excessive Charges

When you see a doctor who doesn’t “accept assignment,” that means he or she doesn’t accept Medicare’s approved amount as payment in full.

You need to pay this in addition to your 20% share, but only up to 15% more than Medicare’s approved amount. The doctor forfeits the rest, but it still is an additional cost to you that you may not be expecting.

Supplemental Plan F covers all of this, your 20% plus any excessive charges. Plan N covers your 20% but not excessive charges.

Why Supplemental Premiums Can't Be Deducted from Social Security?

Only Advantage Plan and Part D Prescription Drug Plan premiums can optionally be deducted from Social Security benefit payments because both of these are primary insurances.

Supplemental Insurance is considered a secondary insurance, and therefore its premium cannot be deducted from Social Security.

With Medicare Part B, you actually have a choice. You can pay for it yourself in quarterly installments, or you can have it deducted from your monthly Social Security benefits if you are already collecting.

When Do You Need to Start Extra Coverage to Avoid Penalties?

Remember that Medicare Parts A and B do not cover everything.

Basically, Part A covers hospital costs up to 150 days. However, you still share part of those costs, and you pay all the costs after 150 days.

Part B only pays 80% of doctor bills. You are responsible for the rest, including deductibles and excessive charges.

Because of all this, you may want to consider adding a supplemental plan to original Medicare or replacing it with an Advantage Plan, also known as Part C. I know. That’s so confusing. They should never have called it Part C. It really is a total replacement of Medicare that includes Parts A, B, and D.

Anyway, keep in mind that there are penalties for delaying extra coverage.

You must sign up for a Supplemental Plan or Advantage Plan within six months of your 65th birthday month. That is your one-time Initial Enrollment Period. However, if you begin Part B later because you had insurance from an employer or a spouse, then this six-month period starts when you start Part B.

Is It True That Supplemental Plans Can Be Changed Anytime Throughout the Year?

One can apply for Supplemental Insurance without penalty during the Initial Enrollment Period, which is within six months of the 65th birthday month.

Supplemental Plans can be started or switched from one plan to another at any time. However, penalties may apply if started or changed after the Initial Enrollment Period.

Penalties include:

  1. Higher premium.
  2. Waiting period before covered.
  3. Refusal based on medical conditions.

These Penalties do not apply during the Initial Enrollment Period.

Advantage Plans can only be changed annually, but Supplemental Plans can be changed anytime. However, penalties may be imposed when you make changes, such as higher premiums or refusal to accept preexisting conditions. These penalties can also stand in the way if you try to apply after the open enrollment period.

Doctors can join or leave an Advantage Network anytime. Since you can’t change Advantage Plans during the year, you’ll have to select a new primary doctor or another provider if they leave the network mid-year.

There is an exception to the annual open enrollment period that I discuss below.

What Is the Open Enrollment Period?

Once a year, from October 15th to December 7th, one can change, join, or drop Advantage Plans. That does not apply to Supplemental Plans, however, which can be changed anytime with restrictions, as I mentioned above.

What Is a Special Enrollment Period?

If you move to a new location that's not covered by your present Advantage Plan, you can change your insurance midyear within a Special Enrollment Period.

Note that Supplemental Plans cover you all over the United States, so this only is necessary to consider if you have an Advantage Plan that might service only a local area.

What Is an Enrollment Exception?

You can also request a special enrollment period to change Advantage Plans mid-year if the insurance company you have is not following Medicare regulations.

You need to contact Medicare and register a grievance. After their investigation, they will make an "Enrollment Exception" if approved. At that time, you'll be able to select an alternate plan or go back to original Medicare.

How Is Shingles Vaccine Covered?

I include this discussion because several people have asked about this. I discovered there is some confusion about payment for Shingles Vaccination.

The new vaccination is done with two injections, with the second dose done two to six months after the first. The name of the vaccine is Shingrix. It's not covered by Medicare Parts A and B. However, some prescription drug insurance plans (Part D) pay a portion of its cost, and you pay a co-pay, which still could be around $150 for each dose.

Some Advantage Plans (Part C) will pay for Shingles Shots since they include coverage for Part D as well. You still have to pay a co-pay for each dose.

Do Your Own Due Diligence

As extensive as you may have found this article, I only gave you the vital information that most people have trouble understanding. I know, because since I started with Medicare, a lot of people have been asking me for help.

So I hope this has helped you have a good understanding with a thorough background of information to help get you started in the right direction.

You will have to do your own research since no one can tell you what’s best for your particular situation. Only you know that.

Just remember that as you delve into it, ask questions and be curious. That’s what I did.

This content is accurate and true to the best of the author’s knowledge and is not meant to substitute for formal and individualized advice from a qualified professional.

Questions & Answers

Question: Are Medicare premiums going higher?

Answer: The Medicare Access and CHIP Reauthorization Act of 2015 was signed into law by President Obama on April 16, 2015.

This law reduces the inflation adjustment, which causes more beneficiaries to be subject to higher Medicare premiums. This affects wealthier Medicare beneficiaries, who will have higher premiums for their Part B (physician services) and Part D (prescription drugs) in the future.

Medicare Part B and Part D premiums are based on one's tax bracket and specified by the following income thresholds:

Individuals with a modified adjusted gross income (MAGI) under $85,000 and couples under $170,000 are in tier 1 and pay only the standard Part B premium., which is $134 in 2018 and 2019.

For individuals earning $85,000 to $107,000 and married couples between $170,000 and $214,000 the Part B premium in 2018 and 2019 is $187.50.

Individuals earning more than $214,000 and couples above $428,000 pay more than three times the standard premium.

The income thresholds have been frozen until 2019 but will increase by about 2% in 2020. After 2020 it will be indexed to general inflation.

Question: Does Medicare include dental and vision care?

Answer: Vision care for medical conditions is included in all Medicare plans, but it does not cover eyeglasses or contact lenses. Dental is not covered.

If you want dental and eyeglass coverage, look at the Medicare Advantage plans available in your area. Some of them offer coverage for dental X-rays and two cleanings per year, as well as partial reimbursements on eyewear.

See how advantage plans differ from regular Medicare in this other article:

Question: Will I be charged for Medicare Part B if I don't retire?

Answer: Most people enroll with Medicare at the age of 65. This includes Part A for hospitals and Part B for doctors.

If you don’t retire and you have group health insurance from your employer, or from your spouse’s employer, then you can legally delay enrolling in Part B. There will be no penalty as long as you have other coverage from employment.

There is a catch though. You can only delay enrolling in Part B under the above condition if your company employs at least 20 people. In that case, you must enroll in Medicare (both A and B). Also, your employer’s insurance is considered secondary since Medicare will pay claims first.

If you do work for a larger company and can delay enrollment as I mentioned above, then when you do eventually retire you’ll have eight months to enroll in Part B without penalty. This is known as a special enrollment period.

Question: If I take a leave of absence from my job after 65, but later return to work, are there any Medicare penalties?

Answer: If your employer continues to provide you with uninterrupted health insurance that includes pharmaceutical coverage, then there are no penalties.

© 2016 Glenn Stok


Glenn Stok (author) from Long Island, NY on October 31, 2019:

Note: Medicare Open Enrollment is from October 15 to December 7, 2019. I updated this article to reflect the latest changes for 2020.

Glenn Stok (author) from Long Island, NY on December 07, 2018:

Cindy Moore, Congratulations on your upcoming marriage. Here is my reply to each of your questions:

1. You need to carefully check his insurance to be sure it covers the 20% portion that regular Medicare does not cover. In either case, you need to keep part B for doctor coverage. Part D for drugs is optional, but if you don’t take it, you will have a penalty later when you do need it, as I described in the article.

2. If you want eye and vision care then you should look into the various Advantage plans available in your area. This is known as Part C. In some cases they have a zero premium.

3. Disability follows different regulations. Depending on your type of disability, you need to check what’s available. Contact Medicare and ask for specifics in your case. Since you have a disability, you may not need to wait till you’re 65, but you need to ask them.

C moore from MB, NY on December 07, 2018:

Hi im hoping you can answer for me the following

1-im on ssd so i have my medicare due to that (im 47)i have A,B and D. Which as u said im responsible for the 20%. Im getting married next year. Im wondering do u advise i keep B and D and add supplemental for the 20% coverage or am i better leaving it as is and take his insurance as a secondary which does have hosp,drs,scripts?

2-I also dont have eye and vision care. His policy doesnt offer it. Do you feel i should take out coverage to include those and what kind would it be?

3- is there a difference between disability medicare vs 65 retirement medicare? If so,what?

once i hit 65 how does it work here in NY do i keep ssd medicare or it changes to retirement medicare, is there any difference?


David Hunt from Cedar Rapids, Iowa on February 28, 2018:

Also, as I understand it, Plan G is not going away. It is exactly the same as Plan F except you pay the deductible which is currently something like $180.

Glenn Stok (author) from Long Island, NY on November 14, 2017:

Thank you, David, for adding that info. It’s very useful for people to know that.

David Hunt from Cedar Rapids, Iowa on November 14, 2017:

Jay, whenever you go on Medicare you will have a window of time when supplemental insurance is not allowed to ask health questions or up the premium. Verify when this window occurs if you defer going on Medicare. Sorry I can't be more definite. Glenn, this is an article that just keeps giving!

Glenn Stok (author) from Long Island, NY on November 14, 2017:

Jay Dunham - That a legal question and I’m not an attorney so I can’t answer that with any authority. I would suggest you discuss it with the employer you are considering to so if they provide that option.

As for your health related condition, a supplimental Plan F is probably the best for you since it covers everything, if you decide to go with that instead of a HC coverage.

Jay Dunham on November 14, 2017:

I turn 65 this month. I've had employer-provided HC insurance for may years. I am still actively working and, frankly, don't anticipate "retiring"per se. I suspect I'll do so until I drop dead. Literally.

That said, I'd like to save my employer some money, if possible. As it happens, I'm an expert in employee benefits (ERISA) but only the litigation side.

Can my employer replace my HC coverage with Medicare and/or a Supplemental and/or an Advantage plan?

You should probably know I had a quad bypass about four years ago and, though I'm in very good health, I do have to take BP and cholesterol meds every day.

Glenn Stok (author) from Long Island, NY on November 09, 2017:

Nola Kent - You would need to pay the amount of your Part B deductible before Medicare kicks in. You might want to check out the Advantage plans in your area. Many of them cover the Medicare deductible as well as the other 20% that Medicare doesn't cover. Most of them even include Part D so you don't accumulate a monthly penalty that you have to pay when you end up needing drug coverage. Obama kept that penalty in there to force people to get drug insurance.

Glenn Stok (author) from Long Island, NY on November 09, 2017:

True. Insurance should one be used for catastrophic major issues. Self-insuring for minor issues is a good way to do it, but it takes discipline, as your parents had. I'll look for your article.

Nola Kent on November 09, 2017:

I had a dermatologist tell me I would have to meet my medicare deductible or I would pay more than the 20% I have part A and B only no supplemental, I had never seen this in any of my research, do you know what they were talking about?

Rochelle Frank from California Gold Country on November 09, 2017:

The government insurance plans (Obamacare especially) are outrageous. My parents, many many years ago before there was medicare, started their own personal insurance plan, to save for emergencies. They did it so well that they could afford to travel the world with the money they saved and invested.They weren't rich, just good managers. I wrote a hub about how they did it. If people would just use their common sense, there would be no need for insurance.

Glenn Stok (author) from Long Island, NY on November 09, 2017:

Dolores Monet - You brought up an interesting point. Before I started with Medicare at 65, I lost my good insurance when Obamacare started. I was also forced to switch doctors, losing good ones I had for years.

When I talk about this with friends who were employed (I was self-employed) they couldn't understand why I had so many problems. It was because they were protected–being covered by their employer.

Now it gets worse. Just today the IRS announced that they are fining small businesses that failed to meet Obamacare reporting guidelines.

Dolores Monet from East Coast, United States on November 09, 2017:

Thanks for trying to simplify this complicated topic. It's funny how when you work and are at the top of your game, health insurance is pretty simple if you are covered by your employer. Then, once you retire, older now in a world that becomes more technically confusing every day, you have to understand the morass of extra insurance. Then you have crooks calling on the phone pretending that they are calling to help when they are really after your information. One is also faced with the fact that when you are on a limited income and have limited ability to earn more income, your health care isn't cheap.

Glenn Stok (author) from Long Island, NY on November 08, 2017:

WReidBrown - There is no tax advantage with having your premium deducted from your Social Security payments. It's just more convienient for most people.

Remember that only advantage plan and part D premiums can be deducted from SS. If you use a supplimental plan, you have to get a separate bill.

WReidBrown on November 07, 2017:

You mention paying the premium from Social Security funds. Is there a tax advantage to doing it that way? Or is it simply a convenience?

Glenn Stok (author) from Long Island, NY on October 21, 2017:

Sue C. - There is no rule that you have to have supplemental insurance. However, since Medicare only pays 80%, you’ll have to pay the other 20% out of pocket. Supplemental insurance covers that.

As an alternative, you might want to consider an advantage plan (Part C).

You will only be penalized if you don’t have a drug insurance (Part D) after age 65. The penalty is 1% of the average premium for every month that elapses without insurance after turning 65. But most advantage plans include creditable drug coverage too—another reason to consider that.

Sue C. on October 21, 2017:

When I am on Medicare disability insurance right now I will be 64 next month will I still be penalized for not having supplemental insurance when I turn 65

Glenn Stok (author) from Long Island, NY on October 17, 2017:

Thanks David. That’s the way to do the analysis, and this is presently the open enrollment period—so it’s the time to do it.

David Hunt from Cedar Rapids, Iowa on October 17, 2017:

Thanks, Glenn. I would recommend going to and follow the instructions. One section allows you to enter your medications. Though it may take some time if you take a lot, it really allows you to compare plans specific to your needs. You are allowed to save your list so you can come back later.

Glenn Stok (author) from Long Island, NY on October 17, 2017:

David Hunt - Your analysis is very important for others to understand. Everyone needs to do their own analysis of the tier ranges of each Part D plan that’s available in their area, to find the best fit for their situation.

As you discovered (and my opinion too) the star rating system is useless.

David Hunt from Cedar Rapids, Iowa on October 17, 2017:

A PS regarding part D drug plans. The "5-star" designation seems, um, a little fishy to me. I was comparing my wife's current plan (a 3-star) to a 5-star. The 5-star was almost $100 a month (compared to $33), but, more importantly the 5-star did not cover her two brands of insulin, which would have cost thousands more per year. As an addendum, the 3-star would put her into the donut hole months earlier than the 5-star. Sounds good for the 5-star? That's because paying for the insulin isn't counted-- only the cheaper drugs it DOES cover are counted. The 5-star (in our case) is worse by far. The devil is in the details.

Glenn Stok (author) from Long Island, NY on October 17, 2017:

Kathleen - That medication is in a higher tier and that’s why the copay is so high.

From October 15 through Dec 7th you have the opportunity to change your part D insurance. So this is the time to examine the options you have in your area. Each insurance company has different tier groups, so you’ll want to search for one that has a better copay for that particular medication.

Another thing you can do is ask your doctor if there are alternative medications that’s fall into a lower tier group.

Kathleen on October 16, 2017:

I am still so confused my insurance Humana will pay for some of my repatha med but the go pay is 455 dollars for 2, shots a month I tried getting help from manufacturer but I was denied because I have insurance I can't afford this copay so I even asked for help because the manufacturer has a 5dollar copay card but I am not eligible because I am on this insurance I need to choose a new plan because I just can't afford this I am 66 and so confused can you please direct me I really need help and don't know what I schould do

Glenn Stok (author) from Long Island, NY on September 22, 2017:

David Hunt - I can see that you understand everything about Medicare very well. You've definitely done your homework.

I haven't heard anything about Supplemental Plan F being phased out. Maybe only in your area.

By the way, there are two versions of Plan-F, but maybe not where you live. There is a regular Plan-F and a High-Deductible Plan-F that you mentioned, which of course has a lower premium. Both cover the the Part B deductible, unlike Plan G. But that's animal expense anyway. Thanks for your wonderful comment.

David Hunt from Cedar Rapids, Iowa on September 22, 2017:

Glenn, like you I worked in IT many years before retiring. I signed up for Medicare in March of this year. I also spent a lot of time analyzing my options (using I am pretty healthy for my age; nevertheless I also understood the implications regarding extra coverage and drug coverage. I decided early on that I did not want an Advantage plan. When it comes to having to trust the government or trust for-profit corporations, the "gummint" wins hands down (sounds kind of incredible, but that shows my low opinion of health insurance companies). I take no medications, but have the lowest premium Part D drug coverage for exactly the reasons you state. Also, I opted for Plan G supplemental which is the exact same as Plan F except there is a small deductible. So, I actually have more coverage than I currently need, but, as you so correctly state, I've locked in for future downturns. Anyway, excellent article. Oh, and I wonder if you've heard anything regarding Plan F being phased out in a few years (though people already in Plan F will be able to keep it)? That's why I went with Plan G, but it was almost a toss-up for me.

Glenn Stok (author) from Long Island, NY on September 21, 2017:

Arcee Chow - If you only have Medicare, you still have to pay the 20% of bills that they don't cover.

I didn't underdstand what you meant that you also have a medical coverage. Is that in addition to Medicare? Will that cover what Medicare does not? Maybe you are talking about a supplemental plan. That wasn't clear in your comment. That will cover the other 20%, with limitations depending on which supplemental plan you have. I can't help you with that choice. You have decide how much you want to risk, compared to the premium for each plan option. That's a choice you make.

The other option is to go with an advantage plan, which completely replaces Medicare as I discussed in this article. That's also a choice you have to make based on your needs. Some advantage plans are better, some are worse.

It's important to review the plans available in your local area and match them up with you needs. Since you are planning to get cataract surgery, you may want to have that extra 20% covered by one of the options I just mentioned.

Arcee Chow on September 20, 2017:

Hi Sir!

I just turned 65 last April and i have medical and medicare part A and B.since i have no income only fr.surviving spouse SSA so i was automatically enrolled on part D prescription drug..just now i learned fr.this helpful tips of medicare.that there is a need to enroll in medicare advantage plan or suplemental plan..i dont know anything about these since i enrolled in will i know if in the near future i have to undergo a cataract surgery is it for free since i have also medical?what is the best plan for me? Pls oct. will be my sixth month in monthly premium of $134.00 is paid by the state..can you pls.tell me what to do..i am now under L.A.Care health plan..

Glenn Stok (author) from Long Island, NY on September 02, 2017:

Al rowland - There are many variables that affect your covereage. It's best to talk with Medicare directly. They have your complete records and will be able to answer your questions. I wish you all the best.

Al rowland on September 02, 2017:

I have stage four cancer I am currently on permanent disability I'm coming up on my two year waiting period before Medicare could you suggest which way I Should go with Medicare

Glenn Stok (author) from Long Island, NY on August 28, 2017:

Vera Byler - Most hearing tests are not covered by Medicare. You need to ask your doctor if you would be covered based on your situation.

vera byler on August 28, 2017:

how often will medicare pay for a hearing test?

Glenn Stok (author) from Long Island, NY on September 01, 2016:

norlawrence - It's good he has a Supplimental plan and Part D for the medications. It's true that Part D does not cover all medications very well. This is because Obama signed a bill not allowing insurance companies to negotiate lower drug prices. As long as we have a system of government where drug companies can lobby the politicians and get what they want, Medicare will never be a perfect solution. Sorry to hear about Mike. I wish him well.

Norma Lawrence from California on September 01, 2016:

Very good article Glenn. I am fighting Medicare with Mike who has Heart and Lung problems. He now is in stage 3 Kidney disease which they say was brought on by medications. It is kind of like if the disease do not kill you the cure will. He has a supplement insurance so everything is going pretty well so far. His drug program went from 29.00 a month to 71.00. There are some drugs they will not pay for so there is the problem of finding a drug that will do the job that they will pay for. Thanks for article. Your supplied some great information.

Glenn Stok (author) from Long Island, NY on September 01, 2016:

Todd Elzey - Thank you Todd. Since you have been a Medicare Appeal Officer you definitely are an authority on this and I appreciate the time you took to add this information.

Advantage plans are very different from one another, unlike standard Medicare. I find them quite unclear what they actually cover. I even talked about how one agent failed to give clear answers when I asked about a particular Advantage plan, as you had noticed in my article. This is why I personally chose a supplemental plan instead. Thanks for adding that I could have reported that agent, and also for your other useful info in your comment.

Todd Elzey from Phelps, NY on August 31, 2016:

Mr. Stok: This is a very good article, but I would like to point out two things that you might wish to consider adding. First, in addition to being available to those 65 and over, Medicare is also available to those who are permanently disabled (according to Social Security Criteria), and who have received Social Security Disability benefits for 24 months.

Second, I worked as a Medicare Appeal Officer for Maximus Federal Services for 8 years from 2006-2014. In that job I adjudicated somewhere in the neighborhood of 10,000 Medicare Advantage (Part C) enrollee appeals. And I can say with certainty that Medicare Advantage Plans do not always cover the 20% coinsurance that is part of Medicare Part B coverage. In fact, the plans very widely nationwide. Some plans really aren't much more than what is covered with the exact same 80%/20% cost sharing structure as original Medicare (Parts A & B), while other plans cover almost everything with absolutely no cost sharing for the enrollee at all. And of course there is a lot of variation between these two extremes. Consequently, it is essential that individuals considering enrolling in a Medicare Advantage (Part C) plan look at the actual Evidence of Coverage documents for the plans they are considering to fully understand what is covered and what the cost sharing is for the covered services. By the way, the plan documents are required to be available on the Plan's website and any agent who tells a potential enrollee that they can't get the documents until they have signed up is violating Federal regulations and can be reported to CMS. I believe Medicare still considers it a type of Medicare marketing fraud. Thanks again for your article, and I hope these comments are helpful.

Jean Bakula from New Jersey on July 02, 2016:

Thanks, I'll check out plan F. That isn't something I recall reading about at the time I was deciding what plans to get.

But since I have been on Medicare, beginning Jan 1st of this year, I'm paying so much less. So it is getting better.

Glenn Stok (author) from Long Island, NY on July 01, 2016:

Jean Bakula - If you are having constant medical issues and you find yourself paying half the bills, you may want to look into switching from your advantage plan (Part C) to a supplemental plan. Specifically, Plan F will cover all your bills and you'll never get a bill from doctors or hospitals. Just the monthly premium for plan F. With a supplemental plan, any doctor that accepts Medicare will be covered. You'll have to compare the premium cost to your present medical costs to see if that works for you any better.

Jean Bakula from New Jersey on July 01, 2016:

Thanks for your kind words, my life has changed a lot. Especially in the health insurance area. When my husband first passed, his company paid my COBRA for 6 months, and then we split it 50/50 the rest of the year. We had been together for 39 yrs. and the company loved him. Then I had to get BC/BS of NJ, and it was really a ripoff, I paid almost $800.00 monthly, and it was going up to $1,000.00 monthly if I didn't get on Medicare a little younger than most. My ophthalmologist is on Plan C. I also always get weird, hard to diagnose illnesses, which usually sends me on a whirlwind of specialists, so I thought it best to just get everything. I'm still paying half of what I would have been if I hadn't gone on Medicare, so it works for me.

Glenn Stok (author) from Long Island, NY on July 01, 2016:

Paul Kuehn - Thank you for sharing that information about overseas limitations with Medicare.

Paul Richard Kuehn from Udorn City, Thailand on July 01, 2016:

While visiting the States in June of 2016, I met with a Medicare rep in the city near where my sister lives. I found out that because I live overseas I am not able to get any of the Medicare services available in the States. The reason for this is due to billing as the agent explained. As a veteran, however, I can get VA medical benefits while living overseas.

Glenn Stok (author) from Long Island, NY on June 30, 2016:

Jean, Part C is an advantage plan. You need to be sure your ophthalmologist is signed up with the one you chose and that they cover cataract surgery. Sorry for the loss of your husband two years ago.

Jean Bakula from New Jersey on June 30, 2016:

Hi Glenn,

This is a really helpful hub. I was widowed two years ago, and also have several health problems, and had tried to go on disability several times. I was finally able to get SS at 60, but didn't know much about Medicare, as both my parents died young and I didn't have to deal with it. I found the people at 1-800-medicare to be very helpful. Since I was already on SS, they had my info on file, no matter who I spoke with.

I had a cataract on my eye last year, before I got Medicare, and had to pay for most of it out of pocket. Now the other eye has one, so I did get Part C, just in case, because friends have told me eye problems are hard to get covered. I don't want to get stuck again. They surely could make the process easier.

bgigstead on April 15, 2016:

Glenn, Sorry about the link. Anyway as I had mentioned, I am a Independent Licensed Medicare and Individual/Family Health Agent, currently licensed in 42 states. There are important cost factors to look at with Original Medicare Part A and B. For 2016 Part A has a $1288 deductible per benefit period. A benefit period starts the day you go into a hospital and ends 60 days after you leave the hospital. If you are readmitted into a hospital within 60 days for the same reason as the prior visit or on day 61, you are subject to a new deductible. Thus you can be responsible for multiple deductibles through the year.

Part B has a $166 deductible for 2016 and the biggest thing to look at is there is no maximum expense, so if you have a $100,000 medical bill you will owe $20,000.

Medicare Supplements and Medicare Advantage plans can help with those numbers. Medicare Supplements, with the certain riders or plans, require only the premium thus a plan with a $150 per month premium, your total expense would be $1800 for the year, even with a $100,000 medical charge.

Medicare Advantage have an Out of Pocket Maximum which limits your total expense to that limit regardless of the total medical charge. Out of Pocket Maximums can rage from $3000 - $6700, at least from the plans I have seen. The insurance company picks up the rest.

My advice is to work with an Independent Agent who works with all the plans in your area for the most unbiased recommendations.

Glenn Stok (author) from Long Island, NY on April 12, 2016:

vocalcoach - Wow! I didn't realize I'd make such a powerful impression. Thanks for your sharing, Audrey. Sorry to hear you're going through so much trouble with the cost of your meds. I also found it stressful analyzing everything about Medicare when I first signed up. That's what motivated me to write this hub. Thanks again for your positive feedback.

Audrey Hunt from Idyllwild Ca. on April 11, 2016:

Hi Glenn

I'm gluing your hub to my cell phone, computer and even the bathroom walls :) I discovered a whole new level of stress dealing with medicare. I'm going through a situation right now with coverage for my meds for diabetes and thyroid. I can no longer pay the outrageous fees for these drugs and may have to stop them altogether. The system sucks!

What a terrific hub! Will share everywhere.


Glenn Stok (author) from Long Island, NY on March 14, 2016:

Paul Kuehn - That's interesting. I don't know about how Medicare applies to US citizens living in Thailand. Hopefully you'll find the information you're looking for. Part B is important to cover visits to doctors. Thanks for sharing.

Paul Richard Kuehn from Udorn City, Thailand on March 13, 2016:

Glenn, Thank you very much for a very informative article. I am retired living in Thailand and am covered by Blue Cross-Blue Shield with my federal employee plan. At the present I am only covered with Part A of Medicare. I will definitely check out the website. I am sharing this hub with HP followers.

Glenn Stok (author) from Long Island, NY on January 28, 2016:

FlourishAnyway - Thanks for letting me know my hub was crystal clear, as you said. That's what motivated me to write this. Ever since I studied the Medicare rules, a lot of friends and acquaintances have asked me to clarify the convoluted instructions that Medicare provides in their literature. People tell me I have the ability to clarify things because of my logic and programming background. It's always nice to hear that confirmed.

FlourishAnyway from USA on January 28, 2016:

I learned a lot from this. I never knew what the A, B, C & D stood for and I sure didn't know about the impact of that penalty on D. Your example was crystal clear.

Glenn Stok (author) from Long Island, NY on January 21, 2016:

UnnamedHarald - Thank you so very much for those kind words and your validation of my article. The drug plans have been rising, as you discovered, mainly because the ACA included a ruling that Medicare cannot negotiate with drug companies for better prices. Hopefully that may change if we ever have a president who doesn't accept contributions from lobbyists such as the pharmaceutical industry.

As for possible issues with preexisting conditions and higher premiums if one switches plans, I had to do a lot of research on that to be sure. I included that information based on confirmation when I called and spoke to an rep at Medicare.

It's worse when you switch to an Advantage Plan and then change your mind and want to switch back to original Medicare. You can get turned down. These are things people need to know before making drastic changes. Many people just stick with original Medicare and never run into these problems, So that's why you don't hear much complaint about this.

Glenn Stok (author) from Long Island, NY on January 21, 2016:

MizBejabbers - You explained all that really well. I would like to have taken Plan G myself, but it's not available where I am. So that's why I took Plan N instead. I don't feel I need the total security of Plan F. If someone has a lot of illnesses then Plan F would be the right choice so that they never have to worry about getting any bills, other than the insurance premiums.

As I am sure you know, all plans are the same everywhere. Plan G is Plan G no matter where one is. Plan F is Plan F, and so on. The only thing that varies from one insurance company to another is the premium. So the premiums you quoted may be different for other people selecting the same plan elsewhere.

Advantage Plans are a completely different animal. They can be totally different since they are independent of Medicare. I just want to let other readers know that this discussion here was in relation to Supplemental Plans.

David Hunt from Cedar Rapids, Iowa on January 21, 2016:

This is by far the best, clearest overview of the choices one faces when nearing age 65 I have ever read. While I am more than a year away from my 65th birthday, I have gone through this with my wife. We chose original Medicare with supplemental/Plan F and a drug plan during her enrollment period. While supplemental premiums have increased each year, the increases have been extremely moderate for the healthcare industry and based on age (so far). The drug plan we chose has increased premiums from $31 a month to $61 over a three year period, causing us to choose a different drug plan which looks like it's better and cheaper. We utilized our state's Senior Health Insurance Information Program (SHIIP) to help us wend our way through Medicare choices, but articles like yours are a great foundation. I heartily recommend utilizing your state's SHIIP when making Medicare (and SS) decisions. And I thoroughly agree that non-governmental sources of information are biased (and that's being kind). I was NOT aware that switching supplemental plans (even during the annual window) was not simply a matter of switching but having to be accepted. That, I find disturbing, but I will almost certainly not put myself in the hands of an Advantage Plan. All I have to add is that our experience so far with Medicare has been very good so far. Again, two thumbs up for this fantastic article.

Doris James MizBejabbers from Beautiful South on January 21, 2016:

Glen, you are so correct, I did interchange "Part" and "Plan". That's what I get for replying so close to lunch. Thanks for correcting my blunder. However, as far as Plan G and Plan F go, I think it may depend on your medical needs. Plan G in my state costs me $126 a month and Plan F premium is $166 unless they went up this year. That's a savings of $40 per month or $480 a year for me. I pay a $149 deductible but everything else is exactly the same. so Plan G saves me $480 - $149 = $331 per year. therefore with my medical needs, I can't say that Plan F would be the best plan for me. I don't believe G is offered in every state, and it isn't offered in every county in my state. I don't know why the discrimination. Again, thanks for catching my blunder because I surely didn't.

Glenn Stok (author) from Long Island, NY on January 21, 2016:

denise.w.anderson - Medicare starts when you are 65. Presently the Social Security full retirement age is 66. But you can start sooner or delay it. The longer you wait you get more monthly. But delaying may not be a good idea since the Social Security Trust Fund will be exhausted by 2037 unless changes are made financially. They tell you this in your annual statement, but most people never read those messages.

Denise W Anderson from Bismarck, North Dakota on January 21, 2016:

Thanks, Glenn, for sharing this information with us. We are getting closer to this time ourselves, and may have the situation where we will have employer based insurance when my husband turns age 65. Does one qualify for Medicare at the same time as they qualify for Social Security, or are there two different ages involved here?

Glenn Stok (author) from Long Island, NY on January 21, 2016:

MizBejabbers - Thanks for that detailed info. I do have to correct a few things you said just so other readers don't get confused. Medicare has "Parts" but Supplemental Plans have "Plans". You were confusing parts and plans.

Plan F is the best Supplemental Plan, but the most costly too. It's best because you will never get a bill - they cover everything. I chose Plan N which is one step down. It saves $100 a month in premium and the only thing I need to watch for is those doctors who have excessive charges. Plan F and Plan G both cover excessive charges. The other Plans do not. You have Plan G in your area, which only has a low $150 deductible. It's good when you can get it, depending on your location.

When you mentioned Plan D, you really meant Part D for prescription drugs.

Sorry for correcting you but I need to be sure others don't get confused. It's confusing enough already, especially when people don't notice the difference between Medicare Parts and Various Plans available under Supplemental Insurance. Parts and Plans, Oh my!

Doris James MizBejabbers from Beautiful South on January 21, 2016:

Glen, Medicare is the biggest mess I've ever seen. I'm still working at way past Medicare age, but I've carried Part A since I was 66. When my state employees insurance became rife with ridiculous copays and deductibles, I decided to drop it and get Parts B and D. We will see how that works out this year. I must say that I got a good agent who helped me through this. I learned that my state is a participant in Part G, that must be bought within 6 mos. of Part B. It has a small ($150 deductible -- my private insurance ded. was $500) but otherwise has the same benefits as Part F, and the premiums are about 30% lower. My Plan D prescription coverage went down by $10 mo. this year.

My husband has an Advantage plan because he is also a VA patient and this covers things the VA won't do, like his total knee replacement. Anyhow, he wasn't eligible for Part G because he went on SS disability many years ago. We have a really good agent who puts her clients before her commission. She recommended an Advantage plan with no premium, but we rejected that for one with a $30 premium because it had prescription drug coverage and some other benefits the VA didn't provide. So, I think whether or not you are happy with Medicare depends on which state the person lives in. I'm afraid our new governor Republican governor is going to wreck the good organization of Obamacare authored by our former governor.

Glenn Stok (author) from Long Island, NY on January 21, 2016:

MsDora - You're not the only one. Many people miss that requirement. I have a friend who never took Part D prescription drug coverage. I kept telling him about the penalty. He didn't believe me. Now he needs drug insurance so he started Part D and discovered he has a $62 penalty added to his monthly premium for waiting so long.

Dora Weithers from The Caribbean on January 21, 2016:

Very helpful. I was shocked to find that there were penalties for not accepting some benefits later than at the start. I'm paying for benefits I can never use here where I am, but just in case . . . New subscribers should this useful.

Glenn Stok (author) from Long Island, NY on January 20, 2016:

Austinstar - Back when I first started with Obamacare (before my Medicare kicked in) I had selected Blue Cross on the ACA site and I actually had the same experience as you are describing you're having with Blue Cross's Advantage Plan. So I'm not surprised. Three times I tried to select a PCP and a month later they removed him. I ended up getting my premium back in a dispute where I claimed they never really insured me all that time since they kept removing the PCP from their database. It's troubling to see that Blue Cross still never fixed that problem since 2014.

I'm glad I got away from them. And with Medicare I chose not to use them either, especially since their agent refused to answer my questions as I mentioned in this article. I found out later they only answer questions that are positive. Anything that can lose a sale, they play dumb. I'm seeing a pattern here. Thanks for your info on your experience.

Lela from Somewhere near the heart of Texas on January 20, 2016:

This year, i wanted to change ins. Companies and i asked my doctor of 15 years which insurance she would be a member of for 2016. She gave me her list and i signed up with blue cross blue shield of texas. Now they are telling me that she is not part of their hmo and they assigned me a pcp that i had never heard of. 5 phone calls and several letters later they still have not straightened this out. My doctor has even called them. They keep saying she is not taking new patients or their software is disallowing me to have her as my pcp. Ive told them today to fix it or i will drop them. Weird thing is that when i signed up, it let me choose her as my pcp. Then they switched it saying she wasnt in their network, but she is. I just want to scream.

Glenn Stok (author) from Long Island, NY on January 20, 2016:

moonlake - It's really unfortunate how complex the rules are, especially when they cancel one another out just to benefit the insurance companies.

moonlake from America on January 20, 2016:

We did have private insurance. If Medicare doesn't cover it our insurance wouldn't cover it. The only thing they did cover was Hospice they covered that without Medicare.

Glenn Stok (author) from Long Island, NY on January 20, 2016:

Austinstar - Yes! I went through the same crazy things when I researched several Advantage Plans. They each sent me a really thick notebook with all their mumbo jumbo. Each was around 200 pages. I decided if they put so much money into printing these books, there wouldn't be anything left to pay the claims. So that was a big red flag too.

And I also had the experience you had when calling. One agent from Anthem Blue Cross couldn't answer me over the phone and she told me I'd get my answer in print after I sign up. What good is that!

Glenn Stok (author) from Long Island, NY on January 20, 2016:

moonlake - What a shame. Sorry to hear about your husband. That's one of the problems with Medicare. It's not as good as private insurance. But private insurance costs much more.

Lela from Somewhere near the heart of Texas on January 20, 2016:

Thank you for this hub. I have pretty much figured this out on my own, but it took a while and I do feel sorry for people that do not know how to do their research. But of course, there is just too much confusing information out there for people who are elderly and not web savvy.

My biggest issue with Advantage plans is the stupid way they run things. Their member web sites are extremely unhelpful and they continue to send snail mail letters for EVERY claim, every inquiry, every bit of information (handbooks, etc.)! I have a huge box full of Private Health Info that they insist on sending through the mail.

And if you call their customer service lines, it's 10 minutes of legal mumbo jumbo before you can even ask a question. And then the human you get to talk to doesn't have a clue about how to be helpful.

I can only hope I live long enough to see National Health Care like in Canada or Europe.

I hate insurance companies! I have worked in the health care field for over 30 years and I have watched them destroy the health care industry.

moonlake from America on January 20, 2016:

The problem we ran into with Medicare was it wouldn't pay for a medical test that should have been done. For example, my husband had lung cancer. He should have had a brain scan and some chemo for his brain just to make sure and catch cancer before it did go to his brain. The doctors were going to do that but Medicare wouldn't pay for it.

The lung cancer did go to his brain and that is what he died from.

Medicare is hard to deal with and I know your hub will help a lot of people understand it.