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12 Things You Need to Know About Medicare

12 minute readLast updated September 26, 2023
Written by Rebecca Schier-Akamelu
Reviewed by Letha Sgritta McDowell, CELA, CAPCertified Elder Law Attorney Letha Sgritta McDowell is a past president of the National Academy of Elder Law Attorneys.
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Medicare can play a major role in the life of anyone 65 and older. But applying for this federal health insurance program is a lengthy and complicated process. There are no easy, one-size-fits-all coverage options, and the system is underfunded. At times, you may feel like you and your loved one are on your own in dealing with the application and enrollment process. As you navigate Medicare, keep the following 12 points in mind to help maximize Medicare coverage while minimizing stress and expenses for you and your loved one.

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Medicare is the primary insurer for anyone 65 or older

Most people initially become eligible for Medicare three months before turning 65. A person may also be eligible earlier if they have a disability, End-Stage Renal Disease (ESRD), or ALS, also known as Lou Gehrig’s disease.[01]

Before becoming eligible for Medicare, your loved one may already be insured with another form of insurance, such as retiree health insurance, individual health insurance, or COBRA insurance. Regardless, they’ll be required to enroll in Medicare once they turn 65. After their 65th birthday, any other forms of insurance will be considered a secondary insurer. This is true even if they haven’t applied for Medicare yet.

This consideration is an important factor to know and understand. It means once their 65th birthday passes, your loved one can’t count on their other forms of insurance to pay for their hospital or physician bills.

Medicare has 4 main parts

Medicare is divided into four separate parts. Each part helps pay for different health care costs as outlined below:[02]

  • Part A is hospital insurance and covers most care related to inpatient hospital visits, skilled nursing facilities, home health care, hospice care, or palliative care.
  • Part B is medical insurance and covers most outpatient care, durable medical equipment, and medically necessary doctors’ services. It can also cover preventive care like laboratory tests, X-rays, mental health care, and some home health and ambulance services. You pay a monthly premium for this coverage.
  • Part C refers to Medicare Advantage Plans. These plans are offered through private health insurance companies that have contracts with the government. Medicare Advantage Plans may provide all of hospital and medical insurance coverage (Parts A and B), or they may offer extra coverage on things like vision, hearing, and dental. In many cases, Medicare Advantage Plans will offer Part D (prescription drug) coverage as well. These plans are not provided directly by the government like Medicare is.[03] You’ll learn more about Medicare Advantage Plans in the next section.
  • Part D refers to Medicare’s prescription drug insurance, including many recommended shots or vaccines. Part D is never provided directly by the government and is a separate, optional plan to help cover the cost of medication.

Choose your plan wisely: Original Medicare vs. Medicare Advantage

You can choose either Original Medicare (Parts A and B) or a Medicare Advantage Plan (Part C). You can also opt for the other parts as mentioned above, like adding prescription drug insurance (Part D).

The type of Medicare a person selects will depend on their unique circumstances — there’s no right or wrong answer. Consider the following when choosing between Original Medicare and a Medicare Advantage Plan for your loved one.

What you get with Original Medicare:[04]

  • Your loved one can usually choose to see any doctor. However, you should check with your loved one’s preferred doctor first, as some doctors choose not to participate in the original Medicare program. This is a critical step if it’s important to remain with a family doctor.
  • Initially, there may be more out-of-pocket costs compared to those with the Medicare Advantage Plan.
  • Your loved one will have a choice of the drug plans available in their area.

What you get with a Medicare Advantage Plan:[04]

  • There are limits to the doctors your loved one can visit. If remaining with the family doctor is important to you and your loved one, you should check to ensure your doctor is covered under this plan.
  • There may be fewer initial out-of-pocket expenses, although Medicare Advantage may cost more in the long run.
  • Your loved one may have access to extra hearing and vision benefits.
  • Drug coverage is included in some, but not all, types of Medicare Advantage Plans.

Applications should be completed before your loved one turns 65

It’s preferable to apply for Medicare as soon as your loved one is eligible. You must apply during the initial enrollment period, which starts three months before their 65th birthday and ends four months after their 65th birthday. This allows a seven-month window to apply.[05]

Because applying for Medicare is a lengthy process, you and your loved one should start researching when they turn 64. Applying before turning 65 helps avoid late penalties or having to go temporarily without coverage.

Let our care assessment guide you

Our free tool provides options, advice, and next steps based on your unique situation.

Seniors already receiving Social Security Benefits will automatically be enrolled in Medicare

For anyone who’s just turned 65 who is already receiving Social Security benefits, the Social Security Administration will automatically sign them up for Medicare Parts A and B. They’ll send you or your loved one a welcome package three months before Medicare coverage starts that explains additional coverage decisions (such as Part D coverage) that you’ll need to make.[06]

Even if you think your loved one will be automatically enrolled in Medicare, you should still double check these materials well in advance of the initial enrollment period.

Seniors who miss enrollment may have to pay penalties

If your loved one misses the initial enrollment period, they may be charged a late enrollment penalty. Depending on the part of Medicare your parent applies for, these penalties can vary.

In the Part A late enrollment penalty, their monthly premium may go up 10% for twice the number of years they go without coverage. For example, if your parent didn’t sign up for Part A for three years, they’d have to pay the higher premium for six years.[07]

Your loved one could be charged a Part B late enrollment penalty for every 12 months enrollment is delayed. This penalty is 10% of the standard Part B premium. For example, if they waited 12 months to sign up and their monthly premium is initially $170.10, the penalty for enrolling late would be an additional $17.10 added to their monthly premium.[07]

Seniors may also face a Part D late enrollment penalty. For every month your loved one was without creditable coverage, they’ll be charged 1% of the standard Part D premium. The monthly penalty is rounded to the nearest $0.10. So, for example, if their initial premium is $33.37, and they go without coverage for 29 months, they’d pay an additional $9.70 on their premium every month.[08]

Keep in mind that these penalties don’t go away. With the exception of the Part A penalty, they’ll follow your loved one through life, and the amounts change every year.

Anyone who is eligible can sign up for Medicare during the general enrollment period from October 15 to December 7 every year. During this time, seniors are free to switch to a different Medicare plan that may better suit their needs. Those who are already enrolled in a Medicare Advantage Plan can switch to a different Medicare Advantage Plan during the Medicare Advantage Open Enrollment Period from January 1 to March 31 every year.[09]

Seniors can't enroll in Medicare as a family

There are no family Medicare plans. Medicare is an individual benefit — each member of a family or couple needs to apply for Medicare separately.[10] This is different from private insurance, which allows spouses and families to enroll together. One benefit of Medicare is that senior couples can each choose their own Medicare plan to help ensure that their most important medical needs are covered.

Updated Medicare policies may help avoid a gap in coverage

When your loved one applies for Medicare used to have a great impact on their coverage. For seniors who missed their initial enrollment period, this meant waiting up to six months for Medicare coverage to begin.

However, the Consolidated Appropriations Act (CAA) revised Medicare enrollment rules. Seniors can now get coverage the first day of the month following their enrollment.[11]

Seniors may be able to avoid penalties if they qualify for a special enrollment period (SEP)

While it’s best for your loved one to enroll in Medicare during the initial enrollment period that occurs when they turn 65, sometimes circumstances don’t allow it.

Under extenuating circumstances, your loved one can enroll during a special enrollment period (SEP). The CAA has affected some of these circumstances and the waiting period before coverage starts.

SEPs may be allowed in the following situations:[11]

  • An emergency or disaster. If your loved one lives in an area where the federal, state, or local government declared an emergency, they may qualify for an SEP. The SEP typically begins the date the emergency is declared and ends six months after the end date of the emergency.
  • Misinformation from an employer. If your loved one is still working and received incorrect information from either their employer or the employer’s group health plan, they may qualify for an SEP. They’ll need to provide documentation proving that they received misinformation. If your loved one doesn’t have this, they can also submit a written statement describing the situation. In this case, the SEP would begin the day they inform the Social Security Administration of the situation and ends six months later.
  • Incarceration. If your loved one was incarcerated and released after January 1, 2023, they’re eligible for an SEP that begins the day that they’re released. The SEP lasts for one year.
  • Loss of Medicaid coverage. If your loved one had Medicaid, but has become ineligible, they’ll have an SEP that begins when they’re notified about their Medicaid coverage ending. This SEP will last for six months after their Medicaid coverage is terminated.
  • Exceptional circumstances. Your loved one can request an SEP if they were dealing with an exceptional circumstance that was beyond their control. However, these requests are reviewed on a case-by-case basis and may not be granted.

Supplement Original Medicare with a Medigap policy

If you or your loved one can afford it, it is possible to supplement Original Medicare with a Medicare Supplement Plan called a Medigap policy. Medigap policies are offered by private insurance companies and help pay for costs associated with Original Medicare, such as the following:[12]

  • Coinsurance, the portion of the money your loved one pays after their insurance has paid your benefit
  • Copayments, the money your loved one pays each time they seek care
  • Deductibles, the money they pay before their insurance benefits kick in

However, Medigap doesn’t cover the following:[12]

  • Long-term care
  • Vision and dental care, including glasses and hearing aids
  • Private-duty nursing
  • Prescription drug coverage

What seniors should do if they're still working at 65

Many seniors have retired by the age of 65 and applying for Medicare is a logical next step. If your loved one plans to continue working or has employer health coverage through a spouse, they might have other options:[13]

  • If their employer has 20 or more employees, your loved one can choose to wait to sign up for Part B without a late enrollment penalty, or they can enroll in Medicare while keeping employer insurance.
  • If their employer has fewer than 20 employees, your loved one will need to ask their employer whether they need to sign up for Parts A and B or if they can wait.
  • If they have health coverage through a spouse’s employer, your loved one may be able to delay enrollment, or they may still need to enroll at age 65. This will depend on the employer’s terms.

Talk with a Senior Living Advisor

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For more details about how employment affects whether your loved one needs to enroll in Medicare, refer to Medicare’s page on working past 65.

Whether or not a senior plans on continuing to work, Medicare plays a crucial role in health coverage for everyone 65 or older. Understanding ahead of time what they need to know about Medicare plans will help your loved one make an informed decision about their health care coverage and overall well-being.

For additional information about Medicare, you can contact:

How Medicare may affect your loved one's senior living decision

Whether you’re helping your loved one look for senior living now or are simply considering their future care needs, it’s best to plan ahead. Many seniors and their families think Medicare will cover long-term care costs such as assisted living, but unfortunately Medicare only pays for medically necessary parts of care. Things like assistance with activities of daily living aren’t covered. If paying for senior living is a concern, you can view our complete guide to paying for long-term care.

A Place for Mom also offers free, personalized assistance for families. You can connect with one of our Senior Living Advisors today to discuss your loved one’s care needs, budget, and lifestyle to get personalized senior living options.

Original article by Grace Styron.


  1. Centers for Medicare and Medicaid Services. Get started with Medicare. Medicare.gov.

  2. Centers for Medicare and Medicaid Services. Parts of Medicare. Medicare.gov.

  3. Digital Communications Division (DCD). (2021, October 20). What is Medicare Part C? U.S. Department of Health and Human Services (HHS).

  4. Centers for Medicare and Medicaid Services. Compare original Medicare and Medicare Advantage. Medicare.gov.

  5. Centers for Medicare and Medicaid Services. When does Medicare coverage start? Medicare.gov.

  6. Centers for Medicare and Medicaid Services. Welcome to Medicare package (automatically enrolled). Medicare.gov.

  7. Centers for Medicare and Medicaid Services. Avoid late enrollment penalties. Medicare.gov.

  8. Centers for Medicare and Medicaid Services. Part D late enrollment penalty. Medicare.gov.

  9. Centers for Medicare and Medicaid Services. Joining a plan. Medicare.gov.

  10. Centers for Medicare and Medicaid Services. How does Medicare work? Medicare.gov.

  11. U.S. Department of Health and Human Services. Administration for Community Living. (2023, April 20). Quick guide to recent changes to Medicare.

  12. Centers for Medicare and Medicaid Services. Learn what Medigap covers. Medicare.gov.

Meet the Author
Rebecca Schier-Akamelu

Rebecca Schier-Akamelu is a writer at A Place for Mom. Her writing supports a person-centered approach to senior care and she’s written on a range of topics from home care to finances. She holds a certificate in digital media and marketing from Duke University and a bachelor’s degree from Creighton University.

Edited by

Jordan Kimbrell

Reviewed by

Letha Sgritta McDowell, CELA, CAP

The information contained on this page is for informational purposes only and is not intended to constitute medical, legal or financial advice or create a professional relationship between A Place for Mom and the reader. Always seek the advice of your health care provider, attorney or financial advisor with respect to any particular matter, and do not act or refrain from acting on the basis of anything you have read on this site. Links to third-party websites are only for the convenience of the reader; A Place for Mom does not endorse the contents of the third-party sites.

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