Common Medicare Questions and Answers

Understanding the complex rules and regulations of Medicare coverage is important, but it’s not always easy. To receive the healthcare benefits that you are entitled to under federal law, it helps to know how the system works. If you are facing issues related to Medicare and feel lost, contact a healthcare attorney. They can help you understand your rights and ensure you are receiving the proper Medicare benefits.

This article provides a comprehensive overview of Medicare’s most frequently asked questions (FAQ).

What is Medicare and who is eligible?

Medicare is a medical insurance coverage program that the U.S. government administers to qualified individuals. This program works under the Social Security Act, and is overseen by the U.S. Department of Health and Human Services. Its purpose is to provide healthcare coverage to people 65 years old and above. Certain individuals under 65 years old with disabilities or illnesses such as end-stage renal disease may also qualify.

Medicare plans have four parts: A, B, C, and D. Each parts of Medicare covers different portions of healthcare. Here’s a quick look at what each is responsible for:

• Part A covers overnight hospital stays, including room, food, tests, and doctor’s fees
• Part B helps pay for some services and products not covered by Part A, such as outpatient costs
• Part C plans give those eligible for Medicare the option of receiving their benefits via private health insurance plans
• Part D covers certain prescription medicines

While that gives an overview of what each plan covers, knowing more details can make understanding what you need easier. Let’s take a deeper dive into each plan:

What is Medicare Part A?

Medicare Part A is a component of Medicare that helps patients pay for inpatient hospital stays, access to hospitals, and nursing facilities. It also helps cover costs for hospice care and other home health care.

The following is a list what Medicare Part A covers:

• Overnight hospital stays, including room, tests, meals, general nursing, facility fees, and miscellaneous hospital services and supplies
• Critical access hospital stays and mental health care
• Reasonably necessary medical in-home services such as skilled nursing care, physical and occupational therapy, speech therapy, and medical social services
• Home-use equipment such as wheelchairs, hospital beds, walkers, oxygen, and certain medical supplies
• Hospice, if you’re terminally ill and have six months or less to live
• Brief nursing home visits if you were previously required to stay at least three midnights in the hospital, your nursing home stay is due to something diagnosed during that previous stay, you have another issue requiring skilled nursing care, or your nursing home care is skilled care and not merely custodial, non-skilled, or long-term care

Medicare Part A also covers a maximum of 100 days of nursing home stay. The first 20 days are paid in full, while the other 80 require a co-payment. The clock for your maximum days covered for inpatient treatments (hospital and nursing home) resets after 60 days of not using facility-based service coverage.

Am I eligible for Medicare Part A?

You are eligible for Medicare Part A if you are at least 65 years old. Most people receive this healthcare coverage for free based on their work history or their spouse’s. You may also need at least 40 credits of Medicare-covered employment in order to qualify for Part A Medicare.

If you do not meet the Medicare eligibility requirements, you can still enroll and receive the same coverage by paying a monthly premium. The Medicare premium is based on the number of work credits you have accumulated throughout your career.

What does Medicare Part B cover?

Medicare Part B covers necessary medical services and supplies. This includes preventing illnesses or detecting the need for an early treatment. In addition, Medicare Part B also covers:

• Doctors’ services at a hospital, a doctors office, or at home
• Laboratory tests (100%)
• Periodic exams such as mammograms, bone density tests, and pelvic exams for women
• Outpatient treatment, such as ER and clinic visits, X-rays, tests, and shots
• Medicines given while in the hospital or at your doctor’s office
• Medical equipment and supplies
• Some outpatient therapy
• Some counseling services
• Some preventive services
• Some Alzheimer’s-related care

This is not an exhaustive list.

Am I eligible for Medicare Part B?

You’re eligible for Medicare Part B if you meet at least one of the following criteria:

• You are at least 65 years old and are a U.S. citizen
• You are at least 65 years old and are a lawful permanent resident who has lived in the United States for five continuous years before filing an application for Medicare

You do not have to be eligible for Medicare Part A to be eligible for Medicare Part B. However, you will pay monthly premiums for Part B coverage, and the amount may be higher based on your income.

How much of my bill will Medicare Part B pay?

When added all together, Medicare ends up paying for about half of your total medical expenses. This is due to a few different factors:

• You’ll likely have routine exams, medicines, glasses, hearing aids, dentistry, etc., that Medicare doesn’t cover
• Medicare decides on its own what the appropriate amounts, or approved charges, are for each of your services
• These approved charges are usually far less than what doctors are actually charging, as participating providers cannot bill you above the Medicare‑approved amount. 
• For non‑participating providers, a limiting charge applies in most states, and balance billing is restricted
• Although several services are fully covered by Medicare Part B, it only pays about 80% of the approved charges for other services

Federal regulations from the Department of Health and Human Services establish a reimbursement structure. They determine payment rates for medical services across the health system.

What is Medicare Advantage (Part C) and what does it cover?

Medicare Part C is a private health insurance plan. Anyone who’s eligible for Parts A and B is also eligible for Medicare Advantage. Beneficiaries pay monthly premiums. For some, Medicare Advantage is  a better fit than Plan A and Plan B, often because of the more complete coverage of prescription drugs. Medicare beneficiaries also pay a monthly premium to receive Medicare Part B coverage. The following is a list of benefits that various Plan C plans offer:

• Medically necessary services from any hospital or doctor in the country
• Prescription drugs
• Dental care
• Vision care
• Gym and health care memberships

Medicare Advantage offers more flexibility and coverage than other Medicare plans, but at a cost.

Who is eligible for Medicare Part D coverage?

You’re eligible for Medicare Part D coverage if you’re:

• Eligible for Medicare Part A 
• Enrolled in Medicare Part B

Medicare Part D helps beneficiaries pay for prescription drugs. You don’t have to enroll unless you also receive Medicaid. If so, the government will automatically enroll you in Medicare Part D.

How much does Medicare Part D cost?

Medicare Part D requires you to pay premiums, deductibles, and copayments. It also has a coverage gap, during which you pay full price for all of your prescription costs. Referred to as the “Donut Hole,” the gap begins once Medicare has paid a certain dollar amount for your prescriptions. Once you have paid an out-of-pocket amount, the prescription drug coverage gap ends. You are only responsible for the co-payments for the rest of that calendar year.

Medicare Part D plans pick and choose what types of drugs and brands they want to cover based on the prescription drug plan. They can also choose to deny coverage altogether. You should review the different Part D plans carefully to choose the one that is best suited for your needs.

Can I get any of Medicare Part D’s costs waived?

If your income is below a certain amount, you may qualify for supplemental assistance from Social Security. In certain situations, your copayments may be significantly reduced, or even waived. You may qualify for this copayment assistance if any of the following apply:

• You’re eligible for Medicaid
• You have an income level that does not reach above 149% of the federal poverty level
• You live in a long-term nursing home, are enrolled in Medicaid, and are enrolled in Medicare Part D

You also may qualify for assistance through pharmacies and drug companies if you:

• Take certain types of medications, like generic brands
• Use a pharmacy that waives copayments for those under a certain income (ask your pharmacy if it participates in this program)

How much does Medicare cost?

Medicare costs vary based on your medical needs and choice of coverage. The following are an idea of what you may have to pay:

Part A costs

Most people pay no premium if they or their spouse has earned 40 quarters of Medicare-covered employment. Beneficiaries face annual deductibles and coinsurance for hospital admissions. For 2025, individuals pay $1,676 as their deductible per benefit period. Beneficiaries pay a deductible that covers part of the costs for a Medicare-approved inpatient hospital stay within the first 60 days of each benefit period.

Part B costs

For Medicare Part B, the standard monthly premium cost is $185 for 2025. The annual deductible for beneficiaries of Medicare is $257. 

Since 2007, the monthly premium for Medicare Part B has been adjusted for higher-earning beneficiaries. Higher-earning beneficiaries pay an additional Income-Related Monthly Adjustment Amount. This amount is often based on the Modified Adjusted Gross Income from the past two years.

When does a higher premium for Medicare Part B apply?

A higher premium for Medicare Part B applies when, two years earlier, your modified adjusted gross income exceeds a certain threshold:

• $106,000 for individual filers or married individuals filing separately
• $212,000 for married individuals filing jointly

Social Security determines whether you have to pay these higher premiums. If you experienced life-changing events that potentially lowered your household income, you can contact Social Security. They can reduce the additional premium you have to pay.

How do I enroll in Medicare?

If you are already receiving Social Security benefits at least four months before you turn 65, you will be automatically enrolled in Medicare Parts A and B. However, Medicare enrollment is not always automatic. You need to enroll during your Initial Enrollment Period (IEP) if you are not receiving Social Security benefits when you turn 65 years old. The enrollment period lasts for seven months and starts three months before your 65th birthday. The period ends three months after you turn 65 years old.

If you are eligible for Medicaid or Medicare based on disability, you may also qualify to receive Parts A and B. This may only happen if you have received disability benefits for 24 months.

You can apply for Medicare by contacting the Social Security Administration at 1-800-772-1213 and speaking with a representative about enrollment options.

What if I need a referral for specialist care?

Original Medicare (Parts A and B) does not require referrals to see specialists. This allows beneficiaries to make appointments with Medicare-approved specialists directly. 

Medicare Advantage plans often require referrals. Most Health Maintenance Organization (HMO) Plans require a physician’s referral for specialists.

Insurers may have policies that require different guidelines. Consult a representative about your plan to look at their policies related to seeking specialist care.

What are the biggest mistakes that people make with Medicare?

Some mistakes are more common than others when navigating Medicare. Enrollment periods and decisions related to choosing a health plan can cause confusion. The following are some of the most common mistakes associated with Medicare plans:

Missing Enrollment Deadlines

Many people fail to enroll during the Initial Enrollment Period. The delay in enrollment could result in late enrollment penalty or fees. It could also increase your premium payments.

Not Understanding Cost-Sharing Requirements

Some assume Medicare covers 100% of their medical services. That is not the case. For most doctors’ visits and outpatient care, you often have to pay 20% of the cost. Medicare pays 80% after you meet your deductible. 

The costs for prescription drugs are more complex and can vary due to the plan you have. In 2025, a deductible of up to $590 may apply. Once that’s met, you’ll be responsible for 25% of drug costs until reaching $2,000 in out-of-pocket costs.

Not Understanding the Part B Income-Related Monthly Adjustment Amount (IRMAA)

The additional premium payment for those with higher incomes can come as a shock. Higher-income beneficiaries whose income exceeds a certain amount pay a higher Medicare Part B premium, which is often based on the beneficiary’s income.

Assuming All Plans Are the Same

It’s normal to want to pay as little as possible, but that’s not always the best option. Before choosing the cheapest Part D plan,  check to make sure the plan covers the specific medication(s) you take.

Enrollees in the Part D plan pick and choose which prescriptions and brands they cover. There’s no switching of plans during the year. If a required drug isn’t on the chosen list, coverage can be denied. These factors can leave beneficiaries stuck with a plan that does not cover their expensive medications.

Thinking Medicare Covers Long-Term Care

Medicare does not cover long-term care or custodial care. Neither does Supplemental Insurance. Medicare does not classify long-term care as medical care. They look at long-term care as support to the beneficiary for the basic daily activities. This may include assistance with personal care such as bathing, dressing, using the bathroom, home delivered meals, and adult day health care. 

With this in mind, it’s a good idea to start planning your non-medical long-term care ahead of time to ensure that you’ll be able to afford the support you’ll need later in life. If you have concerns or questions about Medicare, consider contacting a healthcare attorney. They can assess your case and help you avoid these common pitfalls related to Medicare.

What are the things Medicare does not cover?

Medicare has limitations in coverage that beneficiaries should understand when they are planning their health care services. If there are items or services that Medicare does not cover. There are some exceptions, such as:

• You have supplemental health coverage insurance that helps cover those costs
• You are enrolled in other Medicare Plans such as Medicare Advantage Plan (Part C), Medicare Cost Plan, or Program of All Inclusive Care for the Elderly (PACE), which cover other services not covered by original Medicare such as dental, hearing, or vision services

Medicare does not cover the following medical services:

• Vision examination for prescription eyeglasses
• Long-term care facility and custodial care
• Cosmetic surgical procedures
• Massage therapy and similar alternative treatments
• Routine wellness examinations
• Hearing aids and related fitting examinations
• Concierge medicine
• Services from providers who do not participate in Medicare programs
• Most dental health care services including routine cleanings, fillings, extractions, and dentures

Other services may not be covered as well.

Seek Legal Guidance From a Healthcare Attorney

If you are facing issues related to Medicare, it’s a good idea to speak with a healthcare attorney. They can help you navigate the federal regulations and ensure that you receive health coverage that you deserve under federal law. They also understand the complexities of the health system and advocate for your rights.  

For immediate assistance with basic Medicare questions, you can also contact the official Medicare helpline at 1-800-MEDICARE or visit Medicare.gov.