Navigating Medicare can often be confusing. Even for those who have had employer-offered or individual health plans for decades, Medicare comes with its own set of plan options and requirements. Fortunately, resources are available to help. Massachusetts residents can access free, unbiased Medicare counseling through the SHINE program for help understanding coverage options and the enrollment process.

Whether you’re enrolling in Medicare for the first time or simply looking to better understand how it works, exploring answers to some common Medicare questions can help build a foundation for making informed coverage decisions. Start with the basics below:

1. When should I start the process of applying for Medicare?

The timeline for applying for Medicare coverage can depend on a variety of factors: 

• You are nearing 65 and ready to switch to Medicare
  Around this time, there is a seven-month period to enroll called an Initial Enrollment Period. The timing for this is different for everyone, as it begins three months before the enrollee turns 65 and ends three months after the month they turn 65. This eligibility calculator can help determine when your Initial Enrollment Period is.
• You are nearing or over 65 but have an employer-sponsored health plan
  If you’re eligible for Medicare, but you (or your spouse) are still on an employer-sponsored health plan, it is an option to keep the employer plan until you and/or your spouse are retired. When ready to retire, you can participate in a Special Enrollment Period without any late penalty. There are also other situations that might qualify for a Special Enrollment Period.
• You’re 65+ but missed the Initial and Special Enrollment Periods
  Each year between January 1 and March 31, you can enroll during the Annual Enrollment Period. However, should you apply after the Initial Enrollment Period and aren’t enrolling as part of a Special Enrollment Period, you may have to pay a monthly late enrollment penalty for as long as you have Part B (and sometimes for Part A) coverage. The same can apply if you have Part A and Part B coverage but opt to sign up for Part D coverage later.

A common misconception about Medicare is that since your tax money pays into Social Security and therefore Medicare, you are automatically enrolled once turning 65. That is not accurate. Regardless of when you choose to get Medicare coverage, you will need to apply for and enroll in it yourself.

2. What are the different Parts of Medicare?

Medicare coverage consists of four Parts:

• Part A is part of Original Medicare, which is offered by the Federal Government. Most people don’t pay a monthly premium for Part A, but there is a deductible. Part A provides coverage for hospital visits, such as inpatient hospital stays or hospice care, provided the facility accepts Medicare. 
• Part B, also part of Original Medicare offered by the Federal Government, provides coverage for medical services. Typically, a Part B premium is deducted from your Social Security payments upon enrollment, although you may receive a bill every three months if you don’t receive Social Security. Part B provides coverage for medical services, like an annual physical or medically necessary ambulance ride.  
• Part C is additional coverage offered by private health insurance companies, also known as Medicare Advantage plans. Part C covers all the benefits of Original Medicare (Part A and Part B), plus additional benefits that Original Medicare doesn’t cover. Many people choose to add Part C because it provides more complete coverage than just Original Medicare. Part C is not required, but if you choose to get it, you must also have Part A and Part B (Original Medicare). Part C offers coverage for additional benefits, like routine eye exams, dental, and prescription drug coverage (available with many, but not all, Part C plans).
• Part D is prescription drug coverage. This can be included with a Part C plan or purchased separately through private health insurers. Like Part C, Part D is not required with Medicare, but if you choose to add it, you must also have Original Medicare. Part D covers a variety of prescription drugs.

3. What choices do I have for Medicare plans?

Anyone enrolling in a Medicare plan must first choose Original Medicare:

Original Medicare, which comes from the Federal Government, includes Part A and Part B. Original Medicare only covers approximately 80 percent of Part B expenses, leaving the remaining amount as your responsibility. 

If only relying on Original Medicare, there will be gaps in your coverage. For example, Original Medicare has deductibles and does not have a limit on out-of-pocket spending. It also does not cover Part D prescription drugs, routine vision and hearing exams, and other services. Those enrolling in Original Medicare have plan options through private health insurers to consider for additional coverage, as many find it does not provide enough coverage on its own. Two other considerations for added coverage:

• A Medicare Advantage plan (Part C) will cover everything that Original Medicare covers, plus additional benefits. Medicare Advantage plans, which come from a private health insurer, typically have lower monthly premiums than Medicare Supplement plans and are often available with prescription drug coverage (Part D), which allows you to have medical and drug coverage all in one plan.
• A Medicare Supplement plan can also cover gaps in Original Medicare. Typically, Medicare Supplement plans have higher monthly premiums than Medicare Advantage plans, but you can see any doctor who accepts Medicare. If prescription drug coverage is needed, a separate prescription drug plan (PDP), Part D, is required, as it’s not included with a Medicare Supplement plan.

4. Is it better to keep my employer’s health insurance or get Medicare?

For those who have the option of either an employer-sponsored health plan or Medicare, the best choice will depend on your current job, lifestyle, and health care needs.

If you work for a company with more than 20 employees, you might choose to sign up for Medicare Part A coverage if there’s no premium for you. In that case, your job-based insurance pays first, followed by Medicare. For those who work for an employer with less than 20 employees, you’ll want to ask your employer if you’ll need to sign up for Medicare Part A and Part B upon turning 65. And for those who have health insurance from Medicaid or Marketplace, whether you need to sign up for Medicare will depend on what your current health plan covers. 

5. How do I choose the right plan for me?

“Many people begin by looking at the monthly premium, but it’s important to consider the full picture,” says Edward Walker, president of government markets for Point32Health, a not-for-profit health organization and the parent company of Tufts Health Plan and Harvard Pilgrim Health Care. “Thinking about your doctors, prescription medications, expected health care needs, and overall costs can help you identify the coverage that best aligns with your individual situation.”

Consider these factors when choosing a plan:

• Your health
  How often do you visit a doctor, specialist, or hospital? If you are in good health, a plan with a $0 or low monthly premium might be best. If you see your doctor more often, you may want a plan with a higher monthly premium in exchange for lower doctor visit copays.    
• Your budget
  Do you want to pay less each month or less when you visit a doctor? Typically, there are lower monthly premiums with Medicare Advantage versus a Medicare Supplement plan, but fewer services require a copayment with a Medicare Supplement plan. Out-of-pocket costs are also a factor. Medicare Advantage plans provide an out-of-pocket maximum that limits the amount you spend on medical costs in a year, but with Original Medicare and Medicare Supplement plans, there is no annual limit to how much you may have to pay out of pocket.  
• Your doctors and specialists
  Choosing a Medicare Advantage health maintenance organization (HMO) plan means you have a primary care physician (PCP) who works together with a team of specialists to help you stay healthy and get the care that is right for you, whereas a Medicare Advantage preferred provider organization (PPO) plan means you can see any doctor but are responsible for coordinating your own care. With a Medicare Supplement plan, you don’t have a PCP, but you can see any doctor who accepts Original Medicare. 
• Drug coverage
  With a Medicare Advantage plan, you can have Part D prescription drug coverage and medical coverage all in the same plan. With a Medicare Supplement plan, if you want prescription drug coverage, you’d need to enroll in a separate prescription drug plan (PDP).

6. Should I review my Medicare coverage annually? 

Yes. Health care needs can change over time, and Medicare plans may also make updates to costs, provider networks, prescription drug coverage, and benefits. During Medicare’s Annual Enrollment Period (October 15 to December 7), you can review your selections and make changes if needed.

“Reviewing your coverage each year can help ensure it continues to align with your health care needs, budget, and health priorities,” adds Walker.

Navigating Medicare isn’t always straightforward, but you don’t have to do it alone. The Medicare website offers a ZIP code-based tool to compare plans available in your area, and Tufts Health Plan’s Medicare Made Simple guide can assist you in understanding your options and coverage decisions.

Tufts Health Plan, a Point32Health company, has Massachusetts-based Medicare Advantage plans to support those who are aging strong. To learn more about your Medicare options, call Tufts Medicare Experts at 1-877-212-9768 or visit thpmp.org.