General Medicare Overview
What if I don’t sign up when I was supposed to?
If you do not sign up for Medicare Part B when you are first eligible you may have to pay a late enrollment penalty when you finally do sign up for as long as you have Part B. Your monthly premium for Part B may go up 10% for each full 12-month period you could have had Part B but choose not to sign up for it.
Medicare is divided into several different parts. The two government parts A and B are “Original Medicare” and there are also several private parts to Medicare. The costs and benefits change every year. The detailed outline that follows can be overwhelming for many people. The good news is you don’t have to worry! We at JL Masters Insurance Services know all this stuff and serve as your cheat sheet.
Medicare Part A: Hospital Insurance
To Qualify for Medicare Part A, you would need to have paid enough payroll taxes through employment in the USA. The requirement to receive Medicare Part A without having to pay any monthly premium is to have worked the equivalent of 40 quarters, or about 10 years.
Enrollees age 65 and older who have fewer than 40 quarters, and certain persons with disabilities, pay a monthly premium in order to voluntarily enroll in Medicare Part A. Individuals who had at least 30 quarters, or were married to someone with at least 30 quarters, may buy into Part A at a reduced monthly premium rate, which will be $285 in 2025. Certain uninsured aged individuals who have fewer than 30 quarters, and certain individuals with disabilities who have exhausted other entitlements, will pay the full premium, which will be $518 per month in 2025.
Medicare Part A includes these services, costs, and limitations in 2025:
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Hospital Insurance:
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$1676 Deductible applies to the first 60 days per “event” which means you can have to pay the deductible more than once per year if you experience a long enough break between hospitalizations.
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$419 per day after day 61-90
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$838 per day after day 91-150
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Maximum covered days is 150 for your entire lifetime. If you need more than 150 days in the hospital you will be paying 100% of the cost for those extra days out of your own pocket.
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Hospice: $0
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Skilled Nursing: 100 days of coverage maximum.
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Days 0-20 $0
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Days 21-100 $209.50 per day
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Home Health Care $0
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There is no Long-term-healthcare benefit to Medicare. Medicare part A offers temporary therapy visits for recovery only.
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Medicare Part B: Outpatient Medical Insurance
Medicare Part B includes these services, costs, and limitations in 2025:
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Most people qualify for the “standard” monthly premium of $185.70 per month in 2025. However, those with higher incomes may pay higher premiums. This is called the Medicare “Income Related Monthly Adjustment Amount” or IRMAA and means the rate you pay in 2025 depends on your income from 2023. If you make above $106,000 per year as an individual or above $212,000 per year as a couple the IRMAA may apply to you.
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$257 deductible per year
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You pay 20% of the cost for all of the following services, provided they are approved by Medicare as “medically necessary.”
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Primary Care Physician and Specialist Visits
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Outpatient Surgery (Hospital or Surgery Center)
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Therapy (physical therapy, chemotherapy, speech therapy, radiation therapy at an office)
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Durable Medical Equipment (examples include walkers, wheelchairs, and hospital beds for home use.)
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Ambulance Air or Ground (Emergency)
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Emergency and Urgent Care
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Telehealth (virtual visit or phone call)
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Preventative Tests (screenings)
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Diagnostic Tests (MRI, CT, Ultrasound, Nuclear Med)
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Part B Drugs (administered in a doctor’s office)
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Pain Management
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Lab tests (medically needed)
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Dialysis (at facility or in home if approved)
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Mental Health (in person or virtual/phone)
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Up to 190 Days in a Mental Health Facility
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There is no limit, or “out-of-pocket-maximum” to the amount you can pay for Original Medicare services. Because the costs of Original Medicare can get very expensive and it does not cover everything, most people choose to take advantage of the private parts of Medicare.
Private Medicare Insurance: Medicare Advantage or Medigap?
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You have two main choices from the private health insurance marketplace to help eliminate deductibles, copays, and coinsurance. You may only choose one strategy, it is an either/or decision. The costs and benefits vary wildly per year, per state, per county, and per plan. For a comprehensive comparison please contact JL Masters Insurance Services. You may also use the quote and enroll tool in the upper right corner of the home page for an estimate, but it will be lacking the context a real live person can provide. But to give you a general idea:
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Medicare Supplement/Medigap:
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Medigap plans help fill the “gaps” in Original Medicare by covering more services and costs like deductibles, coinsurance, and copays. Depending on where you live you have 10 Medigap plans to choose from each designated by a letter (A, B, C, D, F, G, K, L, M, N). Each plan varies in the amount of coverage and costs. The huge positive in choosing a Medigap plan is you can use any provider, doctor, or facility that accepts Medicare, giving you incredible freedom to go just about wherever you want to get your care and not have to go through gatekeeping processes like referrals. This freedom has the potential to save your life. However, you do have to pay a monthly premium for a Medigap plan on top of the monthly premium you pay to the government for Original Medicare. Also, unless you have prescription drug coverage by some other means such as the military, you would need to purchase a separate Medicare Prescription Drug Plan which has its own monthly premium. Lastly, if you want coverage for certain extras not included in Medigap, such as vision, hearing, or dental coverage you would need to purchase this coverage separately as well.
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Medicare Advantage/Medicare Part C
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Medicare Advantage plans are provided by private companies who contract with the government to provide at least the same benefits covered by Original Medicare or better. They offer benefits beyond Original Medicare, such as routine dental or vision care, keep costs much lower than original medicare by charging lower copays for services and placing limits on how much you can pay out of your own pocket per year for the services listed in Original Medicare. These plans usually use PPO or HMO network structures, similar to what most have been accustomed to through employer provider insurance, which place restrictions on which doctors and services are available and how to access them. The great thing is these plans have very low monthly premium amounts. Depending on where you live you may have access to plenty of plans that have $0 monthly premiums. You still have to pay your Original Medicare premium to the government, but you will pay little to nothing per month in extra premiums to your insurance plan. Getting plenty of extra benefits bundled into one plan for cheap is very appealing so many are willing to accept the trade-off of less control over healthcare decisions.
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An Important Note About Medicare Part D Prescription Drug Coverage:
The law requires Medicare beneficiaries to be enrolled in “creditable” prescription drug coverage, known as Medicare Part D, when first eligible. You may get coverage through a standalone Medicare drug plan, bundled into your Medicare Advantage plan, or some people get coverage through their employer or military benefits. If you do not sign up for Part D when you are supposed to, once you do finally enroll you may have to pay a penalty for as long as you have Part D. Your monthly premium could go up 1% for each month you could have had Part D but chose not to sign up for it. To avoid this penalty please don’t hesitate to reach out to JL Masters Insurance Services so you understand the requirements and options for your specific situation.
There is plenty about Medicare that has not been covered here. Common questions we help answer include:
- How do I apply for the government portion of Medicare?
- When should I start taking my Social Security benefits?
- What if I have military benefits?
- How do VA benefits work with Medicare?
- What is TRICARE or TRICARE For Life and how does it work with Medicare?
- How does my employer provided insurance work with Medicare?
- Can I delay enrolling in Medicare Part B if I am still working?
- There are so many choices! What plan option is best for me?
- What if I am enrolled in my state’s Medicaid Program? How does this work with Medicare?
- How do I apply for programs that help pay for my Medicare medical costs?
- How do I get the Long Term Care services I need?