Understanding the Parts of Medicare
Medicare has four main parts, and each covers different aspects of your healthcare. Understanding what each part does — and doesn't do — is the first step to building coverage that actually works for you.
Hospital Insurance
Covers inpatient hospital stays, skilled nursing facility care, hospice, and some home health services. Most people pay $0 premium for Part A if they or their spouse worked and paid Medicare taxes for at least 10 years.
Medical Insurance
Covers doctor visits, outpatient care, preventive services, and durable medical equipment. Most people pay the standard monthly premium (currently $174.70/month in 2024, income-adjusted for higher earners). You must sign up — it's not automatic.
Medicare Advantage
An alternative to Original Medicare offered by private insurers. Must include at least Part A & B benefits; most plans also include Part D drug coverage and extras like dental, vision, and hearing. Premiums range from $0 to $100+/month.
Prescription Drug Coverage
Standalone prescription drug plans that work alongside Original Medicare (or Medigap). Covers outpatient prescription drugs. Premiums, formularies, and pharmacies vary widely — choosing the wrong plan can cost hundreds per year.
Who Is Eligible for Medicare?
You may be eligible for Medicare based on age, disability, or a specific medical condition:
- Age 65+: You're eligible if you or your spouse have worked and paid Medicare taxes for at least 10 years (40 quarters). Most people qualify automatically.
- Under 65 with a disability: If you've been receiving Social Security Disability Insurance (SSDI) for 24 months, you automatically become eligible for Medicare.
- End-Stage Renal Disease (ESRD): Permanent kidney failure requiring dialysis or a transplant qualifies you for Medicare at any age.
- ALS (Lou Gehrig's Disease): Medicare coverage begins the same month you start receiving Social Security disability benefits — no 24-month wait.
Original Medicare vs. Medicare Advantage
One of the biggest decisions you'll make is whether to stay with Original Medicare (Parts A & B, plus optional Part D and Medigap) or enroll in a Medicare Advantage plan. Here's what you need to know:
Original Medicare
- Works at virtually any doctor or hospital in the U.S. that accepts Medicare (most do)
- No prior authorization requirements for most services
- No annual out-of-pocket maximum — exposure to unlimited costs without supplemental coverage
- You'll typically add a Medigap policy and Part D drug plan for complete protection
Medicare Advantage (Part C)
- Often $0 or low premium; frequently includes dental, vision, hearing, and fitness benefits
- Has an annual out-of-pocket maximum — your costs are capped
- Network-based: you typically must use in-network providers (HMO) or pay more for out-of-network (PPO)
- May require prior authorizations and referrals
- Plans vary significantly by county — quality matters more than brand name
Matthew's take: Neither choice is universally better. The right answer depends entirely on your health situation, your doctors, your medications, and how much flexibility you need. That's exactly what a consultation helps you figure out.
Medicare Enrollment Periods
Enrolling at the wrong time is one of the costliest mistakes Medicare beneficiaries make. Here are the periods that matter:
Initial Enrollment Period (IEP)
Your personal 7-month window: 3 months before the month you turn 65, the month of your birthday, and 3 months after. This is your primary opportunity to enroll without any penalty.
Special Enrollment Period (SEP)
If you're still working at 65 and have qualifying employer coverage, you can delay Medicare without penalty. Once that coverage ends, you have an 8-month SEP to enroll in Part B. This is the most commonly misunderstood period — talk to me before assuming you qualify.
General Enrollment Period (GEP)
January 1 – March 31 each year. If you missed your IEP and don't qualify for a SEP, this is your only option — but your coverage won't start until July 1, and you may face a late penalty.
Annual Open Enrollment (AEP)
October 15 – December 7 each year. Current Medicare beneficiaries can switch between Original Medicare and Medicare Advantage, change Part D plans, or change their Medicare Advantage plan. Changes take effect January 1.
Late Enrollment Penalties Are Permanent. If you miss your Initial Enrollment Period for Part B and don't qualify for a SEP, your monthly premium increases by 10% for every 12-month period you were eligible but didn't enroll — and that penalty lasts for life.
How Matthew Helps
The Medicare decision landscape is genuinely complex, and the consequences of getting it wrong — wrong plan, wrong timing, missed enrollment window — can follow you for years. Here's what a consultation with Matthew looks like:
- We review your current doctors and specialists to make sure any plan we're considering keeps your care intact
- We run your medications through each plan's formulary to find the lowest real-world cost
- We compare side-by-side every competitive plan in your county — not just the ones with the best marketing
- We time your enrollment correctly to avoid penalties and ensure seamless coverage transitions
- We handle all the paperwork for your enrollment
- We review your plan every year at Open Enrollment to make sure you're still on the best option
And the whole thing costs you nothing. Matthew is paid by the insurance carriers — not by you — so there's no financial reason for you to go it alone.