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How Does Medicare Actually Work?


Decoding the complexities of Medicare can be daunting, but understanding how it works is crucial for seniors. From coverage details to enrollment tips, this article will guide you through what Medicare does and doesn’t cover and explore practical advice for choosing the right plan that aligns with your health care needs.

Get ready to demystify Medicare and make informed decisions to ensure you receive the health care coverage you deserve.
Medicare Health


Medicare is a health insurance program the United States federal government provides for individuals aged 65 and older. Medicare enables older adults and certain younger individuals with dire medical conditions to access essential health care. The program helps cover a range of medical expenses, including hospital care (Medicare Part A), medical services like doctor visits and outpatient care (Medicare Part B), prescription drugs (Medicare Part D), and additional coverage options through Medicare Advantage plans (Part C). Remember, Original Medicare consists of Parts A and B, while Parts C and D offer expanded coverage.

It's critical to note that Medicare isn’t free, and its coverage has limits. For example, you’ll pay premiums for some portions of Medicare (such as B and D), deductibles, and out-of-pocket expenses for some types of care. Furthermore, you’ll have to pay the entire cost of care that Medicare doesn’t cover, such as long-term care and routine dental care. In addition, each part addresses a distinct array of medical services, as outlined below.


Original Medicare has two parts: A and B. Each covers specific types of health care. Here’s a breakdown of coverage for each part.

Part A Covers: 

  • Hospital/inpatient care
  • Skilled nursing-facility care
  • Nursing-home care (distinct from long-term care)
  • Home health care
  • Hospice care 


Part B Covers:

  • Ambulance services
  • Durable Medical Equipment (DME), such as blood sugar meters, oxygen equipment, and walkers
  • Clinical trials
  • Mental health care
  • Preventive care

Visiting Doctor

While Medicare provides substantial coverage for various health care services, some items and services are not covered or have limited coverage. Here are some examples:

  • Long-term care, such as custodial care in a nursing home, assisted-living facilities, or extensive in-home care
  • Basic dental services, including routine checkups, cleanings, fillings, and dentures
  • Routine eye exams, eyeglasses, or contact lenses
  • Hearing exams and hearing aids
  • Cosmetic procedures
  • Acupuncture
  • Prescription drugs
  • Foreign health care, with a few exceptions for specific situations, such as emergencies in certain bordering countries

Remember, while Medicare may not cover certain services, individuals can obtain coverage through private insurance plans such as Medicare Advantage (also called Medicare Part C) or supplemental insurance policies (Medigap plans). Therefore, it's advisable to review specific coverage details and consult with Medicare or insurance providers to fully understand what is covered under the various Medicare plans.


American citizens and permanent residents turning 65 qualify for Medicare if they have lived in the U.S. for at least five years and have paid 40 quarters of Medicare payroll taxes. In addition, the spouse of a person fitting these circumstances is also eligible.

You can also receive Medicare if you're under 65 and on Social Security Disability benefits for at least two years. Lastly, those under 65 with a disability from the Railroad Retirement Board or diagnosed with End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS) are eligible.
Visiting Doctor

When preparing to enroll in Medicare, consider the following tips to make informed decisions and choose the right coverage for your needs:

  1. Explore Medicare Plans in Your Area. Visit Medicare and enter your ZIP code to view the available Medicare plans in your location. Doing so will give you an overview of your options.
  2. Assess Star Ratings. Take advantage of the star-ratings system provided by the Centers for Medicare and Medicaid Services (CMS). These ratings evaluate the quality and performance of Medicare plans, offering insights into each plan's level of coverage and care.
  3. Consider Your Health Needs. Beyond meeting the eligibility requirements, consider your specific health needs and goals when researching potential Medicare plans. Evaluate factors such as prescription drug coverage, access to preferred health care providers, and coverage for needed services.
  4. Review Costs and Coverage. Compare the costs and coverage details of different Medicare plans, including premiums, deductibles, copayments, and out-of-pocket limits, to determine which plan aligns with your budget and health care requirements.
  5. Understand Enrollment Periods. Familiarize yourself with Medicare's enrollment periods to ensure you enroll on time. For example, the Initial Enrollment Period (IEP) is the seven-month window around your 65th birthday. This is when you can sign up for Medicare without penalty.
  6. Seek Assistance from Experts. If you need guidance in selecting a plan or want more information about specific options, consult a local broker or community adviser specializing in Medicare.
  7. Don't Rush the Decision. Take your time to evaluate your options and gather all the necessary information before deciding. Researching and understanding the details of different Medicare plans will help you make an informed choice.