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Understanding Medicare: A Comprehensive Guide
- Michael Braden
- Apr 22
- 13 min read
Updated: 7 minutes ago
Breaking Down Medicare So It Makes Sense and Is Easy to Understand
I have been an independent, licensed Medicare Broker and Certified Medicare Planner for the past 11 years. Every day, I am honored to speak to people who need help understanding Medicare and where to start the process.
I often compare learning about Medicare to cleaning and organizing your garage. You have to know what you have so you can feel more confident about anything else you may need.
Ten Things Everyone Needs to Know About Medicare Right Off the Bat
Medicare is the National Health Insurance Program for all adults 65 and over, and others with full-time disabilities.
Medicare is NOT FREE. Most folks will never pay for Medicare Part A, which covers hospitalization. We paid for Medicare Part A through our Medicare and Social Security taxes during our working careers.
Medicare is not a health care provider; it’s a federal program. You’re responsible for making your own choices about how you want to receive your Medicare benefits. You can enroll in Original Medicare or Medicare Part C, also known as Medicare Advantage.
Each person has their own Medicare policy. There are no policies for couples. Even if you are married, you are entitled to have your policy under your name, with your own Medicare ID number, similar to your Social Security number.
Once you turn 65, you have three options for healthcare:
Stay with your employer's healthcare until you retire, as long as your employer has more than 20 employees.
If your employer has less than 20 employees, you must join Medicare.
You can enroll in an ACA/Obamacare plan, but they are often not cost-effective. Medicare has many options and a full range of solutions to choose from. We will cover those options later in this article.
Medicare has strict rules and penalties if you miss certain enrollment dates. This could cause you to pay more for coverage for the rest of your life, so please be aware of these dates to avoid being caught off-guard. The first date is your Initial Enrollment Period (IEP). The second deadline is once you are enrolled in Medicare Part B; you must enroll in a Medicare Part D Prescription Drug Plan within 63 days of your Medicare Part B effective date.
You are not legally obligated to enroll in Medicare, though most people do.
Everyone enrolls in Medicare through the Social Security Administration. Most people think they need to contact Medicare, which is true once you have your Medicare card. However, until you have your Medicare card, you need to apply for Medicare either using the Social Security website at www.ssa.gov or by calling your local SSA office to apply over the phone or in person by appointment.
If you are currently receiving Social Security benefits, you will be automatically enrolled in Medicare when you turn 65. There’s nothing for you to do, and you will receive your Medicare ID card in the mail. If you get stuck along the way, please reach out to me at mike@bradenmedicare.com, and I will be happy to help you.
Medicare always starts on the first day of the month in which you turn 65. If your birthday is on the 1st, then your Medicare will start on the 1st of the month preceding your birth month.
10. Some individuals determined by the IRS as “high wage earners” may need to pay a Medicare Part B and/or a Medicare Part D surcharge. Please refer to the IRMAA (Income-Related Monthly Adjustment Amount) chart below.
When to Sign Up for Medicare
Everyone approaching age 65 needs to become familiar with your IEP or Initial Enrollment Period. As the chart above shows, your IEP begins three months before your birth month and extends three months beyond your birth month.
During your IEP, you can enroll in Medicare. If you choose to receive your Medicare benefits through Original/Traditional Medicare, you can enroll in a Medicare Supplement or Medigap Plan without having to answer any medical questions. Your acceptance is guaranteed for any Medigap plan you choose. THIS IS A HUGE BENEFIT that needs to be considered by everyone.
If you or your spouse are still working but your employer has less than 20 employees, you MUST enroll in Medicare at age 65. If your employer has more than 20 employees, you can enroll in Medicare or stay on your employer’s plan. If you stay on your employer's plan, you will have eight months to enroll in Medicare without a penalty once you decide to retire.
If you are opting to stay on your employer's plan, please look closely at your deductible. If you have a deductible of $4,000 or more, it probably makes more sense to enroll in Medicare. The annual Medicare Part B deductible is just $283.
Many companies will reimburse their employees for their Medicare costs in exchange for opting out of their Group Health plan. This saves both you and your employer money. I recommend that everyone request a meeting with your Benefits Administrator or HR department three to six months before you turn 65 so you can understand all of your options. Employers pay $650 - $800 per month for each employee's healthcare costs. Original Medicare, with a Medigap Plan G and a Medicare Prescription Drug plan, is around $350, with a $240 deductible!
What If You Already Receive Health Benefits From the Government?
If you are a military retiree or spouse of a veteran insured with Tricare or Tricare For Life, you will need to enroll in Medicare. Why? Once you turn 65, Medicare becomes the primary payer. You must enroll in Medicare Part B to continue receiving all of your Tricare, Tricare for Life, or Champ VA benefits. Once you are enrolled in Medicare, Tricare and Champ VA become your secondary payer.
If you are a current or former federal employee insured under FEHB (Federal Employee Health Benefits), it’s a bit more complicated. FEHB beneficiaries are NOT required to enroll in Medicare at age 65, but those who qualify are encouraged to enroll in both Medicare and FEHB to help fill in the coverage gaps that are not covered by FEHB alone. If you are not sure what to do, please contact your FEHB benefits administrator or visit the FEHB plan information on their website at www.opm.gov.
Medicare Has 4 Parts
Three Options for Receiving Your Medicare Coverage
Option 1: Original Medicare
Medicare in its purest form is known as Original Medicare. It comprises Medicare Part A (In-Patient & Hospitalization Costs and Services) and Medicare Part B (all of your Outpatient costs and services such as doctors, office visits, labs, diagnostics, screenings, procedures, and durable medical equipment).
Original Medicare is a straightforward 80/20 health plan where Medicare pays 80% of all Medicare-approved (medically necessary) procedures, and you are responsible for your 20%. There is no deductible (aside from the annual $283.00 Part B deductible), no minimums, and no maximums. Plus, there is a $1,736 Part A deductible if you’re admitted to a hospital.
With Original Medicare, you can see any doctor and use any physician anywhere in the United States who accepts Medicare. When a doctor or hospital agrees to use Medicare’s service fee schedule, they agree to accept Medicare. This is also known as Medicare Assignment. Nearly 94% of all doctors in the US accept Medicare. The main group of doctors who do not accept Medicare are psychiatrists, psychologists, pediatricians, and homeopathic and naturopathic doctors because there are no networks.
Option 2: Original Medicare with a Medicare Supplement or Medigap Plan
A Medicare Supplement can pay for all of your 20% share of healthcare, depending on which Medicare Supplement Plan you choose. Plan G is the most popular and has the best value. In most states, a Medigap Plan G costs between $150-$200 per month, depending on where you live. This is still an 80/20 plan, but aside from your premium, you would only have to pay the annual Part B deductible of $283.00 out of pocket. Everything else, including the Part A deductible, will be paid by Medicare and your Medicare Supplement plan.
Altogether, the best estimate for the best coverage with no hidden costs would be around $320 per month. This includes absolutely everything, with no deductibles (aside from the $283 annual Part B deductible), no co-pays, and no co-insurance. You can see any doctor or receive services at any hospital in the United States. With a Medicare Supplement Plan G, your maximum annual out-of-pocket expense will be your Medicare Supplement/Medigap plan premium and the annual Part B deductible of $283. About 6 out of 10 people choose this plan, 3 out of 10 choose Medicare Supplement Plan N, and 1 out of 10 choose another Medicare Supplement plan.
Option 3: Medicare Advantage
A Medicare Advantage plan, often referred to as Medicare Part C, is offered by a private for-profit Medicare insurance company. These companies receive money from Medicare to take on the risks for your care (approximately $12,000 annually). Medicare Advantage plans are managed by private, for-profit healthcare insurers, and you are at their mercy when it comes to following their rules for care, service, prior authorizations, networks, etc.
You will either choose an HMO (Health Maintenance Organization) or a PPO (Preferred Provider Organization) plan. An HMO plan typically includes a Part D Prescription Drug Plan, but you will have to see their network of doctors and hospitals. This means you have little or no coverage outside of the county you live in, except for going to a hospital emergency room or an urgent care facility.
A Medicare Advantage PPO plan will have more options for doctors outside of the plan's network. However, some Medicare Advantage plans do not include any Part D benefits; the majority of these plans are designed for veterans who can use their VA prescription drug benefits.
The majority of MA (Medicare Advantage) HMO plans have a $0 premium. However, you will be responsible for any/all coinsurance and co-pays stated in your plan. These include doctor visits, referrals to see a specialist, and co-pays for MRIs, CT scans, and other imaging, which typically cost $300-$400. If you are hospitalized, you can expect to pay $300-$400 per night for up to seven nights.
A MA/PPO plan will range from $0 to $100 depending on where you live. There is an annual maximum that varies by plan; the national average for MOOP (Maximum Out-Of-Pocket) in 2026 is $5,700 in-network and up to $17,000 a year if you go out of network. Once you meet the MOOP amounts for a given year, your plan pays 100% of the charges for the remainder of that calendar year. This means that if you run into bad luck, you could pay out-of-pocket up to the amount of your maximum out-of-pocket expense every year.
Everyone who chooses Medicare Advantage must pick a new plan each year during the Medicare Annual Enrollment Period (AEP), which starts on October 15th and runs through December 7th each year. They can keep their current plan if it is still available, or they can choose a new plan that will start on January 1st.
Medicare Advantage plans offer many extra benefits that Original Medicare cannot offer, such as routine dental, routine vision, routine hearing benefits, and gym memberships. However, these benefits are less and less each year. They are typically divided into four quarters. So, a $1,000 dental benefit is usually only $250 per quarter, and you do not get to roll over what you do not use. Additionally, when it comes to dental, things like root canals, implants, dentures, crowns, and bridges are not included. Anyone considering a MA plan needs to review the full Summary of Benefits (SOB) and their Evidence of Coverage (EOC) for all of the fine print and details of any plan they might be considering.
A Bit of Advice on How to Choose the Right Medicare Plan for You
Health insurance is important, and after age 65, it becomes critical. It’s also a very personal decision. If you are single, involve your children in the discussions and ask them for their opinions. After all, chances are they will need to understand what sort of coverage you have at some point in the future.
Please do not listen to your neighbor, your friends on Facebook, or the woman who does your nails or hair. For the love of Pete, do not blindly do what anyone suggests when it comes to your healthcare. I always recommend that everyone researches things on their own, and then call 2-3 local independent Medicare brokers.
Interview them, see if you “click” with them, and then work with the one you feel best about. Medicare brokers will never charge you a dime.
Here Are a Few Great Questions to Ask the Brokers You Interview
Ask them how long they have been a broker.
Ask them how many insurance companies they represent.
Clarify to ensure that they offer Medicare Supplements/Medigap plans, Medicare Advantage Plans, and Medicare Part C/Medicare Advantage plans.
Ask them for their website address. If they are a reputable broker, they will have a full-fledged website, not just a “landing page.”
Their email address should be a part of their website. See my business card below.
My website is www.bradenmedicare.com, and my email address is mike@bradenmedicare.com.
Ask them if they are a member of the Better Business Bureau and if so, what their rating is.
Ask them how many clients they have.
Ask them how they can provide service to you for the rest of your life.
10. Ask them why they decided to become a Medicare broker in the first place. The answer they give you will tell you a lot about them.
Medicare Part D Prescription Drug Plans
Part D (D for Drugs) is a part of Medicare that is optional. However, it will cost you if you do not enroll in Part D when you first can. The Medicare Part D Late Enrollment Penalty costs about $0.37 a month, but this penalty is forever; it never goes away. So, let's say you have no prescriptions and decide not to enroll in a Part D Prescription Drug Plan for three years. Your penalty would be $0.37 x 36 or $13.32 per month. This means you will have to pay an additional $13.32 in premium each month in addition to your regular Part D premium forever! This is why most Medicare beneficiaries choose the lowest-cost plan from the beginning, as it just makes the most financial sense.
It is helpful to have a list of any/all prescription medications you may be taking, including the dosage and the quantity (1x or 2 times daily). We will use that list along with your most preferred pharmacy when we compare Medicare Part D Prescription Drug Plans. Make sure you include your favorite pharmacy to use, whether it is Costco, Rite-Aid, Walgreens, CVS, Walmart, or most grocery stores with a pharmacy. Amazon Pharmacy may also be used. You can also receive 90-day supplies using your plan's mail-order pharmacy!
Part D Plans can be changed every year. I recommend doing a Part D review at least every other year. Anytime you change plans, you will choose your new plan during the Annual Enrollment Period (AEP) from October 15th through December 7th. If you choose a new plan, your new plan will begin on January 1st.
The average cost of a Medicare Part D PDP (Medicare Prescription Drug Plan) depends on the plan you choose and the medications you are prescribed. The lowest-cost plan is ideal for no medications or for someone with 1-3 generic prescriptions. The plans range from $0 - $169 per month.
Many retirees have no medications, so they enroll in the lowest Medicare Part D plan available in their area to avoid the Medicare Part D penalty. They can change plans each year if their prescriptions change. The rule is that you need to enroll in a Medicare Part D Prescription Drug Plan within 63 days of your Medicare Part B effective date.
5 Things That Original Medicare Does Not Cover
A Few Other Things That Are Typically Not Covered by Medicare
Naturopathic doctors and homeopathic doctors are not covered.
Most psychiatrists and psychologists do not accept Medicare assignments.
Medicare does not cover Botox injections.
Caregivers are not covered under Medicare.
Grab bars are typically not covered under Medicare but may be covered under your long-term care policy.
Gym Memberships
Most Medicare Advantage plans include gym memberships, but most Medigap plans do not. Some Medicare Supplement Plans offered by AARP/UHC, ANTHEM, BCBS, HUMANA, and WELLPOINT can include gym memberships. Other Medigap plans from ALLSTATE, CIGNA, and MUTUAL OF OMAHA offer gym memberships for around $35 per month.
Where Medicare Advantage Plans Are Not Accepted
In Arizona, Barrow Neurological Center, The Mayo Clinic, and Mayo Hospital accept Original Medicare. They also accept Medicare Supplement and Medigap plans. But they DO NOT ACCEPT Medicare Advantage plans.
Many cancer treatment centers and hospitals only accept a few Medicare Advantage plans. Typically, there are not enough good skilled nursing facilities in most Medicare Advantage networks. Most non-Medicare Advantage skilled nursing facilities (rehabilitation and post-surgery rehabilitation) do not accept Medicare Advantage plans.
Reasons to Like Original Medicare More Than Medicare Advantage Plans
You can see any doctor anywhere in the US that accepts Medicare.
You can go to any hospital in America for services.
Perfect if you have homes in different states.
If you like to be in control of your healthcare and not someone else.
If you like having predictable costs.
Peace of mind knowing everything is covered except for the $283 each year for the Part B deductible.
You do not want your kids to have a hard time helping you or understanding your healthcare.
If you itemize your deductions, all of your premiums and costs are tax-deductible!
Virtually no co-pays or co-insurance if you have a Medigap plan.
Once you pick Original Medicare and your Medicare Supplement, you are done. You can always compare premiums for your Medigap plan, but you never have to choose a new plan unless you want to change your Medicare Part D Prescription Drug plan. But with Medicare Advantage plans, you have to choose a new plan every year.
Reasons to Like Medicare Advantage Plans Over Original Medicare
Low or $0 premiums, but higher and never-ending co-pays and co-insurance until you meet your MOOP.
More ancillary benefits than Original Medicare.
You do not mind working with networks.
You like having a primary care doctor.
Some plans have Medicare Part B give-backs.
Some plans offer allowances for pet supplies, food, and OTC supplies, but these are all limited amounts.
Free meals typically refer to meals for 1-2 weeks at home after an extended hospital stay.
Some plans offer transportation to doctor appointments for a preset number of one-way rides to doctor appointments.
Medicare Part D Covers Vaccines
Medicare and Medicare Advantage plans cover the following vaccinations for FREE, as long as you go to any “preferred pharmacy” for your Part D Prescription Plan.
Influenza (Flu Shot)
RSV
Shingrix (Shingles)
Covid Boosters
Hepatitis B
Pneumonia
Medicare Part B covers Prolia and Evenity.
Medicare Advantage plans charge a 20% co-insurance for all cancer treatments, including chemotherapy and radiation. With Original Medicare, cancer treatments are covered 100% if you have Original Medicare and a Medicare Supplement Plan A, C, D, F, G, M, or N.
Preventative Screenings That Are Covered by Medicare
Wrapping Things Up
Thank you for reading this article, "Breaking Down Medicare So It Makes Sense." I hope you found this blog helpful, informative, and an easy-to-follow read that left you much more confident in what Medicare is and what your options are for enrolling in a Medicare plan that fits your unique needs.
If you still have questions or would like any additional information or just have a few questions, please feel free to contact me directly anytime. It will be my pleasure to assist you in any way I can.
