Medicare | My Site

Medicare: Everything You Need to Know

Who is Eligible for Medicare?

You must be a U.S. citizen or legal resident.
You must be 65 years or older.
You must have worked and paid Medicare taxes for at least 10 years.
If you haven’t worked 10 years, you can still get Medicare but must pay a premium ($506/month in 2025 for Part A).

What do the different letters mean?

The first two letters were Original Medicare. The other two came later.

Understanding the Different Parts of Medicare

Part A: Hospital Insurance

Which covers

if you are admitted into the hospital for an overnight stay or longer.
Skilled nursing facility care (though please note: This is only if you have a ‘skilled need.’ Just being too feeble to live on your own any longer does NOT count. Dementia does NOT count
Limited Home health care
Hospice Care

They say part A is free. But…you will have deductibles and copays here which can be substantial.

Part B: Medical Insurance (Doctor Visits & More)

This includes emergency room visits
It includes X-rays, labs tests, some therapies
preventative services like cancer screens and vaccines. Though, in my experience, there is odd variation here. For example, if I get screening blood test for prostate cancer (PSA), it won’t be covered. Same for cholesterol, diabetes, etc. It’s only covered if I say you have a condition. If I write screening test they are NEVER covered. I have to say you have a problem with your cholesterol or your prostate with a code. Mammograms though are always covered.
Durable medical equipment like wheelchairs, CPAP would be covered here. But, not everything. Those motorized scooters so often advertised, electric hospital beds are NEVER covered. Yes, the companies say they are covered but they are lying!

And…Part B comes at a greater cost. In 2025,

If your average earnings are < $100 K then you pay about $175/ month
If more than $160K per year then you pay about $450 / month

Part C: Medicare Advantage Plans

This is complicated. Think of it this way.

Medicare calculates what you will cost them for Parts A and B. Let’s say $50,000 per year.

A company like Blue Cross thinks they can do it cheaper. Medicare says to Blue Cross, ok. I’ll give you $50,000 a year to manage Mr. Jones. At the end of the year, if Blue Cross does it for less money, they get to keep the difference. If it costs them more…then they must eat the extra fees.

To make a profit, they then HAVE TO LIMIT SERVICES. They will tell you which doctors to see, which hospitals you can go to. Which labs you can go to. They will deny things as much as possible. But the advantage to these “Advantage” plans is that they often include things that are not included with classic Medicare parts A and B such as: dental, vision, and prescription drugs.

And yes, you have to still pay things such as coinsurance, deductibles, copays.

Part D: Prescription Drug Coverage

This is technically not Medicare. Medicare contracts with different insurers to provide us with this part of our medical care. It’s supposed to cover generic as well as brand name drugs. But, as we all know, these brand name drugs are ridiculous in price. So, whoever you choose to cover you is fighting as hard as they can to not pay for drugs that we would like to have. Given the prices, it’s not surprising that we are all frustrated with the premiums of Part D plans.

Costs of Part D include:

Annual deductible up to $505
Monthly costs that vary from $10 to $150 depending on how much you earn
The dreaded donut hole. This is where the company will pay up to a total cost, say $10,000. Once you exceed this, then you must fit the ENTIRE bill for your medicines up until another random amount, say $14,000. Then, the company starts paying again. Practically, this can mean paying $500 initially as a deductible, then $50/ month as a monthly share of cost. Then, you hit the donut hole in perhaps September as your drugs cost a total of $1,200 per month. At this point, you must pay the next $4,000. Which means until the end of the year you are paying the entire $1,200 / month. Then, in January, you go back to your $50/ month. For so many, this means foregoing medicines near the end of the year as seniors can’t suddenly pay for that much extra per month.

Note: As of 2025, the donut hole is supposed to go away. They say that there will be an out of pocket maximum of $2,000 for prescription drugs. I find this hard to believe. But, we will see.

As for the donut hole, you may think this wouldn’t happen to you. Or you may wonder why this ridiculous idea came into practice. It’s because medicines cost FAR more than you think. A simple example. You have atrial fibrillation and diabetes. Let’s add on the skin condition psoriasis for good measure. Your doctor is cost conscious and has you on generics primarily but a few brand name drugs as well. This would be the cost as of 2025

Metformin for diabetes: $5/ month
Ozempic for diabetes: $1,200/ month
Atorvastatin for cholesterol: $5/month
Eliquis for atrial fibrillation: $700/ month

Recall that your company was budgeting $50,000/ year to take care of you. This list at $2,000/ month takes away half of that. And, you have yet to pay your doctor fee, your cardiologist fee, your hearing aids… and you are almost halfway there with medicines alone.

Oh, we almost forgot, you asked your doctor for that new drug you saw advertised for psoriasis on TV. Skyrizi you think it’s called. That’s $7,000 per month! Is it a surprise that your insurance company doesn’t think your skin rash is worth $84,000/ year?

I want to be clear. I’m not trying to make a political statement here. I just want you to realize that the stakes are high. There are reasons for you being denied specific treatments. It’s a good idea to find out how much your medicines actually cost BEFORE you try and figure out which plan is right for you. And though some plans may seem like a lot of money up front. They might actually save you a lot for medicines that you need to have that are just not covered by the cheaper plan.

Signing Up for Medicare: When and How?

The simple answer is at age 65. But, read on…

This is one of the strangest government rules I’ve ever heard. And yes, that means it truly makes no sense. Once you start on Medicare, the government is footing the bill for much of your health insurance. If, for whatever reason, you don’t sign up—which means you are saving Medicare money—then you will pay a penalty!

For Part A, the penalty is 10% per year that you don’t sign up. Worse, you pay this penalty until the day you die.

Example: If you were going to pay $400 per month for Part A, and you didn’t sign up until you were age 67. Then, you will have to pay $480 per month (an extra $80) forever.

For Part D (the drug coverage), you only have 63 days. After which you pay a very complicated formula extra…forever. It’s 1% X each month that you missed. So, if you similarly didn’t sign up until age 67 you would pay about 22 X 1% X the approximately $35/ month premium. Which means $40/ month instead.

How one gets out of this is by having full coverage through another means, say your employer who is paying for your health insurance. In this case, you wouldn’t be penalized when you finally transition to Medicare.

Random Questions

Can you switch back and forth between traditional Medicare and Medicare Advantage Plans (Part C)?

Yes, but only at specific times of the year. And, often one will want to add Medicare Part D if they are on simply traditional Medicare. Without Part D, you have no pharmaceutical coverage.

If I’m not on any medications, can I just not enroll in Part D and save the money?

Yes. BUT, once you are eligible and you don’t sign up, you will pay a lifetime penalty once you do. And, you may have to wait to get coverage started. Which means, if a sudden expensive drug is required for you, this may not be the wisest choice.

Hearing Aids, are they covered? A simple answer. NO. Not with traditional Medicare. And, they average around $5,000 for a pair.

Vision? Dental? Are these covered? NO. Not with traditional Medicare. I’m talking NOTHING. No teeth cleaning, fillings, extractions. No simple eye exams, contacts, glasses. Nothing at all.

Wheelchairs, CPAP machines? YES. Finally a yes. But, not for anything you want. You won’t get the best walker, the best wheelchair. And, there is that dreaded 20% copay. Let’s say you want a wheelchair. They will pay 80% of a $400 chair. You pay $80. But, if you want a nicer $1,000 chair, you’d have to pay the extra $600 difference as well. And yes, all of these things require authorizations/ paperwork from your doctors’ office. And remember beds…they just do NOT like to pay for.

HOSPICE? Yes, they pay for this service. Pretty much completely. The positive spin is that they want the end of someone’s life to not have the extra anxiety of a financial burden. The cynic would say it’s far cheaper to pay for someone who agrees not to use hospital services.

Important Medicare Limitations

This is a resounding YES. There are the obvious ones: Fertility drugs, Over the counter drugs, Vitamins.

The not as obvious, weight loss drugs. (No one likes to cover these as they are very expensive)

The Beers list of drugs. This is a list of drugs from the American Geriatric Society that are felt to cause ‘more harm than good.’ Examples on this list would be pain medicines, sleep medicines, anxiety medicines like Xanax and muscle relaxants like Flexeril.

This is a BIG frustration for me. I recommend you look on the internet for the Beers list. Bottom line, the drugs on this list routinely get denied. I can try and request, but they don’t always listen to my pleas. Particularly with pain medicines like Norco and Ambien. These are most often cash pay.

Speaking of MEDICATIONS. Another crazy rule is that every other insurer allows the drug manufacturer to give coupons, lower prices on their ridiculously expensive drugs. Medicare does NOT. If there’s a coupon from the drug company… Medicare does NOT allow you to use it. I’ve never heard of a good reason for this, but the best I get is that they want to encourage recipients to use generic drugs instead. So, if you are in the donut hole, or your drug is simply not covered and you want to pay cash, then you must pay the full price.

An example. If you are on Eliquis, you likely could get a coupon to pay a significant portion. The current deal I see on the internet is $10/ month for 24 months. If you have Medicare, you can’t use this. And the cost is about $700/ month. Practically, if you are 63 years old, you would have paid $10/ month for two years only to find it increase to $700/ month if Medicare refuses to cover the drug. IF it covers the drug, then you likely pay your “coinsurance” of 25% or about $175/month.

Unexpected Costs & Out-of-Pocket Expenses

Hospital Stays (Part A)

YOU pay a $1,600 deductible
The first 60 days are otherwise basically free
IF you are in past 60 days you pay $400/day from day 61 on.

If you do not get admitted, and are only in the ER, even if it’s more than a day, then it falls under Part B YOU pay 20%. A typical ER bill might be $6,000. You would then have to pay $1,200.

Emergency Room Visits (Part B)

Ambulance rides. These are tricky because someone decides if it was actually an emergency and that can make a big difference. You twist your ankle so badly you can’t walk. Painful, but unlikely going to be said to be an ‘emergency.’ As a result, you may have to pay the bill. The statement they use is, “If going by car or taxi could endanger your health.” A typical ambulance ride will be about $1,000

IF deemed an emergency, you pay 20% or $200
IF not felt to be an emergency, then you pay the entire $1,000

WHAT, THERE’S MORE??

Actually yes. And this may be the most important part. There actually is Insurance for your Insurance.

These policies are known as “Supplemental plans” or “Medi-Gap” policies.

Their goal is to cover the things that traditional Medicare Parts A and B do not pay for. Things such as

Copayments
Deductibles
Coinsurance (I know this is confusing. This comes after you have paid your deductible. Often Medicare will pay 80% of a particular bill. You are responsible for the other 20%. That 20% is known as coinsurance)

How much do these cost? Well, there are a lot of them, but often around $200 to $400 per month. Cheaper if you are willing to bear more of the costs. More expensive the older you are.

Why I say insurance for insurance. If you don’t use services—go to the doctor, hospital, get an operation, then you don’t get anything for what you are spending. But, you can definitely save for even simple things. An example, you go to the ER with chest pain. They do numerous tests and tell you don’t have a heart attack. The bill is $14,000. You would need to pay 20% of that bill or $2,800. OR you have one of these policies and you don’t pay anything at all.

FINAL RECOMMENDATIONS

A key difference to realize is that there are definite advantages to the two primary choices you have to make—Medicare Advantage Plans versus Medi-Gap policies. And clear disadvantages.

The Advantage plans are nice in that you get a bunch of ‘stuff’ Vision, Dental, Medicines that Medicare doesn’t pay for. BUT, the disadvantage is that you now belong to a group that is trying to limit how much is spent on you so they can pay their shareholders more money. Think United Health Care. You must go to the doctors they choose, the labs, the hospitals. In other words, you can’t have me as your physician.

Medi-Gap plans (or Supplemental plans) don’t typically include Vision and Dental. They aren’t cheap either. BUT…you can go to any doctor you wish (Myself, for example), you can choose your hospital and specialist and lab. You don’t get hit with unexpected bills even if you get sick (the insurance for your insurance idea).

Helpful Resources

Websites:

To get information specific for you, you can either hire a health broker. But the quickest, easiest way to get informed and find pricing specifically for you is to go the website for Medicare. The site is www.Medicare.gov
Another very helpful site for so many things including to help find a broker is: www.aging.ca.gov

Phone Numbers:

Call 1-800-510-2020 - This toll-free statewide telephone number links older Californians and their caregivers to information and assistance in their own area. Calls are automatically routed to the appropriate AAA.
Call 1-800-434-0222 - Health Insurance Counseling and Advocacy Program (HICAP) serves current Medicare beneficiaries and those planning for future health and long-term care needs. HICAP counseling is confidential and free of charge. Calls are automatically routed to the appropriate HICAP.