Medicare in the US in 2025

1. What does Medicare cover in the USA, who is eligible, and what is included?

Medicare is available only to U.S. citizens who have paid taxes and reached the age of 65. If you do not meet the above criteria, please read this article. Many Medicare plans include coverage for dental treatment, and you can also purchase separate dental insurance. Medicare provides guaranteed protection for the elderly, covering their medical expenses and providing peace of mind!

2. What types of medical benefits for retirees can an employer offer?

If your employee has reached the age of 65 and continues to work for you, employers with fewer than 20 employees (according to the calculations under the Medicare Secondary Payer rules) may offer Medicare Advantage plans to their current employees and dependents. Larger companies cannot offer such plans. In many cases, this helps small businesses save on health insurance costs, as Medicare becomes the primary payer.

3. Does Medicare cover hospice services for aggressive cancer?

Medicare covers hospice services, and they are available in the case of aggressive cancer in the U.S. Medicare Part A provides coverage for hospice services.

4. Can migrants qualify for Medicare Part A coverage?

Most people who are U.S. citizens and have reached the age of 65 are already insured under Part A due to having paid taxes into Medicare while working. However, some may be insured by paying monthly premiums.

5. Can a person undergoing dialysis receive Medicare coverage in the USA?

You can enroll in Medicare at any time, but coverage usually begins in the sixth month after starting dialysis treatment.

6. Is there a penalty in the USA at the age of 68 if you did not enroll in Part B?

You will not have to pay a penalty if you have continuous coverage under a plan. This could be, for example, an employer’s group plan. People who have coverage based on their current employment are not subject to a late enrollment penalty. Medicare provides guaranteed protection for the elderly, covering their medical expenses and providing peace of mind!

7. What regulatory changes have occurred in Medigap plans in the USA since 2020?

As of January 1, 2020, Medigap plans sold to individuals newly eligible for Medicare can no longer cover the Part B deductible. If a person already had one of the plans before January 1, 2020, they may keep their plan. If a person was eligible for Medicare before January 1, 2020, but has not yet enrolled, they may purchase one of these plans.

8. What expenses might you face when enrolling in a standard prescription drug plan under Part D in the USA?

Your share of costs includes a monthly premium, an annual deductible, and cost-sharing for prescriptions.

9. How often do the features of Medicare Part D change, and should these changes be reviewed during the annual Medicare enrollment period?

Part D covers prescription drugs, and it is advisable to annually review your premiums, formulary, and cost-sharing, among other factors, to see if they have changed. Part D provides coverage for prescription drugs, and the premiums, plan formularies, and cost-sharing arrangements may vary from one plan year to another.

10. How can you maintain Medigap coverage and replace an existing plan if it does not cover prescription drugs?

You cannot purchase a Medigap plan that covers prescription drugs, but you can keep your Medigap policy and enroll in a Part D prescription drug plan. People enrolled in Medigap plans can only get prescription drug coverage through a separate Medicare Part D prescription drug plan.

11. What services are provided under Original Medicare in the USA?

People enrolled in Original Medicare do not have any cost-sharing for most preventive services. Those with Parts A and B of Original Medicare do not have any cost-sharing for most preventive services. Medicare provides guaranteed protection for the elderly, covering their medical expenses and providing peace of mind!

12. How can you get prescription drug coverage without being enrolled in a Medicare Advantage plan?

Prescription drug coverage is available to those who enroll in a separate Part D prescription drug plan and continue to receive coverage under Original Medicare Parts A and B. You can enroll in a separate prescription drug plan and continue to receive Part A and Part B coverage through Original Fee-for-Service Medicare.

13. What to do if your Original Medicare application for a particular range of services is denied?

You may appeal this initial determination within 120 days of receiving the MSN by mail.

14. Which of the following services in the USA will be covered by Original Medicare compared to retirement insurance?

Original Medicare may cover emergency services.

15. Does Medigap cover the benefits of Original Medicare in the USA?

Medigap plans do not cover personal participation and benefits from Original Medicare but are related to Original Medicare coverage.

16. Can you enroll in Medigap Plan F when you reach 65?

Unfortunately, Plan F is no longer available to people who turn 65 on or after January 1, 2020, and cannot purchase a Medigap plan that pays the Part B deductible. Typically, these are Plans C, F, or F with a high deductible. You can still purchase a Medigap plan that provides benefits for emergency travel abroad, such as Plan G.

17. What does an enrollment letter for Medicare Part B mean upon retirement in the USA?

Medicare Part B primarily covers physician services. You pay a monthly premium based on your income level and have 20% coinsurance, excluding preventive benefits.

18. What health expenses might you incur under Medicare if you need hospitalization due to illness in the USA?

Under Original Medicare, the copayment for inpatient hospital treatment is a fixed amount per day, which remains unchanged for the first 60 days of your hospital stay. After the 60th day, the amount gradually increases until the 90th day. After 90 days, you will pay the full amount of all expenses.

19. How to apply for insurance with a low fixed income in the USA?

You can apply for programs through your state’s Medicaid office, which can help with Medicare costs. These may include various Medicare savings programs and subsidies for low-income people under Part D and Medicaid.

20. Does Medicare cover glasses and dentures, or massage therapy?

Neither Part A nor Part B of Medicare covers massage therapy in general, dentures, or routine eye exams for glasses.

21. What does Original Medicare cover during rehabilitation in the USA?

Medicare covers skilled nursing care services, provided the person stays in the hospital for more than 3 days. For the first 20 days of stay, care will be fully covered, after which you will have to pay for up to 100 days.

22. How many days of psychiatric hospital stay does Medicare cover?

Medicare Part A provides coverage for inpatient psychiatric treatment for up to 190 days over a lifetime.

23. If a person already has Medicaid from their state, can they enroll in an MA Medical Savings Account (MSA) plan?

You cannot have an MA Medical Savings Account (MSA) if you already have Medicaid.

24. Can you get Part A in Medicare without being enrolled in Part B?

To be eligible for Part A, you must first enroll in Part B.

25. How do the benefits under Original Medicare compare with the benefits package of a Medicare Advantage plan?

Differences between the Original Medicare program and the Medicare Advantage program. Medicare Advantage is a way to receive all Original Medicare benefits through private health insurance companies. In contrast, Original Medicare, Parts A and B, is offered through private health insurance plans. Medicare Advantage plans may offer additional benefits not provided by Original Medicare, such as vision, hearing, and dental services. They must include a maximum out-of-pocket limit for Part A and Part B services.

26. What types of healthcare services under Medicare can an employer offer to an employee?

An employer with fewer than 20 employees can continue to offer William the same employee health insurance plan. Additionally, if the employee enrolls in Medicare Part B, the employer can enroll them in a Medicare Advantage plan that is available to the general public. In many cases, this helps small businesses save on healthcare costs as Medicare becomes the primary payer.

27. What is required to enroll in a private Medicare plan with fee-for-service (PFFS) in the USA?

You need to know if you are eligible for Part A, enrolled in Part B, and reside in the PFFS plan’s service area.

28. Can you enroll in a PFFS plan and a separate Medicare prescription drug plan simultaneously?

Yes, you can enroll in a PFFS plan and a separate Medicare prescription drug plan.

29. What should be done before enrolling in a Medicare Advantage Part C (Part C) plan?

To join a Medicare Advantage plan, you need to be enrolled in Part B.

30. How much can a doctor charge?

If the doctor does not have a contract with the ABC PFFS plan but accepts the plan’s terms and conditions for payment, it is allowed to charge this amount.

31. Can you enroll in Part C without being enrolled in Part B?

Eligibility to enroll in a Medicare Advantage plan requires eligibility for Part A benefits and enrollment in Part B.

32. Which plan is suitable for a person with a not very high income for purchasing prescription drugs?

You can enroll in an MA MSA plan and remain in your current separate prescription drug plan (Part D).

33. What to do if you lost group health and drug coverage from your employer and now want to enroll in a PPO?

You can enroll in a PPO, but you cannot purchase a separate Medicare Part D prescription drug plan.

34. Can you have two plans simultaneously in the USA, one that includes drug coverage and one that doesn’t in Medicare?

You can either enroll in one of the MA plans that includes prescription drug coverage or in Original Medicare with a Medigap plan and separate Part D prescription drug coverage, but you cannot enroll in a PPO plan for MA only and a separate prescription drug plan.

35. What to do if you are dissatisfied with the quality of medical care?

You can file a complaint with your plan to complain about the lack of timeliness in scheduling an appointment.
She could file a complaint with her plan to complain about the lack of timeliness in scheduling an appointment. Members or their representatives can file a complaint if they have issues with their healthcare services, such as timeliness, appropriateness, accessibility, or the setting of the provided medical service, procedure, or item.

36. What types of plans are available in the Medicare Advantage product?

There are Medicare health insurance plans such as HMO, PPO, PFFS (Private-Fee-for-Service), and MSA (Medicare Savings Account) and Special Needs Plans (SNP).

37. What should be done before enrolling in an MA-PD plan in Medicare?

The types of Medicare Advantage plans offered vary by employer. Therefore, you need to compare the benefits in your employer-sponsored group retiree health insurance plan with those in the MA-PD plan to determine which one provides sufficient drug coverage.

38. What to do if your plan did not cover the expected services?

Participants in Medicare Advantage (MA) plans have the right to appeal some decisions regarding the payment of medical services, service coverage, or prescription drug coverage.
You can file an appeal with your plan to review the coverage decision.
Medicare health insurance plans provide participants with a written description of the appeals process.

39. Is there any Medicare plan that could allow an elderly person requiring additional care to avoid going to a nursing home?

There are Programs of All-Inclusive Care for the Elderly (PACE) for seniors who are certified as needing nursing home level care but can safely live in the community at the time of enrollment. The programs include comprehensive systems for providing medical and social services using an interdisciplinary team approach in an adult day health center, supplemented by in-home services and referral services.

40. What do Medicare Savings Account (MSA) plans entail?

MSAs may have no network or a full or partial network of providers. MSA covers Part A and B benefits after the deductible. All out-of-network providers must accept the same payment amount that Original Medicare would pay them. This is the amount the plan participant will pay the provider before the deductible is paid.

41. How can you get prescription drug coverage in the USA under the Original Medicare program if you do not want to enroll in an MA product?

You can continue to participate in the Original Medicare program and enroll in a Medicare prescription drug plan through a private company that has contracted with the government to provide only such drug coverage to eligible Medicare beneficiaries.

42. Is a person eligible to enroll in a Medicare prescription drug plan without being enrolled in Part B?

If a person is eligible for Medicare Part A or is enrolled in Medicare Part B, they can enroll in a Medicare Part D prescription drug plan. Therefore, if a person is eligible for Part A, they do not need to enroll in Part B before enrolling in a prescription drug plan.

43. Can you find a Medicare Part D plan for generic prescription drugs?

Medicare prescription drug plans are required to cover drugs in each therapeutic category. You have the option to enroll in a Medicare prescription drug plan that covers the necessary drugs.

44. Can a person in the USA with limited income qualify for additional help with paying for prescription drugs under Part D?

Additional help is available to all people whose income and assets do not exceed the annual limits set by the government.

45. How can you avoid a late enrollment penalty for a Medicare prescription drug plan if you already have drug coverage from a former employer’s retirement plan and do not want to purchase additional coverage?

To avoid a late enrollment penalty, you must have “creditable” drug coverage. If you do not, you must enroll in a Medicare Part D plan during your initial eligibility period to avoid a late enrollment penalty.

46. What types of tools can Medicare Part D prescription drug plans use that affect a person’s access to medications?

Part D plans do not necessarily cover all drugs. As a result, their formularies or lists of covered drugs will vary from plan to plan. Additionally, they may use cost-containment methods such as tiered co-pays and step therapy.

47. How can you pay Medicare Part D monthly premiums through automatic withdrawals from a savings account and then have the premiums deducted from a Social Security check when the account funds are depleted?

Generally, a Part D participant must remain capable of paying premiums throughout the plan year.

48. Why do plans available in your area charge for co-pays, premiums, and cost-sharing?

Medicare Part D drug plans may have different benefit structures, but on average, they must be at least as good as the standard model set by the government. Some Part D plans may offer these additional benefits for an extra monthly fee.

49. What program helps manage prescription drug costs?

Part D participants can choose a Medicare prescription drug payment plan at the beginning of the plan year or at any time during the year.
Medicare prescription drug plans cannot cover prescription drugs like specialized multivitamins under Part D coverage, but plans may cover them as additional benefits.

50. How can you get a drug under Medicare that is not in your Part D plan’s formulary?

You have the right to request a formulary exception to get coverage for your drug under Part D. You or your doctor can obtain the standard request form from the plan’s website, fill it out, and submit it to your plan.

51. How can a Medicare Advantage participant get two lost prescriptions?

You can fill prescriptions for covered drugs at out-of-network pharmacies, but you will likely pay more than at an in-network pharmacy.

52. Who benefits from a Medicare prescription payment plan?

A person facing financial difficulties who needs expensive medications.

53. How can the Medicare Prescription Payment Plan help if you have trouble paying your share of prescription drug costs and do not want to change your current plan?

The Medicare Prescription Payment Plan helps spread out the participant’s cost-sharing payments, but it does not reduce the total amount owed.

54. How can you get extra help under the Medicare Part D prescription drug program if you are not eligible?

You can check with drug manufacturers to see if they offer an assistance program to help people with limited means get the medications they need. You could also check if your state has a pharmacy assistance program that can help cover the costs. Additionally, some states have assistance programs specifically for their residents. Some of these state programs are “qualified” and count toward TrOOP (True Out-Of-Pocket), while others do not.

55. What does the concept of Medicare TrOOP (True Out-Of-Pocket) mean in the USA?

TrOOP refers to the true out-of-pocket expenses that count toward the Medicare Part D catastrophic limit and include not only the amounts paid by the person but also, in some cases, amounts paid by qualified state pharmaceutical assistance programs or through them.

56. Can any other drugs not in the plan’s formulary count toward TrOOP (True Out-Of-Pocket) if you ever reach the Part D catastrophic limit?

No other drug expenses currently count toward the TrOOP (True Out-Of-Pocket) amount. If necessary, you may request your plan to make an exception to cover a prescription that is not in its formulary, which could then be counted toward TrOOP (True Out-Of-Pocket).

57. What should a person do if they want to retire and enroll in a Medicare Advantage plan after the age of 68?

To enroll in an MA or MA-PD plan, you must not only be eligible for Part A but also be enrolled in Part B. This will allow you to review your options and choose coverage comparable to your employer-sponsored group coverage. Those who waive employer-sponsored coverage to choose an MA or MA-PD plan have a Special Enrollment Period (SEP) that ends two months after the employer-sponsored coverage ends in June. If you want Part D coverage, you must enroll in an MA-PD or PDP (depending on how you decide to receive your Part A and B benefits) during this time.

58. What needs to be done to enroll in a Medicare Advantage (MA) plan?

You can enroll in an MA plan starting three months directly before your first eligibility for Medicare Part A and Part B. Therefore, you can enroll in an MA plan three months before your 65th birthday.

59. Can you change your plan during the enrollment process?

Yes, you can make as many changes to your enrollment as you wish during the Annual Election Period (AEP), but the last choice made before the end of AEP, as determined by the date the plan or marketing representative receives the completed enrollment form, will be the choice that takes effect.

60. Can you drop employer-sponsored retiree coverage and switch to Medicare?

You can drop your employer-sponsored coverage to choose a Medicare Advantage or Part D plan within 2 months of leaving it.

61. What can be done if a person is enrolled in a Medicare Advantage Prescription Drug (MA-PD) plan and moves out of the plan’s service area?

You are eligible for a Special Enrollment Period (SEP) that begins either the month before the move if the plan is notified in advance, or the month you notify the plan of the move, and this period typically lasts an additional two months.

62. How can you get prescription drug coverage under Medicare Part A and Part B benefits?

You can enroll in an MA-PD if, upon enrollment in Part B, you are also eligible for Part A.

63. What is a Special Enrollment Period (SEP)?

It is a period outside of the Annual Election Period when a Medicare beneficiary can choose a new or different Medicare Advantage or Part D prescription drug plan. A Special Enrollment Period usually occurs as a result of events such as when a beneficiary moves out of the service area.

64. Who is eligible for an SEP?

People with severe or disabling chronic conditions who wish to enroll in a Special Needs Plan (SNP) designed to serve people with their specific condition have an SEP during which they can enroll in the SNP designed to serve people with their condition. The SEP lasts as long as the person has the qualifying condition and ends when the person enrolls in a C-SNP.

65. What does eligibility for a Special Enrollment Period (SEP) mean?

It means that you have a one-time opportunity to enroll in an MA-PD or Part D prescription drug plan. During the SEP, you also have one opportunity to drop, add, or change your Part D coverage.

66. What should be done in case of loss of the document confirming eligibility for an SEP?

Under the Medicare Advantage (MA) SEP, people generally have one opportunity to change their MA coverage. Beneficiaries also have the opportunity to return to Original Medicare.