Making Sense of Medicare: Understanding Your Benefits and Planning Ahead
Courtney M. Buechler, Esq., MPH | Attorney, Elder Law and Estate Planning
Christina Herold | Paralegal, Elder Law and Estate Planning
Medicare is the federal health insurance program for people age 65 and older and for certain younger people with disabilities. When it launched in 1966, Medicare consisted of two parts: Part A (Hospital Insurance) and Part B (Supplementary Medical Insurance). Together, Part A and Part B are known today as “Original Medicare.”
Since then, Medicare has grown into a collection of different parts, coverage choices, enrollment rules, and costs. The choices you make affect what you pay, which doctors you can see, and how well your coverage fits with your long-term care and estate plans. Understanding the basic structure can make the decisions ahead feel much more manageable.
Who Is Eligible for Medicare?
Medicare is available to people age 65 and older who meet the applicable eligibility requirements. People under 65 may qualify because of certain disabilities, End-Stage Renal Disease (ESRD), or amyotrophic lateral sclerosis (ALS).
What Are the Parts of Medicare?
Medicare has four parts, plus optional supplemental coverage called Medigap.
- Part A (Hospital Insurance) helps cover inpatient hospital care, skilled nursing facility care, hospice care, and certain home healthcare. Coverage depends on medical need, and some services have time limits, such as skilled care.
- Part B (Medical Insurance) covers doctor visits, outpatient procedures, diagnostic tests, and durable medical equipment. It also covers many preventive services, including screenings, vaccinations, and an annual wellness visit, to help detect health conditions early and manage ongoing health needs.
- Part D provides prescription drug coverage through private insurance plans. Pennsylvania residents with limited income may qualify for state programs such as the Pharmaceutical Assistance Contract for the Elderly (PACE) or PACENET.
- Part C (Medicare Advantage) is an alternative way to receive Medicare benefits through a Medicare-approved private health plan. These plans provide coverage through plan-specific provider networks and may include features such as coordinated care, prescription drug coverage, and rules for accessing certain services.
- Medigap (Medicare Supplement Insurance) helps cover certain out-of-pocket costs that Original Medicare does not pay, such as deductibles, copayments, and coinsurance. Medigap plans are sold by private insurance companies and only work alongside Original Medicare to help reduce the cost of covered medical services.
For official plan details and current costs, visit Medicare.gov.
When Should I Enroll in Medicare?
Most people should enroll during the seven-month Initial Enrollment Period, which begins three months before the month you turn 65 and ends three months after. Delaying enrollment can make sense in some situations, such as when you are still covered by an employer plan. However, delaying enrollment will incur late-enrollment penalties and may even result in coverage gaps.
Open Enrollment, October 15–December 7, is an opportunity to enroll in Medicare if eligible or review and change your existing coverage. Read how to compare plans during Open Enrollment.
How Do I Choose the Right Medicare Coverage?
Medicare planning is not simply a matter of signing up at 65. The right coverage depends on your individual circumstances, your healthcare needs, and your budget. Some questions to get you started include:
- What Medicare coverage do you already have?
- Do you have any health coverage outside of Medicare, including coverage through an employer or another source?
- What doctors, specialists, and medications do you use?
- How much can you afford to spend on medical coverage?
- What is the likelihood you may eventually need long-term care?
Keep in mind that Original Medicare does not cover routine dental care, hearing aids, routine eye examinations for glasses, or long-term custodial care. Paying for long-term care usually requires planning outside of Medicare, including understanding complicated Medicaid rules most families do not learn about until they need them.
Cost is a deciding factor for many people. Plans with little to no monthly premium may be appealing, but it is critical to look carefully at network restrictions, prior authorization requirements, and out-of-pocket costs to make sure your choice does not limit your access to quality care.
How Can an Elder Law Attorney Help with Medicare Planning?
Medicare has many moving parts, but you do not have to figure it out on your own. An experienced elder law attorney can help you understand your options, identify issues that are easy to overlook, and discuss strategies to help fit your long-term care and estate planning goals.
CGA’s elder law attorneys can help. We serve clients from offices in York, East Berlin, Hanover, Red Lion, Gettysburg, and Lancaster.
To schedule a consultation, call (717) 848-4900 or contact us online.
Courtney M. Buechler, Esq., MPH, is a CGA attorney who advises clients on elder law, estate planning, and estate administration. She holds a J.D. from Penn State Dickinson Law and a Master of Public Health. She is licensed in Pennsylvania and Maryland and serves clients from CGA’s York, East Berlin, Hanover, and Red Lion offices.
Christina Herold is a CGA paralegal with over 25 years of experience supporting clients in PA, NJ, NY, and FL. She holds an Associate of Applied Science degree in Paralegal Studies and assists clients with estate planning, estate administration, and elder law across all CGA locations.
