Frequently asked questions about Medicare

Medicare is the U.S. federal health-insurance program, created in 1965. It helps cover medical costs for people 65 and older, and also for younger people with SSDI or specific conditions (ESRD, ALS).

Medicare has four parts: A (hospital), B (doctor visits), C (Medicare Advantage), and D (drugs). Full breakdown on What is Medicare?.

Three main groups:

• People 65 or older, legally residing in the U.S. for at least 5 years.
• People under 65 who have received SSDI (Social Security Disability Insurance) for 24+ months.
• People diagnosed with end-stage renal disease (ESRD) or ALS, regardless of age.

To get Part A free, 40 quarters of U.S. work history (about 10 years) is typically required. Fewer quarters means Medicare is still available, but at higher cost.

Two different programs:

• Medicare. Federal health insurance, based mainly on age (65+) or disability. Income-independent.
• Medicaid. A federal-state program for low-income people, regardless of age. Run separately by each state (Illinois, Florida, Colorado, Arizona each have their own version).

Some people qualify for both at once, called dual eligible. Special enrollment periods and dedicated D-SNP plans apply. Call us if your parent qualifies for both.

Not entirely. Part A is free for most beneficiaries with 40 quarters of work history. Part B has a monthly premium set yearly by CMS, income-adjusted for higher earners. Medicare Advantage, Medigap, and Part D are private plans with their own premiums, varying by plan, location, and situation.

On top of monthly premiums, there are costs when care is used: deductibles, copays, and coinsurance.

Medicare charges late-enrollment penalties for Part B and Part D (and Part A, if it has a premium):

• Part B. 10% of the monthly premium added for every 12 months of delay, for life.
• Part D. 1% of the national base premium for every month over 63 days without creditable coverage, for life.
• Part A (if it has a premium). 10% added for double the number of years delayed.

Penalties are permanent and added to the monthly premium for the rest of your parent's life. They can be avoided by enrolling on time or maintaining creditable coverage, equivalent insurance from another source.

The most important window is the Initial Enrollment Period (IEP), a seven-month window around your parent's 65th birthday (3 months before, the birthday month, and 3 months after).

Other windows: AEP (Annual Election Period, October 15 to December 7), MA-OEP (January 1 to March 31, only for people already on Medicare Advantage), and SEP (Special Election Periods) for qualifying life events.

Full breakdown on the Enrolling in Medicare page.

Depends on the Medicare part:

• Part B. Without comparable coverage, a lifetime penalty of 10% per 12 months delayed. The next enrollment window (GEP) is January 1 to March 31, with coverage starting July 1.
• Part D. 1% of base premium for every month delayed beyond 63 days without creditable coverage, for life.
• Medigap. Loss of the six-month guaranteed-issue window. After that, carriers can refuse the policy or raise the price.

That's why on-time enrollment matters. If a window has already passed, call us. Often we can still minimize the damage.

Depends on the situation. In most cases, changes happen only during specific windows:

• AEP (October 15 to December 7): full plan changes, taking effect January 1.
• MA-OEP (January 1 to March 31): one-time change for people already on Medicare Advantage.
• SEP: for specific life events (move, loss of coverage, getting Medicaid, plan termination, 5-star plan, etc.).

If a situation might qualify for SEP, call us. We'll confirm whether a change window applies.

Yes. If your parent (or their spouse) is still working with group coverage, they can have both. Which one pays first depends on the size of the employer (20+ employees or fewer).

In most cases, Part B can be delayed without penalty, provided the employer coverage is creditable. After losing employer coverage, a Special Enrollment Period (SEP) opens, usually 8 months, for penalty-free Part B enrollment.

This is a common spot for expensive mistakes. Call us before delaying any part of Medicare. We'll verify whether the employer coverage is actually creditable and which windows apply.

No. Medicare is individual. Each person qualifies separately, based on their own age, own work history, and own situation.

However, with 40 quarters of U.S. work history, a spouse may qualify for Part A free at 65 based on the working spouse's earnings (a "spousal benefit").

No. Medicare alone (Parts A and B) covers a very limited range of drugs, mostly those given in a doctor's office or hospital. Most daily prescriptions require a separate Part D plan (Prescription Drug Plan).

Every Part D plan has its own formulary (list of covered drugs) and its own pricing tiers. The same drug can be $0 in one plan and $80 in another. That's why picking a Part D plan starts with the actual drug list, not with the monthly premium.

Details on the Part D page, including the $2,100 annual out-of-pocket cap.

The cap is updated yearly by CMS per the federal Inflation Reduction Act.

In a limited way. Medicare covers skilled nursing facility stays after a qualifying hospital admission, up to 100 days, with higher costs after day 20. That's rehabilitative care, not long-term.

Medicare does not cover permanent, long-term residency in a nursing home (custodial care), or in-home help with activities of daily living when there's no medical reason. Those situations need separate products: Long-Term Care Insurance, certain hybrid policies, or Medicaid (for people who meet income criteria).

Call us. This is a common gap in retirement planning, worth understanding early.

Generally no. Medicare covers care only within the U.S. and its territories. A few narrow exceptions exist (e.g., emergencies in Canada en route to Alaska), but for trips to Poland Medicare doesn't apply.

Some Medigap plans (C, D, F, G, M, N) include emergency care outside the U.S., usually covering 80% with a $50,000 lifetime cap and $250 deductible. Not a full travel-insurance product, but better than nothing.

For longer trips abroad, a standalone travel-medical policy is worth considering. We can suggest options.

No. It's a choice: either Medicare Advantage, or Original Medicare + Medigap. Holding both at once is not permitted under CMS rules: one policy will be canceled, and the agent who set up the combination could face regulatory consequences.

If your parent has Medicare Advantage and wants to switch to Medigap, they must first drop Advantage during a valid window, and then enroll in Medigap (and meet the conditions for guaranteed issue). The sequence and timing matter. Call us to avoid a coverage gap.

Yes. The fastest way is through Social Security: ssa.gov. They'll need to create a my Social Security account and fill out the form online, usually 10–15 minutes.

The online application covers Parts A and B. To enroll in Part D (drugs) or a Medicare Advantage plan, a separate enrollment is needed, usually through an agent or directly with the carrier. We help with both steps in Polish. Just call us and we'll walk through the whole process.

No. Medicare isn't mandatory, but there are important exceptions. People already collecting Social Security benefits are automatically enrolled in Parts A and B in the month they turn 65.

People still working with comparable employer coverage (usually at companies with 20+ employees) can delay Part B without penalty. Otherwise, delaying enrollment triggers a lifetime penalty, 10% of the monthly premium for every 12 months delayed. The right decision depends on the situation; we help analyze it.

With comparable employer coverage, Part B can be delayed without penalty. When that coverage ends (retirement, layoff, hours reduction), a Special Enrollment Period (SEP) opens for 8 months.

In that window, your parent can enroll in Part B and add a Part D plan or Medicare Advantage plan without a late-enrollment penalty. We recommend not waiting until the last month. Enrollment takes several weeks, and gaps in coverage are costly.

Three paths after a missed IEP:

1. Special Enrollment Period (SEP), if your parent had comparable employer coverage, losing it opens an SEP for penalty-free enrollment.

2. General Enrollment Period (GEP), January 1 through March 31 every year, with coverage starting July 1. After GEP, a lifetime penalty usually applies.

3. After a qualifying life event, moving, change in insurance status, etc., may open an SEP. Call us, we'll figure out which path applies.

Three options:

Online: fastest, at ssa.gov/medicare. Requires a my Social Security account. Decision typically arrives in 2–4 weeks.

By phone: 1-800-772-1213 (TTY 1-800-325-0778), Mon–Fri 8 AM–7 PM ET. Sometimes long waits.

In person: at a local Social Security office. Appointment required. Bring: photo ID, proof of citizenship or permanent residency, and bank account info for automatic Part B premium payments.

TPMO (Third-Party Marketing Organization) is a CMS term for firms or individuals promoting Medicare Advantage or Part D plans without being the insurance carrier. Independent insurance agencies like Medicare po Polsku are TPMOs.

CMS requires TPMOs to clearly state that they are not the government, are not Medicare, and don't offer every plan available in a beneficiary's area. That's why the disclosure appears on every page of our site. It's not a formality. It's a regulatory consumer-protection requirement.

The full list of plans in any area can be checked at Medicare.gov or by calling 1-800-MEDICARE.