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What to know about Medicare before enrolling

By The Health News Team | April 30, 2024
Couple on couch discussing paperwork

The only thing that may seem more daunting than enrolling in Medicare is understanding its ins and outs. There are many details to learn and decisions to be made. And everyone has a different story or opinion about their experience.

Medicare is a health care program for people turning 65, retiring or on disability for two or more years. It's accepted throughout the U.S. and its properties, such as Samoa and Guam, and most doctors, hospitals and health care organizations accept it.

How Medicare works

Medicare is a fee-for-service plan that’s managed by the federal government. It covers 80% of Medicare-approved services, and the beneficiary, or person who has Medicare, is responsible for the remaining 20%. You can discover which services are approved and what payment amount is approved for that service on the Medicare website.

Medicare beneficiaries pay a deductible — an amount you pay out-of-pocket — once each year before Medicare covers any services.

There are two primary parts of Original Medicare, Part A and Part B:

  • Part A of Original Medicare covers services in the hospital and services ordered by hospital doctors. If you’ve worked and contributed to payroll taxes for 10 years or 40 quarters, there is no monthly premium due. If you haven’t, Medicare will establish a payment plan for you.

  • Part B of Original Medicare covers doctor’s visits and services ordered by your doctor. There is a monthly premium for Part B that is based on your modified adjusted gross income (MAGI) as reported on your IRS tax return two years prior. Your MAGI is your adjusted gross income (AGI) — your total income with eligible deductions — with some deductions added back in. The Part B premium is calculated each year and Medicare notifies beneficiaries each fall what the premium will be at the beginning of the next year. If you don’t enroll in Medicare Part B within the given time frame, a monthly Part B late enrollment penalty is charged to the beneficiary.

What’s not covered?

There are some health needs not covered by Original Medicare. This includes prescription drug coverage, also known as Medicare Part D. If you do not enroll in a Medicare-approved prescription drug plan when you first get Medicare, Medicare assesses a monthly Part D penalty. Dental coverage, vision care, hearing services and worldwide emergency coverage are also not covered by Original Medicare.

However, there are ways to enhance Medicare benefits to receive complete health care. These include:

  • Medicare Advantage plans, also known as Medicare Part C. There are several types of Medicare Advantage plans, including HMOs, PPOs and special needs plans. These plans offer an all-in-one alternative to Original Medicare and include additional services Original Medicare does not cover. Many Medicare Advantage plans also include fitness benefits.

  • Medicare supplement insurance policies, also known as Medigap, are added to Original Medicare and loosely follow a PPO health care model. You can see any doctor that accepts Original Medicare, and no referral is needed. Supplement plans do not include prescription drug coverage. To avoid the Part D drug penalty, you are encouraged to purchase a stand-alone prescription drug plan.

Both Medicare Advantage plans and Medicare supplement insurance are offered by private companies, such as Sharp Health Plan. At Sharp HealthCare facilities, Original Medicare, all Medicare supplement plans and Medicare Advantage plans offered by Sharp Health Plan and United Healthcare are accepted.

You can find guidance through the Medicare experience by visiting Sharp’s Medicare classes and events page to enroll to speak with an English- or Spanish-speaking specialist or to register to attend a live or virtual webinar. also offers information, resources and a tool to find and compare different types of Medicare providers.

Learn more about Medicare health insurance at Sharp HealthCare; get the latest health and wellness news, trends and patient stories from Sharp Health News; and subscribe to our weekly newsletter by clicking the "Sign up" link below.

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