The ABC’s and 123’s of Medicare and Medicaid

Every year during October, our televisions, radios, and social media accounts light up with ads for Medicare’s Open Enrollment Period that runs from October 15 through December 7. 

For those turning 65, the initial enrollment period for Medicare takes place during the 7-month window around their 65^th birthday—the three months before, the birthday month, and the three months after.  However, if you enroll on the social security website three months before your birthday window, coverage will begin the first day of your birthday month. 

Determining Medicare coverage at age 65 is a significant event, as during the 6-month period beginning the month you turn 65, you can enroll in a Medigap plan with no medical underwriting.  Otherwise, in Florida, unless you have a specific life event (such as losing employer coverage) you cannot switch from a Medicare Advantage Plan to a Medigap plan without medical underwriting. 

There are many myths surrounding Medicare, and one of the biggest is that it covers the cost of long-term care.  It does not. Long-term care expenses are typically covered privately Those that need help paying for long-term care must turn to Medicaid.  Many Americans are eligible for both forms of federal health coverage, and the jumble of all the parts, words, and coverages becomes overwhelming.

Medicare versus Medicaid

Medicare is government-backed health insurance for people 65 or older, as well as some people under age 65 with certain disabilities that have paid into the social security system for at least 10 years.  In sum, Medicare is “short term” coverage for health events including hospitalization, doctor visits, therapy, home health care and preventative care, like the private insurance that most people carry through their employment. Original Medicare includes Part A and Part B, with prescription drug coverage under Part D.  Medicare Advantage Plans are listed under Part C.  Many people confuse Medicare and Medicaid; however, these are two vastly different forms of government health insurance.  Medicaid is a need-based state and federal program for which eligibility is determined by financial and medical standards which differ among the states. In addition to also covering what is covered by Medicare, certain types of Medicaid benefits cover “long-term” custodial health care including in a nursing home, assisted living facility, or at home.

Dually Eligible

Some individuals qualify for and receive both Medicare and Medicaid at the same time. People who have both Medicare and Medicaid are deemed “dually eligible.” When individuals are dually eligible, Medicare pays first for Medicare-covered services and Medicaid pays last, after Medicare and any other health insurance, as the payor of last resort pursuant to Florida law.

How do we pay for Medicare?

Medicare is tied to social security.  Most Social security recipients pay $202.90 (2026) for Medicare Part B, but higher earners prior to retirement pay up to $689.90 due to the Income-Related Monthly Adjustment Amount (IRMAA).  Medicare Part A is free for most people, but for those that did not earn at least 40 work credits, there is a surcharge of up to $565 per month.   

Different Parts of Medicare.

Part A (Hospital Insurance): Medicare Part A covers inpatient hospitalization, skilled care, such as rehabilitation in a skilled nursing facility, hospice care, and temporary home health care. A Medicare recipient can use any doctor or hospital that accepts Medicare in the United States.

Part B (Medical Insurance): Medicare Part B helps cover doctors’ visits, outpatient care, ambulance services, home health care, durable medical equipment, and preventative care such as vaccinations and wellness visits.

Part C (Medicare Advantage Plans): Part C Medicare Advantage plans are Medicare-approved plans from private companies that offer a less expensive alternative to Original Medicare for health and drug coverage. These plans usually bundle the services traditionally available under Part A, Part B and Part D. Although these plans may have lower or no monthly premiums, they require participants to use doctors and providers in their network and can limit healthcare access.  Some Advantage Plans also provide extra benefits such as fitness programs, vision, hearing, and dental services.  Once enrolled in an Advantage Plan, you are generally only permitted to make changes during open enrollment.

Part D (Drug Coverage): Medicare Part D helps cover the cost of prescription drugs. It is mandatory to select a Part D plan when you enroll for Original Medicare.

Medicare Supplemental Insurance (also known as Medigap): A Medicare Supplement is additional insurance coverage that a recipient of Original Medicare can purchase from a private company to assist in covering their share of cost such as copayments at doctor visits or coinsurance for inpatient rehabilitation in a skilled nursing facility.

Making Changes to Your Medicare Coverage

Life circumstances change. Each year during open enrollment it is important to review your coverage and decide if you need a change. In Florida, the SHINE program is a free, government resource to help participants pick the right plan.  SHINE is available through the local Area Agency on Aging.     

Now what? Do you want more information about the ins and outs of Medicare and Medicaid? Contact COHEN SAMUELS, PLLC for a complimentary intake at 561-600-1250.