Medicare Basics for Agents [Free Resources]

We have an Annual Training series for Life & Health Insurance Agents to help you get prepared for an amazing year! This is a recap of Part 1: Medicare Basics & Enrollment Periods.

Watch the full training and get the resources here.

What is Medicare?

Medicare is a national social insurance program providing health insurance to individuals aged 65+ and certain younger individuals with disabilities. Simply put, Medicare is for folks 65 and up, those that are disabled for at least 24 months, and those with End Stage Renal Disease.

There are two governing bodies for Medicare: Centers for Medicare & Medicaid Services (CMS) & Social Security Administration (SSA). CMS regulates Medicare Part C and D plans. SSA handles Medicare enrollment and Part B premium details.

Over 65 million Americans depend on Medicare to cover their health care expenses!

Enrollment Periods

There are a few different enrollment periods throughout the year for different Medicare products. For folks turning 65, there is an Initial Enrollment Period (IEP) that begins 3 months before turning 65 and ending 3 months after the month the person turns 65. The IEP is for Original Medicare and Medicare Advantage.

You can download the full enrollment period diagram here!

Parts of Medicare

Medicare Part A & B Overview

Part A covers inpatient hospitalization, skilled nursing, home health, and hospice. This is funded by FICA taxes and most beneficiaries pay no premium if they worked 40+ quarters.

Part B covers doctor visits, outpatient procedures, lab tests, and durable medical equipment. There is an annual Part B deductible for beneficiaries. Medicare covers 80% of costs and the beneficiary pays 20% after the deductible is met. There are higher premiums for high-income earners.

You can view the 2025 Part A & B premiums and deductibles here.

Original Medicare Exclusions

Medicare Parts A & B (also known as Original Medicare) do not cover everything. Some services like long-term care, routine dental, vision, hearing services, hearing aids, or cosmetic surgery.

Medicare Insurance Options

There are some options to help folks cover the costs that Original Medicare does not cover. There are Medicare Supplement Insurance plans and Medicare Advantage Insurance plans.

Medicare Supplement Insurance Plans

Medicare Supplement Insurance, also known as Medigap policies, help cover the gaps left behind by Original Medicare Part A & Part B. Medigap will pay for copayments, coinsurance and deductibles.

Additionally, people with Original Medicare Part A & Part B see a benefit when purchasing a Medigap policy to supplement their Medicare benefits. Medigap policies will not work with Medicare Advantage plans. The enrollee must switch back to Original Medicare Part A & Part B to have a Medigap policy. Furthermore, an employer or union may pay for additional insurance that a Medicare policy does not cover.

Medicare Supplement policies F, G, K, L, M and N offer a variety of benefits. While the benefits of each policy with the same letter designation are the same, some companies charge more than others.

Medicare Advantage Insurance Plans

A Medicare Advantage plan is a private health insurance plan approved by Medicare. Members get their care from a network of doctors and hospitals. Folks may opt to get their Part A, B and D benefits from a Medicare Advantage plan instead of traditional Medicare. These Medicare private insurance plans usually have an HMO or PPO network of doctors.

Explaining Medicare Advantage

Medicare Advantage is required to offer the same coverage as Original Medicare Part A & Part B. By joining one of these plans, it directs Medicare to pay the Advantage plan a set monthly amount for the beneficiary's care. In return, the plan will deliver all the beneficiary's Part A & Part B services.

The beneficiary must continue to pay their Medicare Part B premium while enrolled in an Advantage plan. They must be enrolled in both Medicare Parts A and B and live in the plan’s service area. Medicare Advantage plans are NOT Medigap policies. They work differently because they pay instead of Medicare, not after Medicare.

Medicare Part D plans

Medicare Part D Prescription Drug plans is insurance for medication needs. The beneficiary will pay a monthly premium to an insurance carrier, then use the insurance carrier’s network of pharmacies to purchase their prescription medications. Instead of paying full price, they will pay a copay or percentage of the drug’s cost.

Beneficiaries can enroll in a standalone Part D prescription drug plan that goes alongside Original Medicare benefits, or they can choose a Part D drug plan that is built in to a Part C Medicare Advantage plan.

Plan N

Premiums for Plan N are lower than Plans G & F and it generally has lower rate increases year over year. There is a co-pay when the policyholder sees a doctor. After the Part B deductible is met, the co-pay is up to $20. There is a $50 co-pay for an emergency room visit. The fee is waived if the policyholder is admitted to the hospital.

There is potential for Part B excess charges that are not covered. These charges can be easily avoided if the policyholder goes to a provider that takes "Medicare assignment".

Resources to Prepare

We have some resources to help you apply this knowledge and to help you explain these concepts to your clients! You can download the materials here!