When it comes to Medicare, facts matter. No opinions, no embellishments, just clear, accurate information. Even “facts” can be misinterpreted or misused, leading to costly mistakes. The challenge is knowing which details you can rely on, and which ones may be misleading.

As you approach Medicare eligibility, verifying the details and applying careful analysis is essential. This article will help to clear up some common myths so you can avoid costly mistakes.

Medicare Enrollment

“I must enroll in Medicare when I turn 65.”

You can delay enrolling in Medicare Part A and Part B indefinitely and without penalty after 65, provided you are covered by a qualified employer group health plan, from an employer with 20+ employees, through either your or your spouse’s employment.

“I’ll be automatically enrolled in Medicare when I start collecting Social Security Retirement Benefits.”

You are only automatically enrolled in Medicare Part A and Part B, at age 65, if you are receiving Social Security retirement benefits. If you are automatically enrolled but you are covered by a qualified employer group health plan, you must take action to defer Part B. There is an associated premium, so you must pay attention to the fine print.

Those collecting Social Security Disability Income (SSDI) for twenty four months are automatically enrolled in Medicare Part A and Part B, regardless of age.

Takeaway: Understand Medicare’s enrollment rules to avoid signing up too early, and paying unnecessary premiums, or too late, (and incurring penalties and be mindful that Social Security can take up to sixty days to process Medicare applications.

Medicare Costs

“I am entitled to premium-free Medicare Part A because I am a U.S. citizen.”

To qualify for premium-free Part A, you must have paid FICA taxes for at least forty quarters (about ten years). If you do not have sufficient quarters paid in, you may qualify for premium-free Part A through your spouse’s work history if you have been married for at least one year. If divorced, the marriage must have lasted at least ten years to claim spousal Medicare benefits. Without enough work credits, you will have to pay a Part A premium amount determined by your work history.

Enrollment rules are different if you are enrolling under a current or former spouse’s work history. Call Social Security in advance to discuss the process and the documentation that is required.

“Everyone pays the same amount for Medicare Part B.”

The standard Part B premium in 2025 is $185 per month. However, higher earners pay more, an Income-Related Monthly Adjustment Amount (IRMAA). If your modified adjusted gross income exceeds $106,000 (single filer) or $212,000 (married filing jointly) two years prior, you will pay an additional surcharge.

The IRMAA amounts and the thresholds can change every year. Data is released by Centers for Medicare and Medicaid Services (CMS) during the Medicare Annual Open Enrollment Season that begins October 15.

Takeaway: Know the full scope of Medicare costs, including how income impacts premiums, to better plan financially for retirement.

Medicare Prescription Drug Coverage

“I don’t need a Medicare Part D drug plan if I don’t use prescription drugs.”

Once Medicare Part A and B become effective and you no longer have access to “creditable” prescription drug coverage, you must enroll in a Part D plan within 63 days or face a lifetime late enrollment penalty (LEP). In other words, if you skip Part D because you do not need medications, you could pay steep costs and penalties later if your needs change.

“Once I enroll in a Medicare Supplement/Medigap and Part D plan or a Medicare Advantage Plan (MAP), I’m done.”

Medicare Supplement/Medigap plans, Part D plans or Medicare Advantage plans may not remain the ideal option year after year. While most Medicare Supplement/Medigap plans are stable, Medicare Advantage plans and Part D drug plans can change premiums, formularies, and coverage rules annually. Plans may also leave the market.

Takeaway: Stay alert during Medicare Open Enrollment (October 15–December 7). Review any notices from your insurer and be prepared to adjust your coverage as needed to meet your needs and to avoid unexpected expenses.

Medicare Advantage Plans

“Medicare Advantage plans (MAPs) offer better benefits and lower costs.”

Medicare Advantage Plans (Part C) may offer low premiums and extra benefits like dental, vision, and hearing. However, they function as managed care plans (HMO or PPO) and come with networks, referral and prior authorization requirements, tightly managed lengths of stay in hospital and other inpatient facilities, and the potential for significant out-of-pocket costs. If you travel frequently or have complex medical needs, restrictions can become problematic.

“Most healthcare providers accept Medicare Advantage Plans.”

Not all providers accept all Medicare Advantage plans. HMO members typically must use in-network doctors and obtain referrals, while PPO members have more flexibility but pay more for out-of-network care. If you have an unexpected medical event resulting in increased utilization of medical services, your out-of-pocket costs can escalate rapidly.

Takeaway: When choosing a Medicare Advantage Plan, do not focus solely on low cost premiums. Understand the limitations on provider access and potential future restrictions that may come with lower premiums. Remember, outside of your initial enrollment window, switching to a Medicare Supplement plan may require medical underwriting (except in three states: Massachusetts, Connecticut, and New York). Pre-existing conditions could also affect your options and your cost.

More Than “Just the Facts”

Preparing for Medicare should be a major component of retirement planning. But Medicare is complex, full of nuances, exceptions, and frequent changes. For many people, long-held beliefs about Medicare may not align with their actual experience.

After losing access to employer-subsidized insurance, many retirees are surprised by the actual cost of healthcare, as well as the restrictions they may face depending on which plans they choose.

Although Medicare would not come into existence until some 55 years after his death, Mark Twain certainly understood our human tendency to rely on what we think we know when he wrote, “The trouble with the world is not that people know too little; it’s that they know so many things that just aren’t so. “

---

Dianne Savastano is Founder and Principal and Diane Reily is a Health Insurer Advisor at Healthassist, a private healthcare advisory firm with a practice devoted to helping those with complex medical issues navigate the healthcare system. The firm also specializes in providing health insurance advisory services to those seeking guidance with private health insurance or Medicare matters.