What Type of Insurance Covers a 68-Year-Old?

As individuals approach and move past age 65, navigating health insurance options becomes important. Understanding the available insurance landscape helps ensure access to necessary medical services and financial protection. For many, Medicare becomes the primary source of health benefits.

Medicare Eligibility and Enrollment

Medicare is a federal program with specific eligibility criteria. To qualify, a person must be a U.S. citizen or legal resident for at least five continuous years. Eligibility depends on having worked and paid Medicare taxes for a minimum of 10 years, or 40 quarters of covered employment. This work history grants eligibility for premium-free Part A coverage.

The Initial Enrollment Period (IEP) is a seven-month window around an individual’s 65th birthday for signing up for Medicare. This period begins three months before the birth month, includes the birth month, and extends for three months afterward. Enrolling during the IEP helps avoid potential late enrollment penalties for Part B, which can permanently increase premiums. If the IEP is missed, individuals may enroll during the General Enrollment Period (GEP), from January 1 to March 31 each year, with coverage starting the month after enrollment. Special Enrollment Periods (SEPs) exist for specific circumstances, such as losing employer-sponsored coverage, allowing enrollment outside these standard periods without penalty.

Understanding Medicare Coverage

Medicare is structured into different parts. Part A, known as Hospital Insurance, covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health services. Most beneficiaries do not pay a monthly premium for Part A because they or their spouse paid Medicare taxes through employment.

Part B, or Medical Insurance, covers medically necessary doctor services, outpatient care, home health services, durable medical equipment, and many preventive services. Unlike Part A, Part B requires a monthly premium for most beneficiaries. Parts A and B together form Original Medicare.

Part C, or Medicare Advantage, offers an alternative way to receive Medicare benefits through private insurance companies approved by Medicare. These plans must cover everything Original Medicare (Parts A and B) covers, but they often include additional benefits like dental, vision, hearing, and prescription drug coverage. Medicare Advantage plans operate with networks of doctors and hospitals, and they may require referrals for specialists.

Part D provides Prescription Drug Coverage, available through private insurance companies that contract with Medicare. These plans cover the costs of prescription medications and can be obtained as a standalone plan or as part of a Medicare Advantage plan (MA-PD). The specific drugs covered and their costs can vary between different Part D plans.

Managing Medicare Costs

Beneficiaries are responsible for various out-of-pocket costs. For 2025, the standard monthly premium for Medicare Part B is $185.00 for most individuals. Higher-income beneficiaries may pay an Income-Related Monthly Adjustment Amount (IRMAA), increasing their Part B premium.

Original Medicare includes deductibles, which are amounts paid before coverage begins. In 2025, the Medicare Part A inpatient hospital deductible is $1,676 per benefit period. For Part B, the annual deductible is $257. After meeting the deductible, coinsurance amounts apply, such as 20% of the Medicare-approved amount for most Part B services.

For longer hospital stays, Part A has daily coinsurance amounts, such as $419 per day for days 61-90 and $838 per day for lifetime reserve days in 2025. Skilled nursing facility stays also incur coinsurance, with $209.50 per day for days 21-100 in 2025. Medicare Advantage plans have a yearly limit on out-of-pocket costs for Part A and B services, which is $9,350 for in-network services in 2025.

Enhancing Your Medicare Coverage

Individuals seeking to enhance their Original Medicare coverage have two avenues: Medigap policies or Medicare Advantage plans. Medigap, also known as Medicare Supplement Insurance, is sold by private insurance companies to cover out-of-pocket costs like deductibles, copayments, and coinsurance that Original Medicare does not fully cover. A Medigap policy only covers one person, requiring separate policies for spouses.

Medigap policies are standardized by federal law, meaning each plan letter (e.g., Plan G, Plan N) offers the same basic benefits regardless of the insurance company selling it. Beneficiaries pay a separate monthly premium for their Medigap policy in addition to the Part B premium. Medigap plans allow individuals to see any doctor or hospital that accepts Medicare, without network restrictions or referrals.

Medicare Advantage (Part C) plans offer an all-in-one approach, bundling Part A, Part B, and often Part D prescription drug coverage. These plans provide additional benefits not covered by Original Medicare, such as routine dental, vision, hearing care, or fitness programs. While Medicare Advantage plans have their own network of providers and may require referrals, they feature lower monthly premiums than Original Medicare plus Medigap, sometimes even $0 beyond the Part B premium. The choice between Medigap and Medicare Advantage depends on individual healthcare needs, financial considerations, and preference for network flexibility.

Coordinating Medicare with Other Coverage

Medicare may not be the sole source of health insurance for some individuals, requiring coordination with other coverage. If an individual is still actively working or covered by a spouse’s employer-sponsored health plan, Medicare coordinates benefits with that plan. For large employers (20 or more employees), the employer’s plan pays primary, and Medicare pays secondary.

If an individual has COBRA coverage, which extends health benefits after leaving employment, Medicare’s role can vary. Medicare becomes the primary payer once an individual is eligible and enrolls, and COBRA then pays secondary. For those with TRICARE (healthcare for uniformed service members, retirees, and their families), Medicare becomes the primary payer for Part A and Part B services once the individual is Medicare-eligible and enrolled. Veterans’ benefits through the Department of Veterans Affairs (VA) operate independently; VA care is separate from Medicare, and individuals can use either benefit depending on their needs, though Medicare does not pay for VA-covered services.