How Medicare Actually Works For South Carolina Residents

What Medicare Is and Who Pays for It

Medicare is a federal health insurance program run by the Centers for Medicare & Medicaid Services (CMS). It is not means-tested — you do not have to prove low income to join. Instead, you become may be able to access based on age, disability status, or end-stage renal disease, regardless of how much money you have.

Most people become may be able to access at age 65. If you worked and paid Medicare taxes (the 1.45% that comes out of your paycheck), you and your spouse can join without paying a monthly premium for the hospital insurance part. If you did not work long enough to earn that benefit, you can still join at 65, but you will pay a monthly premium. South Carolina residents join the same national program as everyone else — there is no separate state version.

Medicare is funded by payroll taxes, general federal revenue, and premiums paid by people enrolled in the program. It is not a savings account where your taxes sit waiting for you; it is a pay-as-you-go system where current workers' taxes pay for current retirees' care.

Key Takeaways

• Medicare has four parts: Part A covers hospital stays, Part B covers doctor visits and outpatient care, Part D covers prescription drugs, and Part C (Medicare Advantage) is an alternative to A and B offered by private insurers.
• You must sign up during your initial enrollment period (usually the three months before and after your 65th birthday) or pay a permanent penalty on your premiums.
• Original Medicare (Parts A and B) has no network — you can see any doctor or hospital that accepts Medicare — but you pay a deductible and coinsurance for each service.
• Medicare Advantage plans (Part C) have networks and lower out-of-pocket costs but require you to use in-network providers except in emergencies.
• South Carolina has a State Health Insurance Assistance Program (SHIP) that offers free one-on-one counseling to help you understand your options and enroll.

The Four Parts of Medicare and What Each Covers

Part A covers inpatient hospital care, skilled nursing facility care after a hospital stay, hospice, and home health services. If you worked long enough and paid Medicare taxes, Part A is free at 65. You pay a deductible per hospital stay (the amount changes each year) and coinsurance if you stay longer than 60 days. Part A does not cover long-term custodial care in a nursing home or assisted living.

Part B covers doctor visits, outpatient surgery, diagnostic tests, durable medical equipment, and preventive care like screenings and vaccines. Part B costs a monthly premium (the amount depends on your income) and requires you to pay a yearly deductible and then 20% coinsurance for most services. You can see any doctor or hospital in the country that accepts Medicare; there is no network.

Part D covers prescription drugs. It is offered by private insurers under contract with Medicare. You choose a plan during enrollment, and the premium, deductible, and which drugs are covered vary by plan. If you do not join a Part D plan when you first become may be able to access and you do not have other creditable drug coverage, you will pay a permanent penalty if you join later.

Part C, also called Medicare Advantage, is an alternative to Original Medicare (Parts A and B). Private insurers offer these plans, and they must cover everything Original Medicare covers, but they do it through a network. Most Medicare Advantage plans include Part D drug coverage and may offer dental, vision, or hearing benefits that Original Medicare does not. The trade-off is that you usually must use in-network providers and may face higher out-of-pocket costs if you need a lot of care.

Original Medicare Versus Medicare Advantage: Which Route to Choose

The choice between Original Medicare and Medicare Advantage depends on your health, your doctors, and how much out-of-pocket cost you can handle. Original Medicare gives you freedom to see any doctor or specialist without a referral, but you pay a deductible and coinsurance for each service. If you have a chronic condition and see many doctors, those costs add up. If you are healthy and see a doctor rarely, your out-of-pocket costs may be lower.

Medicare Advantage plans cap your out-of-pocket costs each year, which can protect you if you need expensive care. However, you must use in-network doctors and hospitals (except in emergencies), and you may need a referral to see a specialist. If your current doctors do not accept the plan's network, switching to that plan means finding new doctors. Plans also change their networks and coverage each year, so a plan that worked well one year may not the next.

Many South Carolina residents use Original Medicare with a supplemental insurance policy (called Medigap) to cover the deductibles and coinsurance that Original Medicare does not pay. Medigap plans are sold by private insurers and have their own premiums, but they work alongside Original Medicare to reduce your out-of-pocket costs. Medicare Advantage and Medigap cannot be used together.

When and How to Enroll in Medicare

Your Initial Enrollment Period is the seven-month window that includes the three months before your 65th birthday, the month you turn 65, and the three months after. If you enroll during this window, your coverage starts on the first day of the month you turn 65 (or the month after, depending on when you sign up). If you miss this window, you can still enroll, but your coverage will start later and you may owe a permanent penalty on your Part B and Part D premiums.

You can enroll online at Medicare.gov, by phone at 1-800-MEDICARE, or in person at your local Social Security office. If you are still working and have health insurance through your employer, you may be able to delay enrolling in Part B without penalty, but you must enroll in Part A and notify Medicare that you are still working. The rules are complex, so ask before you miss the deadline.

Every year, there is an Annual Enrollment Period from October 15 to December 7. During this time, you can switch from Original Medicare to Medicare Advantage, from Medicare Advantage to Original Medicare, or change your Part D drug plan. Changes take effect January 1. If you miss the Annual Enrollment Period and do not have a may have access to life event (like moving, losing other coverage, or getting married), you cannot change plans until the next October.

Costs You Will Pay: Premiums, Deductibles, and Coinsurance

Medicare costs vary depending on which parts you choose and which plan you select. Part A is free for most people at 65. Part B has a monthly premium that increases if your income is above a certain threshold; in 2024, the standard premium is $164.90 per month, but higher-income beneficiaries pay more. Part D premiums vary by plan and range from roughly $7 to $100+ per month. Medicare Advantage premiums also vary by plan and insurer.

Original Medicare has an annual Part B deductible (currently $240) that you pay once per year before Medicare starts paying its share. After you meet the deductible, you pay 20% coinsurance for most services. Part A has a deductible per hospital stay (currently $1,556) and coinsurance if you stay longer than 60 days. These dollar amounts change each year.

Part D has a deductible (varies by plan, currently up to $505), then you pay a percentage of drug costs until you reach a coverage gap called the "donut hole." Once you and your plan have spent a certain amount out-of-pocket, catastrophic coverage kicks in and you pay a small copay for the rest of the year. The exact costs depend on which drugs you take and which plan you choose.

Medicare Advantage plans have a yearly out-of-pocket maximum, which means once you have paid that amount in copays and coinsurance, the plan pays 100% of covered services for the rest of the year. Original Medicare has no out-of-pocket maximum, which is why many people add Medigap coverage.

How to Find Doctors and Hospitals That Accept Medicare

If you have Original Medicare, you can see any doctor, specialist, or hospital that accepts Medicare. You do not need to choose a primary care doctor or get referrals. To find providers, use the Medicare Provider Search tool at Medicare.gov or call 1-800-MEDICARE. You can also call your doctor's office directly and ask if they accept Medicare.

If you choose a Medicare Advantage plan, you must use the plan's network of doctors and hospitals, except in emergencies. Each plan publishes a provider directory that lists which doctors and hospitals are in the network. Before you enroll in a Medicare Advantage plan, check whether your current doctors are in the network. If they are not, you will need to find new doctors or choose a different plan.

Some doctors and hospitals do not accept Medicare at all. These are rare, but they exist. If a provider does not accept Medicare, you will have to pay the full cost out of pocket; Medicare will not reimburse you. Always confirm that a provider accepts Medicare before you schedule an appointment.

Free Help Understanding Medicare in South Carolina

South Carolina's State Health Insurance Assistance Program (SHIP), called Healthy Connections SHIP, offers free one-on-one counseling to help you understand your Medicare options and enroll. SHIP counselors are trained volunteers and staff who work for the state, not for any insurance company. They can explain the difference between Original Medicare and Medicare Advantage, help you compare plans, and walk you through enrollment.

You can reach Healthy Connections SHIP by phone at 1-800-868-9095 or visit their website to find a local counselor. They also offer group workshops in many communities. There is no cost for this service, and the counselors have no incentive to steer you toward any particular plan.

You can also call 1-800-MEDICARE (1-800-633-4227) to speak with a representative who can answer questions about enrollment, costs, and coverage. This is a federal line, not specific to South Carolina, but the representatives can help you understand how Medicare works.

What Medicare Does Not Cover

Medicare does not cover long-term custodial care in a nursing home or assisted living facility. It covers skilled nursing care for a limited time after a hospital stay, but not ongoing personal care. If you need long-term care, you will need to pay out of pocket, use Medicaid (if you may have access to), or have a long-term care insurance policy.

Medicare also does not cover routine dental care, eye exams for glasses or contacts, hearing aids, or most routine foot care. Some Medicare Advantage plans include dental and vision benefits, but Original Medicare does not. If you need these services, you can buy separate dental and vision insurance, or pay out of pocket.

Experimental treatments and some elective procedures are not covered. Medicare covers treatments that are deemed medically necessary and supported by evidence. If your doctor recommends a treatment that Medicare does not cover, ask your doctor why and whether there is a covered alternative.

Frequently Asked Questions

Do I have to enroll in Medicare at 65 if I am still working?

If you are still working and have health insurance through your employer, you can delay enrolling in Part B without penalty. However, you must still enroll in Part A at 65. Tell Medicare that you are still working so they do not charge you a penalty. Once you stop working or lose your employer coverage, you have eight months to enroll in Part B without penalty.

Can I change my mind after I enroll in a Medicare Advantage plan?

Yes, but only during the Annual Enrollment Period (October 15 to December 7) or if you have a may have access to life event like moving out of the plan's service area. If you enroll in a Medicare Advantage plan and then decide you want Original Medicare instead, you must wait until the next Annual Enrollment Period unless you have a may have access to event.

What happens if I do not enroll in Part D when I first become may be able to access?

If you do not join a Part D plan when you first become may be able to access and you do not have other creditable drug coverage, you will pay a permanent penalty on your Part D premium for as long as you have Medicare. The penalty is 1% of the national average Part D premium for each month you were not enrolled. It is better to enroll even if you do not take many drugs.

Can I use my Medicare in other states or when I travel?

Yes, Original Medicare works anywhere in the United States and some U.S. territories. If you have a Medicare Advantage plan, you can use it in-network in any state, but out-of-network coverage may be limited. If you travel outside the United States, Original Medicare does not cover care, but some Medicare Advantage plans and Medigap policies offer limited coverage abroad.

How do I report fraud or problems with my Medicare coverage?

If you see charges on your Medicare bill that you do not recognize, or if a provider refuses to accept Medicare, call 1-800-MEDICARE to report it. You can also file a complaint with the Centers for Medicare & Medicaid Services online at Medicare.gov. Keep copies of your bills and any correspondence with providers.