The Parts of Medicare
Everything in one place — how the parts work, what things cost in 2026, when to enroll, and how Social Security fits alongside it.
The Parts of Medicare
Medicare has four parts. Each covers something different, and which ones you need depends on how you want your coverage put together.
The Four Parts of Medicare
Often called "hospital insurance," Part A covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care services.
Premium-Free for Most
If you or your spouse paid Medicare taxes for at least 10 years (40 quarters), you don't pay a premium for Part A.
What Part A Covers:
- Hospital stays: Inpatient care, semi-private rooms, meals, general nursing
- Skilled nursing: Up to 100 days per benefit period, after a 3-day hospital stay (days 1-20 covered in full; days 21-100 require copayment)
- Hospice care: Pain relief, symptom management, support services
- Home health care: Part-time or intermittent skilled care
2026 Costs
• Deductible: $1,736 per benefit period
• Days 1-60: $0 coinsurance
• Days 61-90: $434/day coinsurance
• Beyond 90 days: $868/day (60 lifetime reserve days)
Part B covers medically necessary services like doctors' visits, outpatient care, preventive services, and durable medical equipment.
2026 Monthly Premium
$202.90
Standard amount (higher for incomes above $109,000)
What Part B Covers:
- Doctor services: Office visits, consultations, second opinions
- Outpatient care: Emergency room, observation, outpatient surgery
- Preventive services: Screenings, vaccines, annual wellness visits
- Medical equipment: Wheelchairs, walkers, hospital beds
- Ambulance: When other transportation endangers health
- Mental health: Outpatient therapy and counseling
2026 Costs
• Annual Deductible: $283
• Coinsurance: 20% of Medicare-approved amount
• No out-of-pocket maximum
Medicare Advantage is an all-in-one alternative to Original Medicare offered by private insurance companies approved by Medicare.
What's Included
Medicare Advantage plans must cover everything Original Medicare covers (Parts A & B), but they can do it with different rules, costs, and restrictions.
Typical Benefits Include:
- All Part A and Part B benefits
- Part D prescription drug coverage (most plans)
- Dental, vision, and hearing benefits
- Fitness programs (gym memberships, SilverSneakers)
- Out-of-pocket maximum protection
- Over-the-counter (OTC) allowances
Important Restrictions
Most Medicare Advantage plans require you to use network providers and may require referrals to see specialists. Coverage can vary by location.
Plan Types: HMO, PPO, PFFS, SNP, MSA
Still pay: Part B premium + plan premium (if any)
Part D helps cover the cost of prescription medications. It's optional, but if you skip it and don't have other drug coverage, the penalty you pick up never goes away.
Late Enrollment Penalty
If you go 63 days without creditable drug coverage after becoming eligible, you'll pay a penalty calculated as 1% of the national base premium ($38.99 in 2026) × number of months without coverage.
This penalty lasts as long as you have Part D!
How Part D Works:
Key Considerations:
- Each plan has its own formulary (list of covered drugs)
- Different pharmacy networks offer different costs
- Formularies can change yearly
Worth knowing
Even if you don't take any medications now, consider enrolling during your Initial Enrollment Period to avoid penalties. You can always choose a low-premium plan.
How to Choose a Part D Plan
- Make a list of all your current medications (names and dosages)
- Check which plans cover YOUR specific drugs
- Compare total costs (premium + copays for your meds)
- Check if your preferred pharmacy is in-network
- Review coverage for each drug tier
How the Parts Work Together
Original Medicare Route:
Part A (Hospital) + Part B (Medical) + Part D (Drugs) + Medigap (Optional gap coverage)
Medicare Advantage Route:
Part C (Includes A, B, usually D) + Extra benefits like dental, vision, hearing
Important: You cannot have both Medigap and Medicare Advantage at the same time.
Common Questions
Part A covers hospital stays, skilled nursing facility care, hospice, and home health services. Part B covers doctor visits, preventive services, medical equipment, and lab tests. Original Medicare does not cover routine dental, vision, hearing aids, or long-term nursing care. Part D, sold separately, covers prescription drugs through private insurers.
Medicare Part D provides prescription drug coverage through private insurers. In 2026, deductibles range from $0 to $615, with a $2,100 annual out-of-pocket maximum. Going 63+ days without creditable drug coverage after your Initial Enrollment Period results in a permanent penalty of 1% of the national base premium per uncovered month added to your premium for life.
Medicare Advantage vs Original Medicare
One of the biggest decisions you'll make is choosing between Original Medicare and Medicare Advantage. Both provide Medicare benefits, but they work very differently.
Quick Comparison
Original Medicare (A + B)
- • See any Medicare provider
- • No network restrictions
- • No referrals needed
- • Consistent nationwide
- • Need separate Part D
Medicare Advantage (Part C)
- • All-in-one plan (A+B+usually D)
- • Extra benefits (dental, vision)
- • Out-of-pocket maximum
- • Must use network providers
- • Plans vary by location
✓ Advantages:
- Freedom of choice: See any doctor or specialist who accepts Medicare nationwide
- No networks: No need to stay in-network or worry about provider directories
- No referrals: See specialists without needing a referral from primary care
- Standardized: Coverage is the same nationwide
- Predictable: Benefits don't change year to year
- Travel-friendly: Coverage anywhere in the U.S.
✗ Disadvantages:
- No out-of-pocket cap: Costs can be unpredictable and unlimited
- Multiple plans: Need separate Part D and possibly Medigap
- 20% coinsurance: You pay 20% of all Part B costs with no limit
- No extras: Doesn't cover dental, vision, or hearing
- Higher total premiums: Part B + Part D + Medigap adds up
Typical Monthly Costs
• Part B: $202.90
• Part D: $20-$80
• Medigap: $100-$300+
Total: $322.90-$582.90+/month
Most plans also include Part D prescription drug coverage, but verify this when comparing plans.
✓ Advantages:
- Out-of-pocket maximum: The most you'll pay in a year for covered in-network services (excludes premiums and non-covered services). Once you hit this limit, the plan pays 100% for covered in-network care.
- All-in-one: Medical, hospital, and usually drug coverage in one plan
- Extra benefits: Dental, vision, hearing, fitness memberships, OTC allowances
- Lower premiums: Many plans have $0 monthly premium (still pay Part B)
- Predictable copays: Know costs upfront for most services
- Coordinated care: Care management and wellness programs
✗ Disadvantages:
- Network restrictions: Must use in-network providers (except emergencies)
- Referrals required: May need PCP approval to see specialists (HMO plans)
- Location-based: Coverage can vary significantly by ZIP code
- Annual changes: Networks, benefits, and costs can change yearly
- Travel limitations: Limited coverage outside service area
- Prior authorization: Some services require approval before treatment
Typical Monthly Costs
• Part B: $202.90
• Plan Premium: $0-$100
• Copays vary by service
Total: $202.90-$302.90/month
- •People who want maximum flexibility in choosing doctors and hospitals
- •Those who travel frequently or spend time in multiple states
- •People with specific doctors or specialists they want to keep
- •Those who can afford Medigap premiums for comprehensive coverage
- •People who want all-in-one coverage with extra benefits
- •Those seeking out-of-pocket maximum protection
- •Budget-conscious individuals (often lower monthly premiums)
- •People comfortable using network providers in their local area
Worth knowing: You Can Switch
You're not locked in forever! During the Annual Enrollment Period (October 15 - December 7), you can switch between Original Medicare and Medicare Advantage, or change Medicare Advantage plans.
Additional opportunity: If you're in Medicare Advantage and want to switch to Original Medicare (with or without Part D), you have another chance during the Medicare Advantage Open Enrollment Period (January 1 - March 31).
Need Help Deciding?
The choice between Original Medicare and Medicare Advantage depends on your health needs, budget, preferred doctors, and lifestyle. Our agents can help you evaluate both options based on your specific situation.
What's the difference between Original Medicare and Medicare Advantage?
Original Medicare (Parts A and B) lets you see any Medicare-accepting provider nationwide without referrals, but requires separate Part D and has no out-of-pocket cap. Medicare Advantage (Part C) bundles A, B, and usually D with extras like dental and vision, includes an out-of-pocket maximum, but requires using network providers. You can switch between them during Annual Enrollment.
Medicare Supplement (Medigap)
Medigap (Medicare Supplement Insurance) is private insurance that helps pay for some of the healthcare costs that Original Medicare doesn't cover, like copayments, coinsurance, and deductibles.
What is Medigap?
Medigap policies are sold by private insurance companies and are designed to "fill the gaps" in Original Medicare coverage. They cover the out-of-pocket costs that add up quickly when you don't have supplemental coverage.
Important: Medigap only works with Original Medicare. You cannot have both Medigap and Medicare Advantage.
Original Medicare does not cover:
- • Deductibles
- • Copays/Coinsurance
- • Outpatient Prescription Drugs
- • Healthcare outside the U.S.
- • Hearing aids, exams, screenings
- • Routine Eye Exams and Most Glasses
- Works with Original Medicare: Must have Parts A & B
- Standardized plans: Labeled with letters (A, B, C, D, F, G, K, L, M, N)
- Portable: Works with any doctor who accepts Medicare nationwide
- Renewable: Guaranteed renewable as long as you pay premiums
- No networks: Use any doctor or hospital that accepts Medicare
- Predictable costs: Helps budget healthcare expenses
- Prescription drugs (need separate Part D)
- Long-term care (nursing home care)
- Vision care or eyeglasses
- Dental care
- Hearing aids
- Private-duty nursing
Plan G - Most Comprehensive
The most popular Medigap plan, offering nearly complete coverage. You only pay the Part B deductible ($283 in 2026), and the plan covers everything else.
Typical Premium: $150-$250/month
Plan N - Lower Premium Option
Offers excellent coverage at a lower premium. You pay the Part B deductible plus small copays for doctor visits ($20) and ER visits ($50).
You pay: Part B deductible, $20 office visit copay, $50 ER copay, Part B excess charges
Typical Premium: $100-$180/month
High Deductible Plan G - Budget Option
Same benefits as Plan G, but with a high deductible ($2,950 in 2026). You pay all costs until you meet the deductible, then the plan covers everything.
Best for: Healthy individuals who want catastrophic coverage and lowest premiums
Typical Premium: $50-$90/month
Other Medigap Plans
Grandfathered Plan
Covers everything including Part B deductible
Only available if you became eligible for Medicare before January 1, 2020
Cost-Sharing Option
Covers 50% of most costs with out-of-pocket limit
Max OOP: $8,000 (2026)
Cost-Sharing Option
Covers 75% of most costs with out-of-pocket limit
Max OOP: $4,000 (2026)
Medicare Supplement Enrollment Period
A six-month window that begins on your Part B effective date or 65th birthday, whichever is later.
No medical underwriting.
Can choose from any Medicare Supplement Plan options.
Critical Timing: Medigap Open Enrollment Period
Your Medigap Open Enrollment Period is a one-time 6-month period that begins the month you're both 65 or older AND enrolled in Medicare Part B.
During this period:
- Guaranteed issue - cannot be denied coverage
- No health questions or medical underwriting
- Cannot charge more due to pre-existing conditions
After this window closes, you may be denied coverage or charged higher premiums based on your health. Don't miss this opportunity!
Medicare Supplement Guaranteed Issue (GI) Situations
There are several other GI situations to enroll into a Medicare Supplement plan with no underwriting. For example:
- • Loss of coverage
- • Moving to a new area, and many more
All plan options may not be available.
If you do not qualify for a GI situation, you may need to undergo medical underwriting.
Tips for Choosing Medigap
- 1.Shop around: Same plan (like Plan G) offers identical benefits from all companies, but premiums vary significantly
- 2.Consider your health: If you see doctors frequently, comprehensive Plan G may save money over lower-premium Plan N
- 3.Factor in total costs: Part B premium + Medigap premium + Part D premium = total monthly cost
- 4.Don't delay: Enroll during your Medigap Open Enrollment Period for guaranteed acceptance
If you're picking a Medigap plan, the number of options and companies can be overwhelming. We'll help you compare plans, explain the differences, and narrow it down to the plans that fit your situation.
Note: You cannot have both Medigap and Medicare Advantage. If you have Medicare Advantage and want to switch to Original Medicare with Medigap, contact us to discuss your options and timing.
Medigap (Medicare Supplement) plans help cover costs not paid by Original Medicare, such as copayments, coinsurance, and deductibles. Popular plans include Plan G (most comprehensive), Plan N (lower premiums with small copays), and High-Deductible G (lowest premium). You cannot have both Medigap and Medicare Advantage. The best time to buy is during your 6-month Medigap Open Enrollment Period starting at age 65 with Part B.
Eligibility & Enrollment
Knowing your enrollment windows matters — miss one and you can pay a penalty for the rest of your life.
Primary Eligibility Requirements
- Age 65+: Most people become eligible at age 65
- Citizenship: Must be a U.S. citizen OR a legal permanent resident who has lived in the U.S. for at least 5 consecutive years
Under 65? You May Still Qualify
You can qualify before age 65 if you have:
- Received Social Security Disability Insurance (SSDI) for 24 months
- End-Stage Renal Disease (ESRD) requiring dialysis or transplant
- ALS (Lou Gehrig's disease) - immediate eligibility
Your Initial Enrollment Period is a 7-month window that begins 3 months before you turn 65, includes your birthday month, and ends 3 months after.
Your 7-Month IEP Window
Best time to enroll
Enroll during the 3 months BEFORE your birthday month for coverage to start on your 65th birthday. If you enroll during or after your birthday month, coverage may be delayed by 1-3 months.
Warning: Late Enrollment Penalties
If you don't enroll during your IEP and don't have creditable coverage, you'll face permanent penalties on Part B (10% per year delayed) and Part D (1% per month delayed). These penalties last for life!
October 15 - December 7
Coverage starts January 1
What you can do:
- • Switch from Original Medicare to Medicare Advantage
- • Switch from Medicare Advantage to Original Medicare
- • Change Medicare Advantage plans
- • Join, switch, or drop Part D coverage
January 1 - March 31
For those already in Medicare Advantage
What you can do:
- • Switch to a different Medicare Advantage plan
- • Drop Medicare Advantage and return to Original Medicare
- • Add a Part D plan when returning to Original Medicare
Note: Can only make ONE change during this period
January 1 - March 31
Coverage starts the first of the month after you sign up
If you missed your Initial Enrollment Period and don't qualify for a Special Enrollment Period, you can enroll during GEP. However, you'll likely face late enrollment penalties.
This means you could wait months for coverage AND still face the late enrollment penalty.
Varies by Situation
Triggered by qualifying events
Common triggers:
- • Losing employer coverage
- • Moving out of plan service area
- • Qualifying for Medicaid
- • Moving to a nursing home
- • Plan discontinuation
Important Enrollment Tips
- 1.Don't wait until the last minute: Applications can take time to process. Enroll early in your window.
- 2.Keep documentation: Save proof of creditable coverage from employers if delaying enrollment.
- 3.Review annually: Even after initial enrollment, review your coverage during AEP each year.
- 4.Get help: Our agents can guide you through enrollment timing and help you avoid penalties.
Common questions
Medicare is the federal health insurance program for people aged 65 and older, certain younger people with disabilities, and people with End-Stage Renal Disease. Eligibility requires U.S. citizenship or legal residency and at least 5 consecutive years living in the U.S. People under 65 may qualify with 24 months of SSDI, ESRD, or ALS.
You should sign up during your Initial Enrollment Period (IEP), a 7-month window starting 3 months before your 65th birthday month and ending 3 months after. The best time is 3 months before your birthday for immediate coverage. Missing this window can result in lifetime penalties. Other key periods include Annual Enrollment (Oct 15 - Dec 7) and Medicare Advantage Open Enrollment (Jan 1 - Mar 31).
Understanding Costs
Your Medicare costs come from several places at once: premiums, deductibles, coinsurance and copayments. Understanding these costs helps you budget effectively and choose the right coverage.
Monthly Premium
$0
For most people with 10+ years of work history
If you don't qualify for premium-free Part A:
• Fewer than 30 quarters: $565/month
• 30-39 quarters: $311/month
Other Part A Costs:
Deductible: $1,736 per benefit period
Days 1-60: $0 coinsurance
Days 61-90: $434/day coinsurance
Days 91+: $868/day (lifetime reserve days)
Skilled nursing (days 21-100): $217/day
Benefit Period:Begins when you're admitted to a hospital and ends when you haven't received inpatient care for 60 consecutive days.
Standard Monthly Premium
$202.90
Most beneficiaries pay this amount
Increase from $185.00 in 2025
Additional Part B Costs:
Annual Deductible: $283
Coinsurance: 20% of Medicare-approved amount
Excess Charges:Up to 15% above Medicare-approved amount (if provider doesn't accept assignment)
No Out-of-Pocket Maximum
Original Medicare has no cap on your out-of-pocket costs. That 20% adds up fast if you need expensive treatment, which is why many people add Medigap or choose Medicare Advantage.
Part D Costs (2026)
Once you reach $2,100 in out-of-pocket costs, you pay nothing for covered drugs for the rest of the year!
If your modified adjusted gross income (MAGI) exceeds certain thresholds, you'll pay a higher premium for both Part B and Part D. IRMAA is based on your tax return from 2 years prior.
2026 Example: Individuals earning over $109,000 (couples over $218,000) pay additional Part B amounts ranging from $81.20 to $487.00/month.
2026 IRMAA Brackets (Based on 2024 Income)
| Individual Income | Joint Return | Part B Premium | Part D IRMAA |
|---|---|---|---|
| ≤ $109,000 | ≤ $218,000 | $202.90 | $0 |
| $109,001 - $137,000 | $218,001 - $274,000 | $284.10 | $14.50 |
| $137,001 - $171,000 | $274,001 - $342,000 | $405.80 | $37.50 |
| $171,001 - $205,000 | $342,001 - $410,000 | $527.50 | $60.40 |
| $205,001 - $499,999 | $410,001 - $749,999 | $649.20 | $83.30 |
| ≥ $500,000 | ≥ $750,000 | $689.90 | $91.00 |
Joint thresholds are double the individual amounts, except the top bracket, which begins at $750,000 — not $1,000,000. Married filing separately uses a lower schedule; ask us.
Life-changing event? If your income decreased due to retirement, divorce, death of spouse, or other major life event, you can appeal your IRMAA determination using Form SSA-44.
Average Costs
• Plan Premium: $0-$100/month
• Still pay Part B premium ($202.90)
• Copays vary by service
Has out-of-pocket maximum
Average Costs
• Plan G: $150-$250/month
• Plan N: $100-$180/month
• Still pay Part B & Part D
Predictable costs
Average Costs
• Premium: $20-$80/month
• Copays vary by drug/tier
+ IRMAA if income exceeds limits
Worth knowing: Calculate Total Annual Costs
Don't just compare monthly premiums! To find the best value, calculate your total expected annual costs:
Total Annual Cost Formula:
- ✓ (Monthly premiums × 12)
- ✓ + Annual deductibles
- ✓ + Expected copays/coinsurance
- ✓ + Prescription drug costs
- ✓ = Your total expected annual cost
We can help you run these numbers based on your specific healthcare needs and medications.
Medicare costs vary. Part A is $0/month for most people with 40+ work quarters, with a $1,736 deductible in 2026. Part B has a standard premium of $202.90/month with a $283 annual deductible and 20% coinsurance. Higher-income individuals pay additional IRMAA surcharges. Total costs depend on your plan choices, deductibles, copays, and out-of-pocket maximums.
Late Enrollment Penalties
Missing your Medicare enrollment deadlines can result in permanent late enrollment penalties that last as long as you have Medicare coverage. Understanding these penalties helps you make informed decisions about when to enroll.
These Penalties Last for LIFE
Late enrollment penalties are not temporary fees—they're permanent additions to your premiums that you'll pay for as long as you have Medicare Part B or Part D coverage. You avoid them by enrolling on time, or by keeping creditable coverage.
How It's Calculated
10% × number of 12-month periods delayed × Standard Part B Premium
Real-World Examples:
Example 1: Delayed 2 years
- • Delayed enrollment: 2 full 12-month periods
- • Penalty: 10% × 2 = 20%
- • Standard premium (2026): $202.90
- • Penalty amount: $40.58/month
- • Your new premium: $243.48/month FOR LIFE
Real Cost Example: Delayed 3 years
Scenario: You delay Part B enrollment for 3 years without creditable coverage
- • Standard Part B premium (2026): $202.90/month
- • 30% penalty (3 years × 10%): $60.87/month
- • Your monthly premium: $263.77
- • Extra cost per year: $730.44
- • This penalty continues for LIFE!
Example 2: Delayed 5 years
- • Delayed enrollment: 5 full 12-month periods
- • Penalty: 10% × 5 = 50%
- • Standard premium (2026): $202.90
- • Penalty amount: $101.45/month
- • Your new premium: $304.35/month FOR LIFE
- • Lifetime cost (age 65-85): $24,348 in penalties alone!
When the Penalty Applies
You'll only pay this penalty if you don't sign up for Part B when you're first eligible AND you don't have creditable coverage (like employer health insurance from a company with 20+ employees).
Exception
You do not have to pay a late enrollment penalty if you meet certain conditions that allow you to sign up for Part B during a Special Enrollment Period.
How It's Calculated
1% × national base beneficiary premium × number of months without coverage
National base premium (2026): $38.99
63-Day Rule
The penalty kicks in if you go 63 consecutive days without creditable prescription drug coverage after your Initial Enrollment Period ends.
Real-World Examples:
Example 1: Delayed 12 months
- • Months without coverage: 12
- • Penalty calculation: 1% × $38.99 × 12 = $4.68
- • Rounded to the nearest 10¢, as Medicare does: $4.70
- • Penalty per month: $4.70 FOR LIFE
- • Added to whatever Part D plan you choose
Example 2: Delayed 36 months (3 years)
- • Months without coverage: 36
- • Penalty calculation: 1% × $38.99 × 36 = $14.04
- • Rounded to the nearest 10¢, as Medicare does: $14.00
- • Penalty per month: $14.00 FOR LIFE
- • Lifetime cost (age 65-85): about $3,360 in penalties alone!
Worth knowing
Even if you're healthy and take no medications, consider enrolling in a low-premium Part D plan to avoid the lifetime penalty. Some plans are as low as $0-10/month in many areas. We can walk you through the lower-cost options available where you live.
- 1.Enroll during Initial Enrollment Period: Sign up when first eligible (3 months before turning 65)
- 2.Maintain creditable coverage: Keep employer or union coverage that's as good as Medicare
- 3.Use Special Enrollment Period: Enroll within 8 months of losing creditable coverage
- 4.Get proof of coverage: Keep documentation from employer showing creditable coverage
- COBRA coverage (after leaving employment)
- Retiree health coverage (in most cases)
- Health savings accounts (HSAs)
- ✓ You take prescription medications
- ✓ You want to avoid future penalties
- ✓ You don't have other creditable coverage
- ✓ You might need meds in the future
- ✓ You have employer drug coverage
- ✓ You get "Extra Help" (Medicaid)
- ✓ You have VA drug benefits (creditable for Part D)
- ✓ You have TRICARE pharmacy coverage (creditable for Part D — but you must still take Part B at 65 to keep TRICARE)
*Get proof of creditable coverage!
What happens if I miss the enrollment period?
Missing your enrollment window is one of the most costly Medicare mistakes. Here's what happens and how to recover.
Missing enrollment results in lifetime penalties: a 10% Part B surcharge for each full 12-month period without coverage, and a 1% Part D penalty per uncovered month. You must wait for General Enrollment (Jan 1 - Mar 31), with coverage starting the first of the month after you sign up. To avoid penalties, enroll during your Initial Enrollment Period, maintain creditable employer coverage, or use a Special Enrollment Period within 8 months of losing employer coverage.
Don't Risk Lifetime Penalties
The cost of late enrollment penalties over your lifetime can easily exceed $20,000. Don't let confusion about enrollment timing cost you thousands of dollars.
Our agents can help you determine the right time to enroll based on your specific situation.
What Medicare Doesn't Cover
Medicare covers a great deal, but there are real gaps in what it pays for. Knowing what is not covered helps you plan for those costs, or decide whether supplemental coverage is worth it.
Coverage Gaps to Know About
Original Medicare (Parts A & B) doesn't cover several common healthcare needs. Medicare Advantage plans often include some of these benefits, which is why many people choose that option.
NOT Covered by Original Medicare:
- • Routine dental exams and cleanings
- • Fillings, crowns, and bridges
- • Dentures and fittings
- • Root canals and extractions
- • Orthodontics
Exception: Medicare may cover dental services if they're part of a covered medical procedure (like jaw reconstruction after an accident).
✓ Coverage Options:
- • Many Medicare Advantage plans include dental
- • Standalone dental insurance
- • Dental discount plans
NOT Covered by Original Medicare:
- • Routine eye exams for glasses/contacts
- • Eyeglasses and contact lenses
- • LASIK and other vision correction surgery
- • Eye exam for refracting (prescribing glasses)
✓ Medicare DOES Cover:
- • Annual glaucoma screening (high risk)
- • Macular degeneration treatment
- • One pair of glasses after cataract surgery
- • Diabetic retinopathy screening
✓ Coverage Options:
- • Most Medicare Advantage plans include vision
- • Standalone vision insurance
NOT Covered by Original Medicare:
- • Routine hearing exams
- • Hearing aids
- • Hearing aid fittings and adjustments
- • Exams for fitting hearing aids
✓ Medicare DOES Cover:
Diagnostic hearing and balance exams ordered by a doctor to see if you need medical treatment
✓ Coverage Options:
- • Many Medicare Advantage plans include hearing aids
- • Veterans benefits (VA)
- • State hearing aid programs
NOT Covered by Original Medicare:
- • Custodial care in nursing homes
- • Assisted living facilities
- • Adult day care
- • Help with activities of daily living (ADLs)
- • Most long-term care services
Important Distinction
Medicare covers up to 100 days per benefit period of skilled nursing care (after 3-day hospital stay), but NOT custodial or long-term care. Most nursing home stays are custodial, not skilled.
✓ Coverage Options:
- • Long-term care insurance
- • Medicaid (for those who qualify)
- • Personal savings
Healthcare Services
- •Cosmetic surgery (unless due to injury/disease)
- •Acupuncture (except chronic lower back pain)
- •Most chiropractic care (except spinal manipulation)
- •Routine foot care (except for diabetics)
- •Weight loss programs
- •Massage therapy
Travel & International
- •Healthcare outside the United States (with limited exceptions)
- •Medical care on cruise ships (beyond 6 hours from U.S. port)
- •Travel or transportation to get care (except ambulance)
Foreign Travel Exception: Medicare may pay for inpatient hospital, doctor, or ambulance services you get in a foreign country in rare cases, such as if you're in the U.S. when a medical emergency occurs and the foreign hospital is closer than the nearest U.S. hospital.
Filling the Coverage Gaps
If you need coverage for dental, vision, hearing, or other services that Original Medicare doesn't cover, you have options:
Medicare Advantage
Most plans include dental, vision, hearing, and fitness benefits at no additional premium — coverage limits and copays vary by plan, so check the Summary of Benefits
Standalone Plans
Purchase separate dental, vision, or long-term care insurance policies
We can help you compare options and find coverage that includes the benefits you need.
Medicare & Employer Coverage
If you or your spouse are still working when you turn 65, how your employer coverage interacts with Medicare decides what you pay to avoid coverage gaps and late enrollment penalties.
The Big Question: Should I Enroll in Medicare at 65?
The answer depends on your employer's size and whether your coverage is considered "creditable." Employer size matters because it determines whether Medicare or your employer plan pays first.
How does Medicare work if I'm still working past age 65?
If your employer has 20 or more employees, you can delay Part B without penalty since employer coverage is primary. Enroll within 8 months of losing that coverage. If your employer has fewer than 20 employees, Medicare becomes primary and you should enroll at 65 to avoid penalties. Coverage through your spouse's CURRENT employer counts the same as your own, so it also lets you delay. COBRA and retiree insurance do not count.
✓ You Can Usually Delay Part B
Your employer coverage is primary and Medicare would be secondary. You can delay Part B without penalty.
Recommended Strategy:
- Enroll in Part A:usually premium-free — but not if you're still contributing to an HSA (see below)
- Delay Part B: Avoid paying the premium while you have employer coverage
- Delay Part D: If your employer drug coverage is creditable
- Enroll within 8 months: After losing employer coverage (Special Enrollment Period)
Worth knowing
Keep proof of your employer coverage (creditable coverage letter) and enrollment dates. You'll need this to avoid penalties when you later enroll in Medicare.
Coordination of Benefits
• Employer plan pays first (primary)
• Medicare pays second (secondary)
• Usually get better coverage staying on employer plan
You Should Usually Enroll at 65
Medicare is primary and your employer coverage is secondary. Delaying Medicare could leave coverage gaps.
Recommended Strategy:
- Enroll in Part A: During your Initial Enrollment Period
- Enroll in Part B: To avoid gaps and ensure coordinated coverage
- Consider Part D: Depending on your employer drug coverage
- Talk to HR: Understand how your employer plan coordinates with Medicare
Warning
Not enrolling in Medicare could mean your employer plan pays less or denies claims, leaving you with unexpected medical bills and potential late enrollment penalties.
Coordination of Benefits
• Medicare pays first (primary)
• Employer plan pays second (secondary)
• Employer may reduce or drop coverage when you're Medicare-eligible
These types of coverage will NOT protect you from late enrollment penalties if you delay signing up for Medicare:
COBRA Coverage
COBRA is considered "retiree" coverage, not active employment coverage.
✗ You MUST enroll in Medicare or face penalties
Retiree Health Insurance
Coverage provided to retirees is not considered active employment coverage.
✗ You MUST enroll in Medicare or face penalties
Spouse's Employer (under 20 employees)
Small employer rules apply even if coverage is through your spouse.
✗ You should enroll in Medicare at 65
TRICARE (once Medicare-eligible)
TRICARE requires you to enroll in Medicare Part B to keep TRICARE coverage.
✗ You MUST enroll in Part B at 65
✓ What You Should Do
- Contact your HR department to understand your coverage
- Get a "creditable coverage" letter from your employer
- Determine if your employer has 20+ employees
- Call us! We'll help you make the right decision for your situation
Important: HSAs and Medicare
You cannot contribute to a Health Savings Account (HSA) once you enroll in any part of Medicare—even Part A.
Key HSA Rules:
- • Stop HSA contributions 6 months before enrolling in Medicare
- • You CAN still use existing HSA funds for medical expenses
- • Employer contributions count—ask them to stop
- • Medicare enrollment can be retroactive up to 6 months
Worth knowing
Even with employer coverage, compare total costs! Sometimes Medicare + Medigap is actually cheaper and provides better coverage than employer plans. We can run the numbers with you.
Get Expert Guidance for Your Situation
The interaction between employer coverage and Medicare can be complex and varies based on your specific situation. Making the wrong decision could result in:
- • Coverage gaps leaving you uninsured
- • Lifetime late enrollment penalties
- • Unexpected out-of-pocket medical costs
- • Tax penalties for improper HSA contributions
Our agents specialize in employer-to-Medicare transitions and can walk you through it. We'll review your specific situation and help you make the right decision.
Financial Assistance Programs
If you have limited income and resources, several federal and state programs can help pay for Medicare premiums, deductibles, and other healthcare costs. These programs can save you thousands of dollars per year.
You May Qualify for Help
A lot of people who qualify never apply — they haven't heard of these programs, or they assume they earn too much. It's worth checking. You could save a significant amount, and applying is straightforward.
What Extra Help Covers
Extra Help is a federal program that helps pay Part D prescription drug costs, including:
- • Monthly Part D premiums
- • Annual deductibles
- • Prescription copayments
- • Costs up to the annual out-of-pocket cap
Potential Savings
$5,000+
Average annual savings for Extra Help recipients
2026 Income & Resource Limits (Individual)
• Annual income: < $23,940
• Resources: < $18,090
2026 Income & Resource Limits (Couple)
• Annual income: < $32,460
• Resources: < $36,100
Resources include savings, investments, and real estate (other than your primary home). Your primary home, one car, personal belongings, and life insurance don't count.
If you meet certain income and resource limits, you may qualify for Extra Help from Medicare to pay the costs of Medicare prescription drug coverage (Part D).
You can apply at: www.ssa.gov/benefits/medicare/prescriptionhelp/
Countable Assets
- • Money in a checking/savings account
- • Stock
- • Bonds
Noncountable Assets
- • Your home
- • One car
- • Burial plot
- • Furniture
- • Other household and personal items
How to Apply:
- • Apply online at SocialSecurity.gov
- • Call Social Security: 1-800-772-1213
- • Visit your local Social Security office
- • Mail application form SSA-1020
Worth knowing
If you have limited income, you may qualify for "Extra Help" with Part D prescription drug costs, even if you don't qualify for Medicaid. This could save you thousands per year! We can help you apply.
State-run programs that help pay Medicare premiums and, in some cases, deductibles and coinsurance. There are four types of MSPs:
1. Qualified Medicare Beneficiary (QMB)
Pays: Part A & B premiums, deductibles, coinsurance, copays
2026 Income Limits (most states)
Individual:
< $1,350/month
(< $16,200/year)
Couple:
< $1,824/month
(< $21,888/year)
2. Specified Low-Income Medicare Beneficiary (SLMB)
Pays: Part B premium only
2026 Income Limits (most states)
Individual:
$1,350 - $1,616/month
Couple:
$1,824 - $2,184/month
3. Qualifying Individual (QI)
Pays: Part B premium only (limited funding, first-come basis)
2026 Income Limits (most states)
Individual:
$1,616 - $1,816/month
Couple:
$2,184 - $2,455/month
4. Qualified Disabled & Working Individuals (QDWI)
Pays: Part A premium only (for working disabled individuals who lost free Part A)
Contact your State Medicaid office for eligibility requirements
2026 Resource Limits (most states)
Individual:
< $4,000
Couple:
< $6,000
2026 Resource Limits — QMB, SLMB & QI (most states)
Individual:
< $9,950
Couple:
< $14,910
How to Apply:
- • Contact your State Medicaid office
- • Applications vary by state
- • We can help you find your state's program and application
How do Medicare and Medicaid differ?
Medicare is federal health insurance based on age (65+) or disability, with premiums, covering hospital and medical care. Medicaid is a joint federal-state program based on income and assets, usually free, covering more services including long-term care. Some people qualify for both (dual eligible), where Medicare pays first and Medicaid covers remaining costs. Medicare Savings Programs can help low-income individuals pay Medicare premiums.
Medicare and Medicaid are often confused, but they're very different programs with different eligibility and benefits.
Federal Health Insurance Program
Eligibility Based On:
Age (65+) or certain disabilities
- No income limits - available to everyone who qualifies by age/disability
- Federally funded and administered
- Most people pay premiums (except Part A for many)
- Covers: Hospital, medical, prescription drugs
State/Federal Assistance Program
Eligibility Based On:
Income and resources (assets)
- Income limits apply - for low-income individuals and families
- Joint federal/state - varies by state
- No premiums for most beneficiaries
- Covers: More comprehensive, including long-term care
Key Differences at a Glance
| Criteria | Medicare | Medicaid |
|---|---|---|
| Eligibility | Age/Disability | Income/Assets |
| Run by | Federal | State + Federal |
| Cost | Premiums vary | Usually free |
| Long-term care | Limited | Yes, covered |
If you qualify for both Medicare and Medicaid (called "dual eligible"), the two programs together cover nearly everything with minimal out-of-pocket costs.
What Medicaid Adds to Medicare:
- Pays Medicare premiums, deductibles, and coinsurance
- Covers services Medicare doesn't (dental, vision, long-term care)
- Prescription drug coverage with minimal copays
- Transportation to medical appointments
How it works: Medicare pays first, then Medicaid covers some or all of the remaining costs.
Special Medicare Advantage Plans for Dual Eligibles:
Dual Eligible Special Needs Plans (D-SNPs) are Medicare Advantage plans designed specifically for people who have both Medicare and Medicaid, offering coordinated benefits and care.
We Can Help You Apply
These programs can save you thousands of dollars annually, but many eligible people don't apply because:
- • They don't know the programs exist
- • They think they won't qualify
- • The application process seems complicated
Our agents can explain these programs in plain English, help you determine if you qualify, and guide you through the application process.
Common Medicare Mistakes
Medicare gets confusing, and the mistakes can cost you. Here are the mistakes we see most often — and how you can avoid them.
Why These Mistakes Matter
Many Medicare mistakes result in permanent penalties, coverage gaps, or unexpected costs. Learn from others' errors and get it right from the start.
Missing the Initial Enrollment Period
The Mistake: The costliest mistake we see. Missing your IEP without creditable coverage results in lifetime late enrollment penalties for Part B (10% per year) and Part D (1% per month).
How to Avoid It:
Mark your calendar 3 months before turning 65. Enroll early in your 7-month window for coverage to start on your birthday. If you have employer coverage, get proof of creditable coverage in writing.
Thinking COBRA or Retiree Coverage Counts
The Mistake: Many people delay Medicare thinking their COBRA or retiree insurance protects them from penalties. It doesn't. These don't count as creditable coverage for delaying Medicare enrollment.
How to Avoid It:
If you lose employer coverage and go on COBRA or retiree insurance, enroll in Medicare immediately to avoid lifetime penalties.
Not Checking If Doctors Accept Your Plan
The Mistake: Medicare Advantage plans have network restrictions. Your current doctors may not be in your plan's network, forcing you to switch doctors or pay out-of-network costs.
How to Avoid It:
Before choosing a Medicare Advantage plan, call your doctors' offices to verify they accept the specific plan you're considering. Provider directories can be outdated.
Choosing Based on Premium Alone
The Mistake: A plan with a $0 premium might cost more overall than a plan with a $50 premium once you factor in deductibles, copays, and out-of-pocket maximums.
How to Avoid It:
Calculate your total expected annual costs: (premiums × 12) + deductibles + expected copays + drug costs. Choose the plan with the lowest total cost for YOUR situation.
Not Reviewing Coverage Annually
The Mistake: Medicare Advantage and Part D plans change every year—benefits, costs, covered drugs, and provider networks can all change. Last year's great plan might be this year's poor choice.
How to Avoid It:
Review your coverage every Annual Enrollment Period (Oct 15-Dec 7). Check if your doctors, drugs, and pharmacies are still covered and compare with other available plans.
Skipping Part D Because 'I Don't Take Medications'
The Mistake: Even if you're healthy now, going without Part D for more than 63 days results in a permanent penalty when you do enroll. Plus, health situations can change quickly.
How to Avoid It:
Enroll in a low-premium Part D plan during your IEP. You can always switch plans during AEP if your medication needs change.
Not Understanding the Part B Deductible & 20% Coinsurance
The Mistake: Many people think Original Medicare covers everything. It doesn't. Part B has a $283 deductible and then you pay 20% of all costs with no out-of-pocket maximum. A $100,000 surgery means $20,000 out of your pocket.
How to Avoid It:
If you choose Original Medicare, strongly consider Medigap to cover that 20% coinsurance. Or choose Medicare Advantage which has an out-of-pocket maximum.
Assuming Medicare Covers Long-Term Care
The Mistake: Medicare does NOT cover long-term custodial care in nursing homes. It only covers short-term skilled nursing (up to 100 days per benefit period, after a hospital stay). Long-term care can cost $100,000+ per year.
How to Avoid It:
Plan separately for long-term care through long-term care insurance, personal savings, or Medicaid qualification. Don't count on Medicare.
Believing You Can Switch from Medicare Advantage to Medigap Anytime
The Mistake: After your Medigap Open Enrollment Period (6 months after enrolling in Part B at 65+), insurers can deny Medigap coverage or charge higher premiums based on your health. Switching from Medicare Advantage to Original Medicare + Medigap can be difficult or impossible.
How to Avoid It:
Make the Original Medicare vs Medicare Advantage decision carefully during your IEP. If unsure, Original Medicare + Medigap might offer more flexibility long-term.
Not Getting Help from an Expert
The Mistake: Medicare has dozens of plan options with hundreds of pages of details. Trying to figure it all out alone often leads to suboptimal choices that cost thousands over time.
How to Avoid It:
Work with a licensed Medicare agent who can walk you through the plans we offer in your area, explain the details in plain English, and help you make an informed decision—at no cost to you.
Avoid These Mistakes—Get Expert Help
You don't have to navigate Medicare alone. We help clients avoid these every day. We'll:
- Review your specific situation and timeline
- Explain your options in plain English
- Help you avoid penalties and coverage gaps
- Compare plans based on YOUR doctors and medications
- Provide ongoing support year after year
Best of all? There's no cost to you for our services. We're paid by the insurance companies, not by you, so you get expert guidance at no charge.
Let's Find Your Medicare Plan
Whether you're new to Medicare or thinking about switching plans, give us a call.