Medicare can be confusing with its multiple parts, enrollment windows, and plan options. This guide breaks it all down so you can make confident decisions about your coverage.
Medicare is the federal health insurance program for people 65 and older, and certain younger people with disabilities or End-Stage Renal Disease (ESRD). It's administered by the Centers for Medicare & Medicaid Services (CMS).
Medicare is divided into four parts — A, B, C, and D — each covering different services. Understanding what each part covers (and doesn't cover) is essential for making smart enrollment decisions.
Part A covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care. Most people don't pay a premium for Part A if they (or their spouse) paid Medicare taxes for at least 10 years (40 quarters).
Part B covers outpatient care — doctor visits, preventive services, durable medical equipment, ambulance services, mental health, and more. Everyone pays a monthly premium for Part B.
If you don't sign up for Part B when first eligible and don't have creditable coverage, you'll pay a 10% penalty for each 12-month period you could've had Part B. This penalty lasts as long as you have Part B.
Medicare Advantage (MA) plans are offered by private insurance companies approved by Medicare. They bundle Parts A and B (and usually Part D) into a single plan, often with additional benefits like dental, vision, hearing, and fitness programs.
Types of MA Plans: HMO, PPO, PFFS (Private Fee-for-Service), SNPs (Special Needs Plans for dual-eligible, chronic conditions, or institutionalized individuals).
Part D covers outpatient prescription medications through private insurance plans. You can get Part D as a standalone plan (with Original Medicare) or as part of a Medicare Advantage plan.
1% of the national base premium ($36.78 in 2025) × number of months without creditable coverage. This penalty is added to your Part D premium permanently.
Medigap plans are sold by private insurers to fill the "gaps" in Original Medicare — the deductibles, copays, and coinsurance that Parts A and B don't cover. There are 10 standardized plan letters (A, B, C, D, F, G, K, L, M, N).
Covers everything except the Part B deductible ($257/year). Best value for most new enrollees.
Lower premium than G. You pay up to $20 copay for doctor visits and $50 for ER visits (waived if admitted). Plus the Part B deductible.
Covers everything including Part B deductible. Only available to people eligible for Medicare before January 1, 2020.
You have a 6-month Medigap Open Enrollment Period starting when you're 65+ AND enrolled in Part B. During this window, insurers can't deny you or charge more for health conditions. After this period, you may face medical underwriting.
7-month window: 3 months before your 65th birthday, your birthday month, and 3 months after.
October 15 – December 7. Switch MA plans, join/leave Part D, or return to Original Medicare. Changes effective January 1.
January 1 – March 31. Switch from one MA plan to another, or drop MA and return to Original Medicare + Part D.
Triggered by qualifying events: moving, losing employer coverage, qualifying for Medicaid, etc.
| Part | Monthly Premium | Annual Deductible | Cost Sharing |
|---|---|---|---|
| Part A | $0 (most people) | $1,676/benefit period | $0 days 1-60; $419/day 61-90 |
| Part B | $185+ (IRMAA adjusted) | $257 | 20% coinsurance |
| Part C (MA) | $0-$200+ (varies) | Varies by plan | Copays/coinsurance; OOP max |
| Part D | $0-$100+ (varies) | Up to $590 | $2,000 OOP cap (2025+) |
| Medigap | $50-$400+ (varies) | N/A | Depends on plan letter |
If your modified adjusted gross income exceeds $106,000 (single) or $212,000 (married filing jointly), you'll pay higher Part B and Part D premiums. Based on your tax return from 2 years ago.
Want freedom to see any doctor? → Original Medicare + Medigap + Part D
Want lower costs and extra benefits? → Medicare Advantage (Part C)
Take expensive medications? → Compare Part D formularies carefully
Travel frequently? → Original Medicare + Medigap (more portable)
Want dental/vision/hearing? → Medicare Advantage or standalone plans
Check each plan's formulary to ensure your drugs are covered and at what tier/cost.
If considering Medicare Advantage, verify your preferred providers are in the plan's network.
Add up premiums + expected out-of-pocket costs based on your typical healthcare usage.
If you're healthy now, Medigap is easier to get. Health conditions can make it harder (or impossible) to get later.
Late enrollment penalties that last forever. Part B penalty: 10% per year delayed. Part D: 1% per month.
After the 6-month window, insurers can deny you or charge more based on health status.
Medicare doesn't cover long-term care, most dental, vision, hearing aids, or care outside the U.S.
A $0 premium MA plan might have high copays and a narrow network. Total cost matters more.
Plans change every year — formularies, networks, premiums, and benefits. Always review during AEP.
High earners pay significantly more for Part B and D. Plan income strategically, especially around retirement.
Some people qualify for both Medicare and Medicaid — known as "dual eligibles." Medicaid can help pay Medicare premiums, deductibles, and copays, and covers services Medicare doesn't (like long-term care).
During your Initial Enrollment Period — the 7-month window around your 65th birthday. If you have employer coverage, you may delay Part B without penalty, but sign up within 8 months of losing that coverage.
Yes. If your employer has 20+ employees, your employer plan is primary and Medicare is secondary. Under 20 employees, Medicare is primary.
Part A is usually premium-free. Part B has a standard premium ($185/month in 2025). Part D and Medigap have separate premiums. You'll also have deductibles, copays, and coinsurance.
Yes, during the Annual Enrollment Period (Oct 15 – Dec 7) or the MA Open Enrollment Period (Jan 1 – Mar 31). But getting Medigap after your initial enrollment window may require medical underwriting.
Only through Part D or a Medicare Advantage plan that includes drug coverage. Original Medicare (Parts A & B) does not cover outpatient prescriptions.
Navigating Medicare doesn't have to be stressful. Our licensed agents specialize in Medicare and can help you find the right coverage at the right price.