Medicare Guidance
- Home
- Medicare Guidance
Simplifying Medicare
Medicare is a federal health insurance program mainly for people age 65 or older, younger people with disabilities, and those with end-stage renal disease. Your responsibilities include enrolling on time, paying your monthly premiums, and choosing the right coverage so you are covered the way YOU want to be covered. In addition, each part of Medicare has a deductible(s) or what some people may call “holes”.
Original Medicare Explained
There are 3 main parts to Medicare
Part A
Considered Hospital Insurance. Whether you are retiring at 65 or not, your federal responsibility is to join Part A. You are given a 7-month period to join Part A. 3 months before your birth month, your birth month, and the following 3 months. This period is your Initial Enrollment Period or IEP.
Part A does not have a cost associated with it if you have worked for at least 10 years in the US. If you miss this period, there will not be a penalty if you have worked the 10 years. However, if you have not worked the 10 years, Part A will not be free, and you will be penalized (10% lifetime premium) for not enrolling during your IEP. To join outside of your IEP, you will use a General Enrollment Period (GEP) designated as January 1 – March 31st.
Part B
Considered Medical Insurance. If you choose to fully join Medicare at the age of 65, you will join both Part A and Part B. However, if you choose to continue to work or have “creditable” (meaning as good as Medicare – most employment insurance meets the criteria) health insurance you can delay joining Part B. When you choose to join Part B, you will be given a Special Enrollment Period (SEP). Why would you choose to delay joining Part B? Part B has a monthly premium – yes, Medicare has a premium and it is normally deducted from your Social Security Check each month. In 2026, the premium is $202.90/month. This premium is a Federally set amount each year and if you are a high-income earner, you will pay a higher premium. Part B also has a Deductible – In 2026, it is a one time per year of $283.00.
There is one caveat to Part B concerning your employer – if they employ 20 employees or less, you are required to join Medicare when you turn 65.
What do you get for the Part B monthly premium?
- 80% of everything medically necessary, as advised by your doctor, coverage is NATIONWIDE. You will be responsible for the balance of 20%.
- Virtually no pre-authorizations.
- No referrals.
- MOST IMPORTANTLY – NO NETWORKS – see any doctor in any state that accepts Medicare (Approx 98% of all doctors nationwide accept Medicare).
Part D
Part D of Medicare is prescription drug coverage. It is optional and not legally required, but going without it or other “creditable” (work insurance) prescription coverage for 63 days or more after you are eligible can result in a permanent late enrollment penalty (LEP). You will check/change your drug coverage every year during the Annual Enrollment Period – October 15th – December 7th. The only way to ensure you are paying the best/lowest price for your drugs is to remail vigilant every year. You can do this with Jo Gallo or utilize the Mecicare.gov site.
Each drug plan has a formulary (drugs covered in the plan) and a monthly premium set by the carrier of the drug plan. This premium will be increased by the Federal Government if you are a high-income earner. The last two pieces of drug plans are phases (when and how much of the drug plan deductible you will pay) and tiers – the tier system in Medicare Part D drug plans is based primarily on drug cost, type of drug (generic versus brand name), and negotiated price agreements between the private insurance carrier and drug manufacturers.
Current Prescription Phases
- Deductible phase: You pay 100% of your drug costs until you meet your plan’s specific annual deductible.
- Initial coverage: Your plan shares the cost of your medications until your total out-of-pocket spending reaches the annual limit.
- Catastrophic coverage: Once your out-of-pocket costs reach $2,100, you pay $0 for covered Part D prescription drugs for the remainder of the calendar year.
Medicare Supplements
Medicare “Supplement” or “Medigap” or “Secondary” – are all synonyms for the same product, insurance that is designed to “fill the holes” of Original Medicare (Parts A and B). Original Medicare has high deductibles, copays and coinsurances, and these Plans help you avoid any large medical bills. A Medicare Beneficiary must be enrolled in both Parts A & B to enroll in a Supplement.
Medigap policies must follow federal and state laws, the only entity that can change these policies is the US Congress. These plans must be identified as “Medicare Supplement Insurance.” Insurance companies can only sell you standardized policies identified in most states by letters A through D, F through G, and K through N.
Medicare Supplements are standardized when offered by any carrier. This means that a Plan G is a Plan G, no matter whom you purchase it from. If you decide to buy Georgie’s One Stop Medicare Shop or one of the large carrier brands, you will still be purchasing the same Plan G. Yes, they have different prices, but these carriers are all private, have different expenses and are allowed to set their own prices.
The Most Popular Plans currently are Plan G and Plan N.
Plan G requires paying a premium, meeting the Part B deductible ($283 in 2026), and then any covered service that Medicare does not pay in full is paid by Plan G. For clients that are looking for the most comprehensive healthcare, Plan G is the answer.
Plan N is similar to Plan G but requires up to a $20 copay to any physician and up to a $50 copay at the ER and does not cover Part B excess charges. For those that do not use provider services often, Plan N is a great way to save money going forward.
Medicare Supplements – Disability
What If I Have Medicare Due To Disability?
Plan D is the only supplement offered to those on Medicare under 65 due to disability who started Medicare after 1/1/2020. It offers comprehensive benefits, however, Plan D is similar to Plan G but requires up to a $20 copay for any physician and up to a $50 copay at the ER and does not cover Part B excess charges.
Medicare Advantage Plans
The Centers for Medicare & Medicaid Services (CMS) defines a Medicare Advantage plan (known as Part C) as a Medicare-approved health plan offered by a private company that serves as an alternative to Original Medicare. These bundled plans must cover all standard Part A and Part B benefits and frequently include extra services. However, because these plans may have a no-premium or low premium, you will have out of pocket costs called co-pays and co-insurance, as you use the plan. These amounts are decided by the Plan Administrator/Carrier. Your out-of-pocket costs will be capped – in 2026, the average Maximum Out of Pocket for most Plan hovered around $9,500.00 – the maximum out of pocket the plan can charge you per year.
Core Coverage Requirements
- Part A and Part B Services: Must cover all hospital, skilled nursing, and medical services provided by Original Medicare.
- Prescription Drug Inclusion: Most options bundle Medicare Part D prescription drug coverage (MAPD).
- Extra Benefits: May offer extra non-Medicare services like routine dental, vision, hearing, and wellness programs.
- Medicare Advantage Plans always cover emergency and urgent care.
- Medicare Advantage Plans provide all your Part A and Part B benefits, excluding clinical trials (clinical research studies), hospice services, and, for a temporary time, some new benefits that come from legislation or national coverage determinations. Be sure to contact your plan if you have questions about the services covered.
Operational Rules
- Private Administration: Run by approved private insurers that receive fixed monthly payments from the government.
- Provider Networks: Often require members to use specific doctors, hospitals, and networks for care.
- Cost Structures: Feature unique premiums, deductibles, and copayments set by each plan rather than standard Part B amounts.
- You will have HMO and PPO Medicare Advantage Provider structures.
- Pre-authorization and referral rules apply to these plans.
