Medicare starts at 65 (earlier with disability, ESRD, or ALS). Enroll during your 7‑month window for timely coverage. Part A covers hospital care, Part B outpatient care, Part C (Advantage) bundles A/B with extras, and Part D handles prescriptions. Original Medicare leaves deductibles and 20% coinsurance; Medigap Plan G or N can limit surprises. Medicare Advantage trades networks for added benefits. Know enrollment deadlines to avoid penalties and protect choices. Next, you’ll see how to match coverage to your needs.
Need to Know
- Medicare has Parts A (hospital), B (outpatient), C (Advantage bundles A/B), and D (prescriptions); know what each covers before choosing.
- Initial Enrollment Period is seven months around your 65th birthday; enroll early to avoid delays and penalties.
- Original Medicare leaves gaps: Part A/B deductibles and 20% coinsurance; consider Medigap to reduce out-of-pocket costs.
- Medicare Advantage offers private plan alternatives with extras, but networks and rules differ from Original Medicare.
- Medigap Open Enrollment lasts six months after Part B starts; guaranteed acceptance applies only during this window.
Who Qualifies for Medicare and When Coverage Begins
Most people qualify for Medicare when you turn 65, and some qualify earlier due to disability. You’re eligible at 65 if you’re a U.S. citizen or permanent resident with sufficient work history.
You may qualify earlier if you’ve received Social Security disability benefits for 24 months, have end-stage renal disease, or ALS.
Your Initial Enrollment Period lasts seven months: the three months before your 65th birthday month, your birthday month, and three months after.
Enroll during the first three months and coverage starts the first day of your birthday month. If you’re already on Social Security before 65, you’re enrolled automatically.
Breaking Down Parts A, B, C, and D
Here’s the 2026, straight-shot breakdown of Medicare Parts A, B, C, and D, what each covers, how you get it, and what’s NEW/IMPORTANT for 2026.
Part A – Hospital Insurance (Original Medicare)
What it covers: Inpatient hospital care, skilled nursing facility (post-hospital), hospice, and some home health.
How you get it: Most people are automatically enrolled at 65 if already getting Social Security; others sign up. (Standard enrollment rules unchanged.)
What you pay: Premium-free for most with sufficient work credits; otherwise a monthly premium applies, plus per-benefit-period inpatient deductible and daily coinsurance at set day limits (exact dollar amounts are set annually).
Part B – Medical Insurance (Original Medicare)
What it covers: Doctor visits, outpatient care, preventive services, labs/imaging, durable medical equipment, many provider services (including certain injected/infused drugs).
How you get it: Enroll during your Initial Enrollment Period around your 65th birthday, or use a Special Enrollment Period if you have creditable job-based coverage tied to current employment. Late enrollment can trigger a lifetime penalty.
What you pay: A standard monthly premium (income-adjusted for higher earners) and an annual deductible, then generally 20% coinsurance of the Medicare-approved amount. (Exact 2026 dollar amounts are set each year—check Medicare.gov when you enroll.)
Part C – Medicare Advantage (private plans)
What it is: An all-in-one alternative that bundles A + B and usually D, often with extras (dental/vision/hearing, fitness). Plans set copays/coinsurance and include an annual out-of-pocket maximum for Part A/B services. Networks and prior authorizations can apply.
2026 landscape: CMS says access remains broad (99%+ have an MA option; plan counts remain high though down slightly), and average MA premiums are expected to be stable/slightly lower overall. Compare locally for benefits, networks, and drug coverage.
Prescription Drug Coverage (stand-alone PDP or inside MA-PD)
What it covers: Outpatient prescription drugs using a plan “formulary” with tiers, preferred pharmacies, and utilization rules (e.g., prior auth).
2026 NEW/IMPORTANT:
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Annual out-of-pocket cap = $2,100. After you hit this cap, you pay $0 for covered Part D drugs for the rest of the calendar year.
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Deductible ceiling rises to $615 (plans may set a lower or $0 deductible).
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Negotiated prices for the first 10 drugs take effect Jan 1, 2026. Your actual costs depend on your plan and pharmacy—check during plan comparison.
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Prescription Payment Plan lets you spread your Part D out-of-pocket costs over the year (it’s a payment option, not a discount).
Understanding Out-of-Pocket Gaps in Original Medicare
Ever wonder where Original Medicare stops and your wallet starts?
Part A hits you with a $1,676 hospital deductible per benefit period. Stay past 60 days and you’ll owe $419 daily through day 90, then $838 per day for lifetime reserve days.
Skilled nursing runs $0 for days 1–20, then $209.50 per day through day 100, and nothing after.
Under Part B, you’ll pay a $257 annual deductible, then 20% coinsurance on covered services with no out-of-pocket cap.
Some non-participating doctors can bill up to 15% more as excess charges. Without added coverage, your financial exposure can be significant.
How Medigap Plans Work: Plan G vs. Plan N
Those out-of-pocket gaps under Original Medicare are exactly what Medigap plans aim to cover.
With both Parts A and B, you can add a Medigap policy to shrink deductibles, coinsurance, and surprises.
Plan G typically runs $150–$200 monthly and covers everything except the annual Part B deductible ($257).
Plan N often costs $90–$130, adds small copays for office visits and ER, and doesn’t cover Part B excess charges.
Choose based on predictability vs. lower premium:
1) You’ll feel protected from big bills.
2) You’ll gain confidence using any Medicare provider.
3) You’ll sleep better knowing there’s no out-of-pocket cap risk.
Comparing Medicare Advantage to Original Medicare
Before you choose a path, understand the trade-offs between Original Medicare (Parts A and B, with optional Part D and Medigap) and Medicare Advantage (Part C).
Original Medicare offers nationwide access to providers who accept Medicare, predictable cost-sharing with Medigap, and no referrals.
But it lacks a built-in out-of-pocket maximum without a supplement, and you’ll add Part D separately.
Medicare Advantage bundles A and B (often D), can have $0 premiums, caps annual out-of-pocket costs, and may add dental, vision, and hearing.
However, you’ll face network rules, prior authorizations, and copays as you use care.
Consider your doctors, medications, travel, and budget.
Key Enrollment Windows and How to Avoid Penalties
Your choice between Original Medicare and Medicare Advantage only works if you enroll at the right time.
Your Initial Enrollment Period spans seven months around your 65th birthday. Enroll early to start coverage the first day of your birthday month and avoid delays.
If you’re covered by active employer insurance (20+ employees), use the eight-month Special Enrollment Period after that coverage ends.
Miss it, and you risk lifelong Part B and Part D penalties. Your Medigap Open Enrollment lasts six months from your Part B start; you’ll get guaranteed acceptance.
1) Avoid regret—mark your dates.
2) Dodge penalties—act promptly.
3) Protect yourself—enroll wisely.
Getting Help and Ongoing Support for Your Medicare Choices
Even when you understand the basics, getting Medicare right is easier with expert guidance and ongoing support. You don’t have to do this alone.
Use trusted, no-cost advisors like Medicare School to compare Original Medicare, Medigap (Plans G or N), and Advantage plans, avoid penalties, and align coverage with doctors and prescriptions. Ask about networks, drug formularies, prior authorizations, and out-of-pocket caps.
Get ongoing help after enrollment. Lean on a dedicated customer care team for billing issues, appeals, prior-authorization snags, and plan changes.
Reassess annually during Open Enrollment. Use SHIP counselors, plan member services, Medicare.gov tools, and educational videos to stay informed and confident.
Frequently Asked Questions
Can I Keep My Current Doctors When Switching Between Plans Midyear?
Usually not guaranteed. You must verify each doctor’s network for the new plan before switching. Ask offices directly, check plan directories, and confirm referral rules. Midyear changes may be limited to qualifying events or Medicare Advantage Open Enrollment.
How Do Medicare and VA Benefits Coordinate for Veterans?
They don’t coordinate; you use each separately. Don’t worry—you can still maximize both. Use VA for service-connected care and prescriptions, Medicare for non-VA providers and emergencies. Keep Parts A and B to avoid penalties and broaden access outside VA.
What Travel Coverage Does Medicare Provide Outside the United States?
You generally don’t have coverage outside the U.S. Original Medicare excludes foreign care, except limited emergencies near borders or on a cruise in U.S. waters. Consider Medigap Plan G/N foreign travel benefit or Medicare Advantage plans with worldwide emergency coverage.
How Are High-Income IRMAA Surcharges Appealed or Reduced?
You appeal IRMAA by filing SSA-44 after a life-changing event. Provide proof of reduced income. You can request reconsideration within 60 days, pursue further appeals if denied, and update tax returns; SSA recalculates when your MAGI drops.
How Does Medicare Work With Health Savings Accounts (HSAS)?
Medicare disqualifies HSA contributions once any part starts. You can’t fund an HSA after Part A or B begins, including retroactive Part A up to six months. Stop contributions beforehand; use existing HSA funds tax-free for qualified Medicare expenses.
