Medicare questions, answered
Medicare is federal health insurance for people 65 and older, certain younger people with disabilities, and people with End-Stage Renal Disease. Coverage breaks into Part A (hospital), Part B (medical), Part C (Medicare Advantage, an all-in-one alternative), and Part D (prescription drugs). Enrollment starts during your Initial Enrollment Period — the 7-month window around your 65th birthday.
When am I eligible for Medicare?
Most people become eligible for Medicare the month they turn 65. You may also be eligible before 65 if you’ve received Social Security Disability Insurance for 24 months, or if you have End-Stage Renal Disease (ESRD) or ALS. You don’t need to be retired to enroll. If you’re already receiving Social Security benefits when you turn 65, you’ll be automatically enrolled in Parts A and B; otherwise, you need to sign up actively.
What are Medicare Parts A, B, C, and D?
Part A covers inpatient hospital care, skilled nursing facility care, hospice, and some home health care — most people get Part A premium-free if they worked 10+ years. Part B covers outpatient care, doctor visits, preventive care, and durable medical equipment — it has a monthly premium ($185 standard in 2026). Part C is Medicare Advantage: private plans that bundle A, B, and usually D into one all-in-one plan. Part D is standalone prescription drug coverage. You can choose Original Medicare (A + B + standalone D + optional Medigap) OR Medicare Advantage (Part C), but not both.
How much does Medicare cost in 2026?
Most beneficiaries pay $0 for Part A. The Part B standard monthly premium is $185 in 2026, with higher-income beneficiaries paying more through Income-Related Monthly Adjustment Amounts (IRMAA). The Part B annual deductible is $257. Part D premiums vary by plan (typically $0-$80/month) plus IRMAA if income-adjusted. Medicare Advantage and Medigap premiums vary by plan and location. Your total monthly Medicare cost depends on which path you choose and your income.
What is the Initial Enrollment Period (IEP)?
The Initial Enrollment Period is the 7-month window when you first become eligible — it starts 3 months before your 65th birthday month, includes that month, and ends 3 months after. To avoid coverage gaps, enroll in the 3 months before your birthday so coverage starts the first day of your birthday month. If you sign up during your birthday month or after, your coverage start date is delayed. This is also when you should evaluate whether Medicare Advantage or Original Medicare + Medigap is the better fit.
What happens if I miss my Initial Enrollment Period?
If you miss your IEP and don’t qualify for a Special Enrollment Period (typically because you had employer coverage), you’ll need to wait for the General Enrollment Period (January 1 to March 31 each year). You may also face permanent late enrollment penalties: 10% added to your Part B premium for every 12 months you delayed enrollment, and 1% per month of the national base Part D premium for going without creditable drug coverage. These penalties stay with you for life on Medicare.
When is the Medicare Annual Election Period (AEP)?
The Annual Election Period runs from October 15 to December 7 each year, with changes taking effect January 1. During AEP, you can switch from Original Medicare to Medicare Advantage (or vice versa), change Medicare Advantage plans, change or enroll in Part D drug plans, or drop coverage. AEP is the most important time of year for Medicare review — your current plan’s formulary, network, and benefits may have changed, and a better plan may be available for next year. We review every client’s plan during AEP.
What’s the difference between Medicare Advantage and Medicare Supplement?
Medicare Advantage (Part C) replaces Original Medicare with a private plan that has its own network and rules. It often includes Part D drugs and extras like dental, vision, and hearing. Medicare Supplement (Medigap) works alongside Original Medicare to pay your share of costs — no networks, no referrals, but you also need a separate Part D plan and Medigap doesn’t include dental, vision, or hearing. They’re alternatives, not complements; you generally can’t have both at the same time.
Do I need a Part D plan if I have Medicare Advantage?
Usually no — most Medicare Advantage plans include built-in Part D drug coverage. You can identify these as “MAPD” plans (Medicare Advantage Prescription Drug). A small number of Medicare Advantage plans (like Private Fee-for-Service plans without drug coverage and Medical Savings Account plans) don’t include Part D, in which case you can enroll in a standalone Part D plan. Enrolling in a standalone Part D plan while on a Medicare Advantage plan that already includes drug coverage will typically disenroll you from your Advantage plan.
What is the Medigap Open Enrollment Period?
Your Medigap Open Enrollment Period is a one-time 6-month window that begins the month you turn 65 AND are enrolled in Part B. During this window, carriers cannot deny you coverage or charge more for pre-existing conditions — it’s called guaranteed-issue. Outside this window, in most states, Medigap is medically underwritten and you can be denied. A few states (New York, Connecticut, Massachusetts, Maine) allow guaranteed-issue Medigap year-round. Getting Medigap right during this window matters — it may be your only chance.
Can I have Medicare and employer insurance at the same time?
Yes, this is common. If you’re still working at 65 and have group coverage through an employer with 20+ employees, your employer plan generally pays first and Medicare pays second. You can delay Part B enrollment without penalty as long as you have creditable employer coverage. When the employer coverage ends, you have an 8-month Special Enrollment Period to enroll in Part B without penalty. Smaller employer plans (under 20 employees) may have different coordination rules — talk through your specific situation with us before delaying enrollment.
Does Medicare cover dental, vision, or hearing?
Original Medicare (Parts A and B) does not cover routine dental, vision, or hearing care. It does cover some related medical services — for example, a Part B-covered eye exam if you have diabetes, or hospital-related dental work needed before another procedure. Medicare Advantage plans often include dental, vision, and hearing benefits as added value, but the depth of coverage varies enormously between plans. If these benefits matter to you, we can compare which Advantage plans offer meaningful coverage versus minimal allowances.
What is the Medicare Part D “donut hole”?
The Part D coverage gap, or “donut hole,” historically meant a period where you paid more for drugs after hitting an initial coverage limit but before catastrophic coverage kicked in. The Inflation Reduction Act has dramatically restructured Part D: starting in 2025, there’s a hard $2,000 annual out-of-pocket cap on prescription drug costs for Part D enrollees, effectively closing the donut hole. The coverage phases still exist, but once you hit $2,000 out-of-pocket, your drugs are covered at no additional cost for the rest of the year.
Can I switch from Medicare Advantage to Medicare Supplement?
Yes, but with caveats. You can switch during the Annual Election Period (October 15 to December 7) or the Medicare Advantage Open Enrollment Period (January 1 to March 31). The catch: if you’re switching to Medigap outside your one-time 6-month Medigap Open Enrollment Period, carriers can use medical underwriting and may deny you or charge more based on health history. There are also “trial right” protections for first-time Medicare Advantage enrollees who switch within 12 months. We can walk through your specific options based on timing and health.
How do I appeal a Medicare claim denial?
Medicare has a 5-level appeals process. Level 1 is redetermination by your plan or the Medicare Administrative Contractor; Level 2 is reconsideration by a Qualified Independent Contractor; Level 3 is an Administrative Law Judge hearing; Level 4 is the Medicare Appeals Council; Level 5 is federal court review. Each level has specific timeframes for filing — typically 120 days from the denial notice for Level 1. As your licensed agent, we can help you understand the denial and your options, though formal appeals are usually filed by you or your authorized representative.