YOUR COMPLETE RESOURCE

UNDERSTANDING

MEDICARE

Simple answers to complex questions.

Medicare can be confusing, but it doesn't have to be. This guide walks you

through almost everything you need to know, from the basics of Parts A & B to

enrollment windows and costs.

67M+

AMERICANS ENROLLED

65

STANDARD ELIGIBILITY AGE

4

PARTS OF MEDICARE

7 MO

INITIAL ENROLLMENT WINDOW

THE FOUNDATIONS

THE ABC's

of MEDICARE

Medicare is divided into four parts, each covering different aspects of your healthcare.

Understanding what each part covers helps you make the right coverage decisions.

PART A

A

Hospital Insurance

Inpatient and facility care

Part A covers inpatient hospital stays, skilled nursing facility care, hospice, and some home health services. Most people don't pay a premium for Part A if they or their spouse paid Medicare taxes for at least 10 years.

Inpatient hospital stays
Skilled nursing facility care
Hospice care
Some home health services
Blood transfusions

PART B

B

Medical Insurance

Outpatient & Preventive Care

Part B covers medically necessary services like doctor visits, outpatient care, preventive services, and medical equipment. A monthly premium applies — the standard amount is set each year by CMS.

Doctor visits and specialty care
Outpatient procedures
Preventive screenings
Mental health services
Durable medical equipment

PART C

C

Medicare Advantage

Private Alternative

Medicare Advantage plans are offered by private insurance companies approved by Medicare. They bundle Part A, Part B, and usually Part D into one plan — often with additional benefits like vision, dental, and hearing.

All Part A and B benefits
Usually includes Part D
Dental, Vision and Hearing (varies)
Fitness benefits
Care coordination

PART D

D

Prescription Drug's

Medication & Pharmacy

Part D helps cover the cost of prescription drugs. Plans are run by private insurers and each has its own formulary (list of covered drugs). Costs vary by plan and a late enrollment penalty may apply if you delay signing up.

Generic medications
Brand name medications
specialty medications
vaccines not covered by Part B
Mail order options

WHO QUALIFIES

ELIGIBILITY

GUIDELINES

Medicare eligibility isn't one-size-fits-all. You may qualify based on age,

disability status, or a specific health condition.

AGE 65+

U.S. citizens and permanent legal residents age 65 or older who have lived in the U.S. for at least 5 consecutive years are eligible for Medicare.

DISABILITY

People under 65 who have received Social Security Disability Insurance (SSDI) for 24 months automatically become eligible for Medicare coverage.

ESRD

End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant) qualifies individuals for Medicare at any age.

ALS

People diagnosed with Amyotrophic Lateral Sclerosis (Lou Gehrig's disease) qualify for Medicare immediately upon receiving SSDI benefits — no 24-month wait.

WHEN TO ENROLL

ENROLLMENT

WINDOWS

Missing an enrollment window can result in permanent late penalties on your

premiums. Know your deadlines.

INITIAL ENROLLMENT PERIOD (IEP)

A 7-Month Window Around your 65th Birthday

Your IEP begins 3 months before the month you turn 65 and ends 3 months after. This is the best time to sign up — enrolling during the 3 months before your birthday month means coverage starts on the 1st of your birthday month.

General Enrollment Period (GEP)

January 1 - March 31 Each year

If you missed your IEP, you can enroll during the GEP. Coverage starts July 1. A late enrollment penalty may apply to your Part B premium for as long as you have Medicare.

Special Enrollment Period (SEP)

When You Have a Qualifying Event

If you or your spouse are still working and covered by employer insurance, you can delay Medicare without penalty. Once that coverage ends, you have an 8-month SEP to enroll in Part B without a late penalty.

Annual Enrollment Period (AEP)

October 15 - December 7 Each Year

During AEP, you can switch between Original Medicare and Medicare Advantage, change your Part D plan, or add/drop a Medicare Advantage plan. Changes take effect January 1 of the following year.

WHAT YOU WILL PAY

MEDICARE

COSTS AT A GLANCE

Medicare costs include premiums, deductibles, and coinsurance. Here's a

general overview — exact amounts are updated each year by CMS.

Medicare Part	Monthly Premium	Annual Deductible	Coinsurance / Copays
Part A (Hospital)	$0 for most people*	$1,736 per benefit period	$0 for days 1–60; $434/day for days 61–90
Part B (Medical)	$202.90/mo (standard)	$283 per year	20% of Medicare-approved costs after deductible
Part C (Advantage)	Varies by plan ($0–$100+/mo)	Varies by plan	Copays vary; out-of-pocket maximums apply
Part D (Drug)	Varies by plan (~$30–$100+/mo)	Up to $615/year	Copays/coinsurance vary by drug tier

*People who paid Medicare taxes for fewer than 40 quarters may pay a premium. Figures shown are approximate 2024 reference amounts — verify current amounts at medicare.gov

FILLING THE GAPS

MEDIGAP

SUPPLEMENT PLANS

Original Medicare (Parts A & B) covers a lot, but it doesn't cover everything. You're still responsible for deductibles, coinsurance, and copays, which can add up quickly. That's where Medigap (also called Medicare Supplement Insurance) comes in.

Medigap policies are sold by private insurance companies and are designed to pay many of the "gaps" in Original Medicare coverage. Depending on which plan you choose, Medigap can cover costs like your Part A deductible, Part B coinsurance, and even emergency care during foreign travel.

There are 10 standardized Medigap plans (labeled A through N) available in most states. Each plan with the same letter offers the same basic benefits. The biggest difference between insurers is price and customer service. Massachusetts, Minnesota, and Wisconsin use different standardized plans.

Important: Medigap policies only work alongside Original Medicare. They cannot be used with Medicare Advantage (Part C) plans.

BEST TIME TO BUY

Your Medigap Open Enrollment Period starts the month you turn 65 and are enrolled in Part B. During this 6-month window, insurers cannot deny you coverage or charge you more due to pre-existing conditions. Once this window closes, you may be subject to medical underwriting — meaning you could be denied or charged higher premiums based on your health status.

Medicare Supplement Plan Comparison

Compare the standardized benefits included with Medicare Supplement plans. Benefits are standardized by plan letter, though premiums vary by carrier.

Benefit	Plans Available to All Applicants								Only for Those First Eligible for Medicare Before 2020
Benefit	A	B	D	G	K	L	M	N	C	F
Part A coinsurance + 365 extra hospital days	✔	✔	✔	✔	✔	✔	✔	✔	✔	✔
Part B coinsurance or copayment	✔	✔	✔	✔	50%	75%	✔	✔*	✔	✔
Blood (first 3 pints)	✔	✔	✔	✔	50%	75%	✔	✔	✔	✔
Part A hospice care coinsurance or copayment	✔	✔	✔	✔	50%	75%	✔	✔	✔	✔
Skilled nursing facility coinsurance			✔	✔	50%	75%	✔	✔	✔	✔
Part A deductible		✔	✔	✔	50%	75%	50%	✔	✔	✔
Part B deductible									✔	✔
Part B excess charges				✔						✔
Foreign travel emergency			✔	✔			✔	✔	✔	✔
Out-of-pocket limit					$7,220	$3,610

Note: Benefits are standardized by plan letter. Plans C and F are only available to individuals who were first eligible for Medicare before January 1, 2020. Plan N may include certain copays for office and emergency room visits.

A DIFFERENT APPROACH

MEDICARE MEDICAL

SAVINGS ACCOUNT PLANS

Medicare MSA plans combine a high-deductible Medicare Advantage plan with a tax-free savings account — giving you more control over how you spend your healthcare dollars.

An MSA plan is a type of Medicare Advantage (Part C) plan offered by private insurers approved by Medicare. Like a Health Savings Account (HSA) in the commercial market, Medicare deposits money into your savings account each year — money you can use tax-free to pay for qualified medical expenses before your deductible is met.

This is a Paragraph Font

Am I required to sign up for Part A and B when I turn 65, if I have insurance through my employer?

If you continue working past age 65 and your employer has fewer than 20 employees, you must enroll in Medicare. Otherwise, your employer-sponsored insurance may deny your claims.

If your employer has 20 or more employees and provides coverage considered "creditable," you may choose to postpone enrolling in Medicare. You can then enroll whenever you decide to retire.

Upon retirement, your employer will complete a form verifying you had continuous creditable coverage after turning 65. You'll submit this form to the Social Security office to ensure you aren't charged any late-enrollment penalties.

In case you are worried about this advice, please reference this article on the Medicare.gov website. - https://www.medicare.gov/basics/get-started-with-medicare/medicare-basics/working-past-65

Can I have Medicare while I have an HSA through my employer insurance?

Once you enroll in Medicare Part A and/or Part B, you are no longer eligible to make contributions to a Health Savings Account (HSA). Many individuals turning 65 opt to retain their employer-sponsored coverage and enroll in Medicare Part A—since it typically carries no premium—while delaying Part B. While this approach is generally acceptable, enrolling even in just Part A means you must stop contributing to your HSA. To remain eligible to contribute to your HSA, you must delay enrollment in both Part A and Part B entirely. However, caution is needed—when enrolling in Medicare after age 65, Social Security often backdates Part A enrollment by up to six months. If you've contributed to your HSA during that retroactive period, it could lead to tax complications.

How much does Medicare cost?

Medicare costs vary depending on the specific coverage you choose and your income level.

Medicare Part A (Hospital Coverage): Most individuals qualify for premium-free Part A if they (or their spouse) have paid Medicare payroll taxes for at least 10 years (40 quarters). If not, Part A premiums can be as high as $518 per month in 2025.

Medicare Part B (Medical Coverage): The standard monthly premium for Part B in 2025 is $185. Higher-income individuals pay an additional premium known as the Income-Related Monthly Adjustment Amount (IRMAA). IRMAA is determined by your Modified Adjusted Gross Income from two years prior (your 2023 tax return affects your 2025 premiums). The higher your income, the greater the IRMAA surcharge you'll pay above the standard premium.

Medicare Part D (Prescription Drug Coverage): Monthly premiums vary widely by the insurance provider and chosen plan. Like Part B, high-income earners also pay an IRMAA surcharge on Part D premiums, based on income from two years earlier.

Medicare Advantage (Part C): These plans typically bundle medical and prescription drug coverage and often include additional benefits. Monthly premiums vary significantly by location, plan provider, and benefits. Many plans feature low or even $0 monthly premiums.

Medicare Supplement (Medigap) Plans: Supplement premiums vary widely depending on the insurance company, the chosen plan type, your age, gender, tobacco use, and geographic location. Generally, monthly premiums range anywhere from approximately $100 to over $300 per month. Supplements help cover the costs that Original Medicare doesn't pay (like deductibles, coinsurance, and copayments), potentially reducing your out-of-pocket expenses significantly.

It's essential to review your income level and chosen coverage carefully to determine your exact Medicare costs and budget accordingly.

Is there a cap on my out-of-pocket expenses with Medicare?

It depends on the type of Medicare coverage you select:

Original Medicare (Parts A & B): Original Medicare does not have an annual out-of-pocket maximum. Therefore, there's no limit on how much you might pay in medical expenses each year. To mitigate this risk, many people opt for a Medicare Supplement (Medigap) plan, which helps limit or cover these costs.

Medicare Advantage (Part C): Medicare Advantage plans are legally required to set an annual Maximum Out-of-Pocket (MOOP). For 2025, the highest allowable MOOP for in-network medical services is $9,350, although many plans offer significantly lower limits. After reaching this limit, the plan covers 100% of covered medical costs for the remainder of the year.

Medicare Part D (Prescription Drug Coverage): Beginning in 2025, Medicare Part D plans will have a newly established annual out-of-pocket maximum of $2,000 for prescription drug expenses. Once you reach this limit, you won't pay anything further for covered prescription medications for the remainder of that calendar year.

It's important to note that many Medicare Advantage (Part C) plans also include prescription drug coverage (Part D). In these cases, each portion (medical and prescription drugs) has its own separate maximum out-of-pocket limit. For example, in a Medicare Advantage plan that includes prescription coverage, it's possible you could reach both limits independently. The combined maximum amount you could pay out-of-pocket for medical and prescription expenses in a calendar year could total up to $11,350 in 2025 (the $9,350 medical maximum plus the $2,000 drug maximum allowed under combined Medicare Advantage plans).

Note: The combined maximum limit ($11,350) mentioned here includes the Part D maximum ($2,000) specifically allowed for Medicare Advantage plans (Part C with Part D), which slightly differs from the $2,000 Part D standalone limit.

Carefully reviewing these limits can help ensure your Medicare coverage adequately protects you financially, matching both your budget and healthcare needs.

Does Medicare cover pre existing conditions?

Yes, Medicare fully covers pre-existing conditions. Original Medicare (Parts A and B) does not exclude coverage or impose waiting periods based on your health history or pre-existing medical conditions.

Additionally:

Medicare Advantage (Part C): Plans must also accept you regardless of pre-existing conditions, and you cannot be denied coverage or charged more because of them.

Medicare Supplement (Medigap): If you apply during your Medigap Open Enrollment Period (which starts the month you're 65 or older and enrolled in Medicare Part B and lasts for 6 months), you cannot be denied coverage or charged higher premiums due to pre-existing conditions. If you apply after this enrollment period, insurers might consider your health status and could apply waiting periods or higher premiums based on pre-existing conditions.

In short, Medicare provides comprehensive protection and coverage for your healthcare needs, regardless of your medical history.

Can I have both a Medicare Advantage Plan and a Medigap Plan?

No, you cannot have both a Medicare Advantage (Part C) plan and a Medigap (Medicare Supplement) plan at the same time.

Medicare Advantage plans are all-in-one alternatives to Original Medicare, often including hospital, medical, and sometimes prescription drug coverage. These plans are administered by private insurance companies and come with their own provider networks, copays, and out-of-pocket limits.

Medigap plans, on the other hand, are designed to work only with Original Medicare (Parts A & B)—not with Medicare Advantage. They help cover some or all of the out-of-pocket costs like deductibles, coinsurance, and copayments that Original Medicare doesn’t pay.

If you’re currently enrolled in a Medicare Advantage plan and decide to return to Original Medicare, you can apply for a Medigap (Medicare Supplement) plan. However, it’s important to understand that you may be subject to medical underwriting unless you qualify for a guaranteed issue right or are within a Medigap Open Enrollment Period.

This means that, depending on your health at the time of application, the insurance company may deny coverage, impose waiting periods, or charge higher premiums. Before making the switch, it's wise to research your eligibility and speak with a licensed agent to ensure the transition to a Medigap plan is possible in your situation.

What if I move to a new state?

When you move across state lines, you’ll usually need to choose a new Medicare plan since most coverage is state-specific. Some Medicare Supplement plans can move with you, but it’s always a good idea to check with your agent or insurance company to be sure. Medicare generally gives you a 60-day window to enroll in a new plan after your move, so it’s important to act quickly to avoid losing options.

How do I compare plans and make a decision?

The easiest way is to work with a licensed insurance broker. We understand the differences between plans and can quickly narrow down which options fit your doctors, prescriptions, and budget. With more than 50 plans to sort through, doing it on your own can feel overwhelming. Best of all, our services are completely free to you, and you’ll never pay more for a plan by working with a broker than if you enrolled directly.

Does Medicare cover dental, vision, or hearing?

Original Medicare (Parts A and B) does not cover most routine dental care, vision exams, eyeglasses, or hearing aids. It mainly covers medical services—like hospital stays, doctor visits, and preventive screenings.

If you want coverage for dental, vision, or hearing, there are two main options:

- Medicare Advantage (Part C) plans: Many of these include extra benefits such as dental cleanings, eye exams, glasses, and hearing aids. The level of coverage varies by plan.

- Standalone insurance plans: You can also purchase separate dental, vision, or hearing policies to fill these gaps.

So, while Medicare by itself doesn’t provide these benefits, you do have ways to add them on.

Can I switch my plan later?

Yes, but when you can switch depends on the type of plan you have. Medicare has specific enrollment periods each year when changes are allowed. For example, during the Annual Enrollment Period (Oct. 15–Dec. 7), you can switch Medicare Advantage or Part D drug plans. Special Enrollment Periods may also apply if you move, lose other coverage, or experience certain life changes.

For Medigap (Medicare Supplement) plans in Idaho and some other states, you also get a special “Birthday Rule” each year. During the 63 days following your birthday, you can switch to another plan of equal or lesser benefits without medical underwriting.

In some other states, you would have to pass a health underwriting process to be able to switch supplement plans.

Will I get penalized if I don’t sign up for Medicare on time?

Yes, there can be penalties if you delay enrolling in Medicare when you’re first eligible—unless you qualify for special exceptions. For example:

-Part B (medical insurance): If you don’t sign up when you’re first eligible and don’t have other creditable coverage (like employer insurance), you may pay a late enrollment penalty that increases your monthly premium for life.

-Part D (prescription drug coverage): If you go without creditable drug coverage for more than 63 days after your initial eligibility, you’ll likely pay a permanent penalty added to your premium.

-Medigap (supplements): If you wait beyond your initial 6-month Medigap window, you may have to go through medical underwriting and could be denied coverage or charged more.

The good news is, if you still have employer-sponsored health coverage, you may be able to delay without penalty. It’s best to talk with an agent to make sure you don’t miss a deadline.

When am I eligible for Medicare?

Most people become eligible for Medicare at age 65. Your Initial Enrollment Period begins three months before your 65th birthday month and lasts until three months after, giving you a 7-month window to sign up.

Some people qualify earlier if they have a disability, end-stage renal disease (ESRD), or ALS.

I’m already receiving Social Security. Do I need to sign up for Medicare?

If you’re already collecting Social Security benefits when you turn 65, you’ll usually be enrolled in Medicare automatically. You should get your red, white, and blue Medicare card in the mail a few months before your 65th birthday.

-Part A (hospital coverage): You’ll be enrolled automatically. Most people don’t pay a premium for Part A.

-Part B (medical coverage): You’ll also be enrolled automatically, and the monthly premium will be deducted from your Social Security check. If you don’t want Part B, you can decline it, but be careful, because dropping it could mean penalties later unless you have other qualifying coverage.

The opposite is true, if you are NOT taking Social Security, you WON'T be automatically enrolled in Medicare, and in that case, you would want to call our agency to help walk you through that process.

What if I missed my Initial Enrollment Period?

If you don’t sign up for Medicare during your Initial Enrollment Period (the 7 months around your 65th birthday), you still have opportunities to enroll:

-General Enrollment Period (GEP): Runs every year from January 1 to March 31. Your coverage will start the month after you sign up. However, if you didn’t have other qualifying coverage, you may face a late enrollment penalty.

-Special Enrollment Period (SEP): If you had creditable coverage, like through an employer or union, you may be able to delay Medicare without penalty. When that coverage ends, you’ll have an 8-month window to enroll in Part B.

Missing your Initial Enrollment doesn’t mean you’re out of luck, but it can affect both your costs and your options. It’s important to review your situation right away so you don’t get stuck with permanent penalties or gaps in coverage.