Medicare Knowledge Guide

Medicare is the government's health insurance program, mainly for people 65 and older. It helps pay for hospital stays, doctor visits, and prescription drugs. About 67-69 million Americans are covered by it in 2026.

Medicare is the federal health insurance program primarily for people age 65 and older, as well as certain younger people with disabilities or specific conditions like ESRD or ALS.

Medicare started in 1965 when President Johnson signed it into law. It was created because most older Americans couldn't get affordable health insurance on their own. Harry Truman was even the first person to sign up.

Medicare was signed into law on July 30, 1965, by President Lyndon B. Johnson to provide health coverage for Americans 65 and older who had limited access to affordable private insurance.

Medicare is split into four parts. Part A covers hospital stays, Part B covers doctor visits and outpatient care, Part C is Medicare Advantage (a private plan option), and Part D covers prescription drugs.

Medicare has four parts: Part A (hospital insurance), Part B (medical/outpatient insurance), Part C (Medicare Advantage), and Part D (prescription drug coverage).

Original Medicare is Parts A and B run directly by the government. It gives you wide freedom to use any doctor or hospital that accepts Medicare, but it doesn't cover prescriptions or cap how much you spend out of pocket.

Original Medicare refers to Parts A and B administered directly by the federal government, without the involvement of a private insurance company.

Medicare is for people 65 or older (or disabled), funded by the federal government. Medicaid is for people with low incomes regardless of age, run jointly by the federal government and each state. They're two separate programs, but some people get both.

Medicare is a federal age-based program for people 65+ (or disabled), while Medicaid is a joint federal-state program for low-income individuals of any age.

You can get Medicare at age 65, or earlier if you have a serious disability, kidney failure requiring dialysis, or ALS. You also need to be a U.S. citizen or have lived legally in the U.S. for at least 5 years.

You are eligible for Medicare if you are age 65 or older, or under 65 with a qualifying disability (after 24 months of SSDI), ESRD, or ALS.

You become eligible for Medicare when you turn 65. If your birthday is on the 1st of the month, Medicare actually starts a month earlier. Your enrollment window opens 3 months before your birthday month.

Medicare eligibility begins at age 65 — specifically on the first day of your birthday month (or the month before if your birthday is on the 1st of the month).

Yes, you can get Medicare before 65 if you have a serious disability. Most disability recipients wait 24 months after their SSDI benefits start. But if you have ALS or Lou Gehrig's disease, you get Medicare right away. Kidney failure patients typically get it after 3 months of dialysis.

Yes — people under 65 can qualify for Medicare after receiving SSDI benefits for 24 months, or immediately if they have ALS, or after 3 months of ESRD dialysis.

You don't have to be a U.S. citizen for Medicare, but you do need to be a permanent resident (green card holder) who has lived legally in the U.S. for at least 5 years. Other visa types generally don't qualify.

No — lawful permanent residents (green card holders) who have lived in the U.S. for at least 5 continuous years are also eligible for Medicare.

If you worked (and paid Medicare taxes) for at least 10 years, you get Part A (hospital coverage) for free. Less than that and you pay $311 or $565 per month depending on how many years you worked. You can still get Medicare either way.

You need at least 40 quarters (10 years) of Medicare-covered work to receive premium-free Part A; fewer quarters means you can still enroll but pay a monthly premium.

When you turn 65, you get a 7-month window to sign up for Medicare — 3 months before your birthday, the birthday month itself, and 3 months after. Signing up in the first 3 months gives you the earliest coverage start. Wait too long and your coverage gets delayed.

The IEP is a 7-month window centered around your 65th birthday: 3 months before your birthday month, your birthday month, and 3 months after.

If you sign up for Medicare 3 months before your 65th birthday, coverage starts right on your birthday. Sign up during your birthday month and it starts the following month. Wait until after your birthday and there can be a 2-3 month delay before coverage kicks in.

Enrollment timing during the IEP determines when coverage starts: enrolling in the 3 months before your birthday month starts coverage the 1st of your birthday month; enrolling in months 5-7 delays start by 1-3 months.

If you miss your normal Medicare enrollment window (the IEP), you have a second chance every year from January 1 to March 31 — called the GEP. But coverage doesn't start until July 1, so you could be uninsured for months. There are also permanent penalties for the delay.

The GEP runs January 1–March 31 each year and allows people who missed their IEP to sign up for Medicare Parts A and/or B, with coverage starting July 1 of that year.

Every year from October 15 to December 7, Medicare beneficiaries can shop for new plans and make changes. It's called the Annual Enrollment Period. Any changes you make take effect January 1. This is when you should review your plan each year to make sure it still fits your needs.

The AEP (also called Open Enrollment Period) runs October 15 – December 7 each year and allows all Medicare beneficiaries to change their Medicare Advantage or Part D plan, with changes effective January 1.

If you're in a Medicare Advantage plan and want to make a change early in the year, you can do it from January 1 to March 31. This is the MA OEP. You get one change — either switch to a different MA plan or go back to Original Medicare. If you're already in Original Medicare, this period doesn't apply to you.

The MA OEP runs January 1–March 31 each year and allows people currently enrolled in a Medicare Advantage plan to make ONE change — either switch to a different MA plan or switch to Original Medicare.

Part A is the hospital part of Medicare. It covers your costs when you're admitted to a hospital, in a nursing home for rehabilitation, getting care at home from skilled nurses, or in hospice. It does NOT cover long-term care or nursing home stays that are just for personal care.

Medicare Part A is hospital insurance that covers inpatient hospital stays, skilled nursing facility care, home health care, and hospice services.

Most people don't pay anything for Part A because they worked long enough and paid Medicare taxes during their career. If you worked less than 10 years, you'll pay a monthly premium — up to $565/month in 2026 for those with very limited work history.

Most people pay $0 for Part A because they or their spouse worked and paid Medicare taxes for at least 40 quarters (10 years). Those with 30–39 quarters pay $311/month; those with fewer than 30 quarters pay $565/month.

When you're admitted to the hospital, Medicare charges you $1,736 in 2026 before it starts paying. The good news is that's per hospital stay (more precisely per 'benefit period'), not per year — but if you're hospitalized multiple times, you could pay it more than once. Medigap plans like Plan G cover this automatically.

The Part A inpatient hospital deductible is $1,736 per benefit period in 2026, which increased $60 from $1,676 in 2025.

Medicare covers most of your hospital bill for the first 60 days (after the $1,736 deductible). From days 61–90, you pay $434/day out of pocket. After day 90, you're using 'lifetime reserve days' at $868/day — and you only get 60 of those in your entire life. After all that's used up, you pay everything yourself.

After the $1,736 deductible, days 1–60 are covered at $0; days 61–90 cost $434/day; lifetime reserve days 91–150 cost $868/day; after 150 days, you pay all costs.

A 'benefit period' is basically your hospital episode for Medicare purposes. It starts when you go in and ends 60 days after you've been out. Each new benefit period means a new $1,736 deductible. So if you get sick again a few months later, you could owe it again.

A benefit period is the unit Medicare uses to measure your hospital and SNF coverage — it begins on the day you are admitted as an inpatient and ends when you have been out of a hospital or SNF for 60 consecutive days.

Part B is the 'doctor and outpatient' part of Medicare. It pays for visits to your regular doctor, specialists, lab tests, X-rays, outpatient surgeries, and medical equipment like wheelchairs. You pay a monthly premium for Part B, plus a $283 annual deductible and then usually 20% of each bill.

Medicare Part B is Medical Insurance that covers outpatient services including doctor visits, preventive care, outpatient hospital care, durable medical equipment, ambulance services, and mental health services.

Most people pay $202.90 per month for Part B in 2026. If your income is higher (generally above $109,000/year single), you'll pay more — up to $689.90/month at the highest income level. Medicare looks at your tax return from 2 years ago to decide which bracket you're in.

The standard Medicare Part B premium is $202.90/month in 2026, an increase of $17.90 from $185.00/month in 2025. Higher-income beneficiaries pay more due to IRMAA surcharges.

Medicare Part B has a $283 annual deductible in 2026. Once you pay that, Medicare pays 80% of your medical bills and you pay 20%. Preventive care — like your annual wellness visit, shots, and most cancer screenings — is free and doesn't count against the deductible.

The annual Medicare Part B deductible is $283 in 2026, up from $257 in 2025. Once met, you generally pay 20% coinsurance for covered services.

There's no yearly limit on what you could owe under Original Medicare. You always pay 20% — no matter how big the bill. That means if you have a $500,000 cancer treatment, you could owe $100,000. This is why Medigap (like Plan G) is so important — it pays that 20% for you, capping your exposure at just the $283 deductible plus your Medigap premium.

No — under Original Medicare, there is no cap on Part B coinsurance. If you have a very large medical bill, you could owe 20% of an unlimited amount. Medigap plans cover this gap.

When a doctor 'takes Medicare assignment,' they agree to charge only what Medicare says is fair. You pay 20% of that approved amount. If a doctor doesn't take assignment, they can charge up to 15% more on top of what Medicare approves — and you'd owe all of it. Very few doctors opt out of Medicare entirely, but it's worth checking.

A doctor who accepts assignment agrees to accept the Medicare-approved amount as full payment, meaning you only pay your 20% coinsurance. Doctors who don't accept assignment can charge up to 15% more above the approved amount.

Medicare Advantage is an 'all-in-one' alternative to Original Medicare, offered by private insurance companies. Instead of going through Medicare directly, you use a private plan that bundles your hospital coverage, doctor coverage, and usually drug coverage together. These plans often include extras like dental and vision that regular Medicare doesn't cover.

Medicare Advantage (Part C) is an alternative way to receive Medicare benefits through a private, CMS-approved insurance plan that must cover everything Original Medicare covers and often includes extra benefits like dental, vision, and drug coverage.

About 35 million people are in Medicare Advantage in 2026 — that's more than half of all Medicare beneficiaries. The program has been growing steadily for years, fueled largely by plans for people with special needs (like those on both Medicare and Medicaid). Despite some big insurers pulling back on benefits, enrollment kept growing.

As of February 2026, approximately 35 million people are enrolled in Medicare Advantage, representing about 51% of all eligible Medicare beneficiaries — an increase of 1.1 million from February 2025.

There are four main types of Medicare Advantage plans: HMO (most restrictive but lowest cost — you need referrals and must stay in network), PPO (more flexible — see any doctor but pay more out of network), PFFS (any doctor who accepts the plan's terms), and SNP (plans for people with special situations like Medicaid, chronic illness, or nursing home residence).

The main MA plan types are HMO, PPO, PFFS, and SNP. HMOs require a primary care doctor and referrals; PPOs offer more flexibility; PFFS plans allow any provider who accepts plan terms; SNPs target specific populations.

Most Medicare Advantage plans cost $0 per month in 2026 — 88% of them. But you still pay your regular Medicare Part B premium of $202.90/month. So your total Medicare cost in an MA plan is usually just $202.90/month plus whatever your plan charges (often nothing). Some plans even offer a 'giveback' that partially offsets your Part B premium.

The average Medicare Advantage plan premium is $4/month in 2026 (down from $5 in 2025), and 88% of MA plans have a $0 monthly premium. Beneficiaries also continue to pay the standard Part B premium of $202.90/month.

Every Medicare Advantage plan has a yearly cap on what you can spend out of pocket. On average, that cap is $6,153 in 2026. Once you hit that limit, the plan pays 100% for the rest of the year. This is a major protection — Original Medicare has no spending cap at all. SNP plans for Medicaid-eligible people often have much lower limits.

The average Medicare Advantage out-of-pocket maximum is $6,153 in 2026 (up from $5,749 in 2025). The CMS statutory maximum for in-network costs is $9,350; for combined in- and out-of-network, it can be higher.

Part D is Medicare's drug coverage program. You enroll in a private drug plan approved by Medicare — either standalone or bundled with Medicare Advantage. The plan helps pay for your prescription medications. As of 2026, your total drug spending is capped at $2,100 per year — once you hit that, all your covered drugs are free for the rest of the year.

Medicare Part D is the voluntary prescription drug coverage program, offered through private insurance plans approved by CMS. It covers outpatient prescription drugs and has a standard benefit structure with deductibles, copays, and an annual OOP cap of $2,100 in 2026.

In 2026, once you spend $2,100 out of your own pocket on covered prescription drugs, Medicare picks up the rest for the year. This is a huge change — before 2025, people could spend $8,000 on drugs before hitting the catastrophic phase. The $2,100 is automatically tracked by your plan — you don't have to do anything when you hit it.

The Medicare Part D annual out-of-pocket cap is $2,100 in 2026 (up from $2,000 in 2025). Once you spend $2,100 on covered Part D drugs, your plan pays 100% of covered drug costs for the rest of the year.

Most Part D plans charge you up to $615 for the first drugs you buy each year before the plan starts helping — that's the deductible. Some plans charge less or $0, but then they usually charge more per prescription. You pay this once per year (calendar year), and after that, your copays kick in.

The maximum Part D deductible for 2026 is $615 per year. Individual plans may have lower deductibles or no deductible at all — plans set their own deductible up to this CMS maximum.

In 2026, Part D works in three steps. First, you pay your deductible (up to $615). Then, you and your plan share the drug costs together until your out-of-pocket total hits $2,100 for the year. After that, all your covered drugs are free for the rest of the year. The old 'donut hole' coverage gap was eliminated in 2025 — no more.

Part D now has three phases in 2026: (1) Deductible phase (pay up to $615), (2) Initial coverage phase (plan and you share costs until you've spent $2,100 OOP), (3) Catastrophic phase (plan pays 100% of covered drugs after $2,100 OOP).

Drug plan premiums range widely. The typical standalone drug plan costs around $46.50/month on average in 2026. Some cost as little as $5–$10/month (with higher copays), others $80–$100+/month (with lower copays). Higher earners pay an extra IRMAA surcharge on top. If you're in a Medicare Advantage plan, drug coverage is usually included in your plan with no separate drug premium.

Part D premiums vary by plan. The CMS national base beneficiary premium is $38.99/month in 2026. Average standalone PDP premiums are approximately $46.50/month. Higher-income beneficiaries pay more due to IRMAA surcharges.

Here's the Medicare cost cheat sheet for 2026: Part B is $202.90/month with a $283/year deductible and 20% coinsurance after that. Part A is free for most people, but has a $1,736 deductible per hospital stay. Drug plans average $46.50/month with a $2,100 annual drug spending cap. Medicare Advantage plans average just $4/month extra and cap your medical costs around $6,153. Higher earners pay more due to IRMAA.

Key 2026 Medicare costs: Part A — $0 premium (most), $1,736 hospital deductible; Part B — $202.90/month premium, $283 deductible; Part D — $38.99 base premium, $615 max deductible, $2,100 OOP cap; MA — average $4/month, $6,153 average OOP max.

For hospitals in 2026: you pay $1,736 upfront for each hospital episode, then nothing for the first 60 days, then $434/day from days 61–90. Nursing home care after a hospital stay is free for 20 days, then $217/day. Hospice and home health are essentially free for covered services. Most people pay $0 for Part A itself — it's already paid through Medicare taxes.

Part A 2026 costs: $0 premium (40+ quarters); $311/month (30-39 quarters); $565/month (under 30 quarters); $1,736/benefit period deductible; $434/day coinsurance days 61-90; $868/day lifetime reserve; $217/day SNF days 21-100.

Part B costs $202.90/month in 2026 (more if your income is high). You also have a $283/year deductible, then 20% of every covered service — with no limit on what you could owe. Labs and preventive care are free. If you signed up late, you pay an extra 10% per year late — forever.

Part B 2026 costs: $202.90/month standard premium; $283 annual deductible; 20% coinsurance for most services (no OOP cap); $0 for preventive services and clinical lab tests. IRMAA applies for income above $109,000 (single).

IRMAA is extra money high-income people pay for Medicare. For 2026, if you're single and made over $109,000 in 2024, you'll pay more. At the highest level ($500K+ income), your Part B premium is $689.90/month and you pay an extra $91.00/month on Part D. The brackets apply to 2024 income — not current income. You can appeal if your income dropped significantly.

IRMAA 2026 brackets (based on 2024 MAGI): Single income ≤$109K pays standard rates ($202.90 Part B, $0 Part D extra). Upper brackets reach $689.90/month Part B and $91.00/month Part D extra for income $500K+ (single).

In 2026, a typical Medicare beneficiary with Original Medicare plus a Medigap Plan G and a drug plan will pay roughly $5,600–$6,500 total for the year — mostly fixed monthly premiums with very little unpredictable spending. A Medicare Advantage enrollee pays about $2,400 in Part B premiums, then has copays up to an average $6,153 cap if health is bad. Going with no supplemental coverage at all is a gamble — one serious illness under Original Medicare can cost tens of thousands of dollars.

A typical Original Medicare + Medigap Plan G + Part D beneficiary spends approximately $5,500–$6,500/year total in 2026. A Medicare Advantage enrollee on a $0-premium plan typically spends $2,400–$4,500/year depending on health utilization.

IRMAA is an extra charge added to your Medicare Part B and Part D monthly premiums if your income was above a certain amount two years ago. In 2026, it kicks in if you earned more than $109,000 as a single person or $218,000 as a married couple filing jointly in 2024. The higher your income was, the more you pay.

IRMAA (Income-Related Monthly Adjustment Amount) is a surcharge added to Part B and Part D premiums for higher-income Medicare beneficiaries whose MAGI exceeds $109,000 (single) or $218,000 (joint) based on their 2024 tax return.

Your Part B monthly premium in 2026 depends on what you earned in 2024. Most people pay $202.90 per month. But if you earned more than $109,000 single or $218,000 married, your premium goes up — all the way to $689.90 per month at the highest income level.

2026 Part B premiums range from $202.90/month (income ≤$109,000 single) to $689.90/month (income ≥$500,000 single), with six tiers based on 2024 MAGI.

If your income is above $109,000 (single) or $218,000 (married) in 2024, you'll pay an extra amount on top of your regular drug plan premium in 2026. This extra charge ranges from $14.50 to $91.00 per month depending on your income, and Medicare takes it out of your Social Security check.

2026 Part D IRMAA surcharges range from $0 (income ≤$109,000 single) to $91.00/month (income ≥$500,000 single), added on top of your Part D plan premium.

Your IRMAA-related income is basically everything on your tax return — wages, Social Security, retirement account withdrawals, investment gains — plus any interest from tax-free bonds like municipal bonds. Roth IRA withdrawals and HSA spending on medical costs don't count, which is why those accounts are so valuable for managing Medicare premiums.

For IRMAA, MAGI = Adjusted Gross Income (Form 1040, Line 11) plus tax-exempt interest income (Form 1040, Line 2a). This includes wages, RMDs, Roth conversions, capital gains, Social Security benefits, and municipal bond interest.

Medicare looks at your taxes from 2 years ago when deciding how much extra you pay for premiums this year. So in 2026, they're looking at your 2024 income. That's just because it takes time for the IRS to share that data with Social Security. If your income dropped recently due to retirement or another life event, you can appeal to use newer numbers.

Medicare uses a 2-year lookback because that is the most recent IRS tax data the SSA can access when setting premiums. For 2026 IRMAA, your 2024 federal tax return is used.

Most people get Part A for free because they or their spouse paid Medicare taxes for 10+ years. If you're one of the few who has to buy it and you sign up late, your monthly cost goes up by 10% for twice as long as you waited. So if you waited 2 years, you pay 10% extra for 4 years.

If you have to buy Part A and enroll late, your monthly premium increases by 10%. In 2026, that means $565/month x 10% = $56.50 extra per month. The penalty lasts for twice the number of years you delayed enrollment.

If you wait too long to sign up for Medicare Part B without a good reason (like having employer coverage), your monthly premium goes up 10% for every year you waited — and that extra charge stays with you forever. Two years late means a 20% higher premium, every month, for the rest of your life.

The Part B penalty is 10% added to the monthly premium for each full 12-month period you could have had Part B but didn't. It is permanent — you pay it for life. In 2026, 2 years late = $202.90 + $40.58 = $243.50/month.

If you go more than 2 months without drug coverage after Medicare eligibility begins, you'll owe a penalty on your drug plan premiums — forever. For every month you were without coverage, you pay 1% extra based on Medicare's national base premium of $38.99 in 2026. It's a small amount per month, but it adds up over a lifetime and changes each year.

The Part D penalty is 1% of the national base beneficiary premium ($38.99 in 2026) per month without creditable drug coverage. A 14-month gap = 14% x $38.99 = $5.46/month rounded to $5.50/month, added permanently to your Part D premium.

Creditable coverage means your existing insurance is good enough that Medicare considers it a valid reason to wait before enrolling. As long as you have this kind of coverage from a job, VA, TRICARE, or other qualifying sources, you won't be penalized for delaying Medicare. Your employer or insurance plan is required to tell you each year whether your coverage counts.

Creditable coverage is drug or health coverage that is at least as good as Medicare's standard coverage. Having creditable coverage allows you to delay Medicare enrollment without incurring late enrollment penalties.

When you leave a job (or your employer stops covering you), you have 8 months to sign up for Part B without being penalized. This window starts when your job coverage ends — not when COBRA runs out. If you switch to COBRA thinking that buys you more time for Part B, it does not. The 8-month clock is already running.

After losing employer group health coverage (or stopping active work), you have an 8-month SEP to sign up for Part B without penalty. The SEP begins on the first month after the employment or group coverage ends, whichever comes first.

Medigap fills in what Medicare misses. Original Medicare has deductibles and you pay 20% of most costs — Medigap picks up most or all of that. You still need a separate drug plan. Think of Medigap as the 'safety net' under Original Medicare that keeps your out-of-pocket costs predictable.

Medigap is private insurance that fills the gaps in Original Medicare — covering costs like the Part A deductible ($1,736), Part B coinsurance (20%), and more. There are 10 standardized plans (A, B, C, D, F, G, K, L, M, N), each with a different coverage level.

Plan G is the gold standard for Medigap coverage right now. It pays almost everything Medicare doesn't — hospital bills, the 20% coinsurance on doctor visits, skilled nursing costs, and even medical emergencies abroad. The only thing you personally pay is the Part B deductible, which is just $283 per year. After that, your costs are essentially zero for covered services. Average cost: around $220 per month.

Plan G covers nearly everything Original Medicare doesn't — including the Part A deductible, Part A coinsurance, Part B coinsurance (20%), skilled nursing coinsurance, and foreign travel emergency (80%). The only cost not covered is the Part B deductible ($283 in 2026). Average premium is ~$220/month.

Plan N is like Plan G's more affordable sibling. You save about $50 per month in premium, but you'll pay up to $20 when you go to the doctor and up to $50 for ER visits. You also need to make sure your doctors 'accept assignment' — meaning they charge exactly what Medicare approves — otherwise you could owe extra. For healthy people who don't see doctors often, Plan N can be a good deal.

Plan N covers the same core benefits as Plan G except it does NOT cover Part B excess charges and requires copays of up to $20 for office visits and $50 for emergency room visits. Average premium is ~$171/month.

Plan F is the most comprehensive Medigap plan — it covers everything including that $283 yearly Part B deductible. But it's closed to anyone who became Medicare-eligible after January 1, 2020. If you turned 65 before that date, you might still be able to get it, but you'd likely need to pass a health review since your enrollment window may have passed.

Plan F is only available to beneficiaries who were Medicare-eligible before January 1, 2020. Those who first became eligible for Medicare on or after January 1, 2020 cannot enroll in Plan F.

High-deductible Plan G works like a high-deductible health plan — you pay everything up to $2,950 per year on your own, but after that the plan covers almost everything. The monthly premium is much lower (around $50–$100/month) because you're taking on more initial risk. If you're healthy and rarely need major care, you could save a lot compared to a standard Plan G at $220/month.

High-deductible Plan G (and Plan F for eligible individuals) requires you to pay a $2,950 deductible in 2026 before the plan begins paying. In exchange, premiums are significantly lower — making it ideal for healthy beneficiaries who want catastrophic protection.

Your best chance to get Medigap is in the 6 months after you turn 65 AND enroll in Part B. During this window, insurance companies must sell you a plan at the same price as anyone else, no matter your health history. After this window closes, they can turn you down or charge you more based on your health.

The Medigap Open Enrollment Period (OEP) is a 6-month window that begins on the first day of the month in which you are both age 65 or older AND enrolled in Medicare Part B. During this period, you have guaranteed issue rights — no medical underwriting.

Guaranteed issue rights mean an insurer has to sell you Medigap without asking about your health or turning you down. You get these rights during your 6-month enrollment window at 65, but also in other situations — like when your Medicare Advantage plan leaves the market or you lose employer coverage. If you have guaranteed issue rights, use them — it's your best chance to get Medigap without medical questions.

Guaranteed issue rights mean that insurers must sell you a Medigap policy at standard rates without requiring medical underwriting. These rights apply during the Medigap OEP and in specific qualifying situations.

If you miss the enrollment window at 65 and try to get Medigap later, the insurance company can ask you all about your health history. If they don't like what they see, they can turn you down completely — or charge you more and exclude coverage for certain conditions. This is why enrolling during the 6-month window is so critical.

Medical underwriting is the process insurers use to evaluate your health and decide whether to offer you Medigap coverage, at what price, and with what exclusions. Outside the OEP and without guaranteed issue rights, insurers can deny you, charge more, or exclude pre-existing conditions.

If you enroll during your 6-month window at 65, you're protected — no waiting period for pre-existing conditions in the main standardized plans. But if you try to enroll later without a qualifying event, the insurance company can make you wait for coverage of conditions you already have, or they might turn you down completely. The 6-month window is your protection.

During the Medigap OEP with guaranteed issue rights, pre-existing condition exclusions are limited — some older standardized plans may have a 6-month waiting period for conditions treated in the prior 6 months. Outside the OEP without guaranteed issue, underwriting can exclude or deny conditions entirely.

If you're under 65 and on Medicare because of a disability, getting Medigap can be difficult and expensive. Federal rules don't require insurers to sell to you, but about two-thirds of states do. If Medigap is too expensive or unavailable, Medicare Advantage may be a more accessible alternative — most MA plans accept all Medicare beneficiaries regardless of age.

Federal law does not require Medigap insurers to sell to those under 65. However, about 33 states mandate at least one Medigap plan be available to under-65 Medicare beneficiaries (due to disability), though pricing may be significantly higher.

If you're still working at 65 with employer insurance, whether you need Medicare right away depends on your employer's size. Big company (20+ employees)? You can keep using just the employer plan and delay Medicare Part B penalty-free. Small company (under 20 employees)? Medicare needs to be your main insurance — sign up for Part B right away.

If your employer has 20+ employees, your employer plan is primary and Medicare is secondary. You can delay Part B without penalty. If your employer has fewer than 20 employees, Medicare is primary — you should enroll in Part B at 65.

Medicare Secondary Payer means Medicare steps back and lets your other insurance pay first. This happens when you have employer coverage, are in a workers' comp situation, or have auto insurance involved in a medical claim. Medicare pays the remainder — but only if the primary payer hasn't already covered the full cost.

Medicare Secondary Payer (MSP) means Medicare pays after another insurer (employer plan, auto insurance, workers' comp) has paid first. This applies when employer coverage, ESRD coordination, liability insurance, or workers' compensation is involved.

With both Medicare and employer insurance, one pays the first bill and the other picks up what's left. If you're at a big company, your employer insurance goes first and Medicare pays the leftover. If you're at a small company, Medicare goes first and employer insurance covers the rest. Together, they often cover 100% of the approved costs.

When both Medicare and an employer health plan exist, one pays primary and the other pays secondary. The primary payer is determined by MSP rules (employer size, disability status, etc.). The secondary payer fills in remaining covered costs after the primary has paid.

The 20-employee rule checks if your employer had at least 20 people on the payroll during at least 20 weeks of the year (or last year). It counts everyone — part-timers, too. If your employer has been around 20 people for 20 weeks, their health insurance has to pay your bills first before Medicare does.

The employer must have had 20 or more employees on each working day in at least 20 calendar weeks during the current or preceding calendar year. All employees — full-time and part-time — are counted.

If you're on Medicare because of a disability and you're still working, the rules are stricter. Your employer needs to have 100 or more employees (not just 20) for your employer insurance to pay your bills first. Smaller companies mean Medicare steps in as the first payer, even for disabled workers under 65.

For disabled (under 65) Medicare beneficiaries, the employer must have 100 or more employees for the group health plan to be primary over Medicare. At fewer than 100 employees, Medicare is primary.

Being dually eligible means you have both Medicare and Medicaid covering you at the same time. Medicare pays your medical bills first, then Medicaid picks up some or all of the remaining costs depending on which Medicaid program you're enrolled in.

Dual eligibility means a person qualifies for both Medicare and Medicaid simultaneously, receiving coverage from both programs.

There are four programs that help people with limited income pay their Medicare costs. QMB is the most comprehensive and covers almost all Medicare cost-sharing. SLMB and QI cover the Part B monthly premium. QDWI is for specific disabled workers and covers the Part A premium.

The four MSPs are QMB, SLMB, QI, and QDWI — each pays a different set of Medicare costs based on income level.

To qualify for QMB in 2026, a single person can earn up to $1,350 per month and have up to $9,950 in savings or investments. A married couple can earn up to $1,824 per month and have up to $14,910 in countable resources. Your home and one car don't count toward the resource limit.

In 2026, QMB income limits are $1,350/month for individuals and $1,824/month for couples; resource limits are $9,950 and $14,910 respectively.

If you're enrolled in QMB, doctors and hospitals that take Medicare are not allowed to send you a bill for deductibles or copays. The government pays those costs. If you receive a bill, you can dispute it — you don't owe it.

No — providers who accept Medicare are legally prohibited from billing QMB enrollees for Medicare cost-sharing, including deductibles, copays, and coinsurance.

To qualify for SLMB in 2026, a single person needs monthly income of $1,616 or less, and savings under $9,950. If you qualify, the program pays your $202.90 monthly Medicare Part B premium — that's over $2,400 in savings each year. It won't cover your copays or deductibles, but the premium help is still significant.

In 2026, SLMB income limits are $1,616/month for individuals and $2,184/month for couples; resource limits are $9,950 and $14,910.

The Welcome to Medicare visit is a free one-time checkup you get during your first year on Medicare Part B. Your doctor will review your health, check your vitals, talk about screenings, and help you plan preventive care. There's no copay, no deductible — it's completely free.

The Welcome to Medicare visit (IPPE) is a one-time preventive visit available within the first 12 months of enrolling in Part B, covered at $0.

The Annual Wellness Visit is your free yearly Medicare checkup — available every 12 months with no cost to you. It's different from the one-time Welcome to Medicare visit. It's also not a full physical — it's focused on your health risk factors, screening for memory issues, fall risks, and planning your preventive care for the coming year.

The AWV is a yearly $0 preventive visit available after 12 months of Part B; unlike the IPPE, it focuses on a personalized prevention plan and can be repeated annually.

At the Annual Wellness Visit, your doctor goes through a checklist of preventive items: your health history, medications, blood pressure, BMI, memory screening, fall risk, depression screening, and they create a plan for all the screenings you should get over the next several years. Everything in the AWV itself is free — no bills.

The AWV includes a health risk assessment, cognitive screening, depression screening, fall risk evaluation, medication review, and a personalized prevention plan — all at $0.

For your free preventive services under Medicare, you don't pay the Part B deductible and you don't pay the 20% coinsurance — they're covered at 100%. However, if your doctor treats an illness or orders a diagnostic test during the same visit, those portions can cost you money. Be aware that a screening colonoscopy that finds and removes a polyp can become partly diagnostic and may trigger cost-sharing.

No — Medicare-covered preventive services are exempt from the Part B deductible ($283 in 2026) and are covered at $0 for the preventive component.

If you're a woman age 40 or older, Medicare pays for one mammogram every year with no cost to you. If you're between 35 and 39, you can get one baseline mammogram for free. If your doctor orders a mammogram because of a specific concern or symptom, it becomes diagnostic and you may owe your deductible and 20% coinsurance.

Medicare covers one screening mammogram per year at $0 for women 40 and older; one baseline mammogram is also covered for women ages 35–39.

If you're on Original Medicare and need a cleaning, filling, or dentures, you'll pay everything yourself — Medicare won't help. Your best options are a Medicare Advantage plan, a standalone dental plan, or a discount dental program.

No. Original Medicare (Parts A and B) does not cover routine dental care including cleanings, fillings, extractions, root canals, or dentures.

Original Medicare won't pay for your yearly eye exam or glasses. It will cover treatment for serious eye diseases like glaucoma or cataracts. For routine vision coverage, you'd need a Medicare Advantage plan or a separate vision plan.

No. Medicare does not cover routine eye exams for prescription glasses, eyeglasses, or contact lenses, except following cataract surgery.

Medicare won't cover hearing aids or the exam to get fitted for them. These can cost thousands of dollars per ear. Many Medicare Advantage plans include a hearing benefit, and over-the-counter hearing aids are now an affordable option starting around $200.

No. Original Medicare does not cover hearing aids or exams for fitting hearing aids, though it may cover medically necessary hearing and balance exams.

Medicare won't pay for nursing home or assisted living if you just need help with daily activities. It will cover a short stay in a skilled nursing facility after a hospital stay, but only for up to 100 days and you pay $217/day after day 20. After that, you're on your own — which can cost over $11,000/month.

Medicare does not cover long-term custodial care in nursing homes or assisted living. It only covers up to 100 days of skilled nursing care following a qualifying 3-day hospital stay.

If you just need someone to help you shower, get dressed, or prepare meals at home, Medicare won't cover that. Medicare only covers home health when a nurse or therapist also needs to provide medical care. For personal care help, you'd need to pay privately, apply for Medicaid, or purchase long-term care insurance.

No. Medicare does not cover custodial home health care (help with bathing, dressing, meals, housekeeping) unless it's provided alongside skilled nursing or therapy services.

Under the Inflation Reduction Act, you can't pay more than $2,100 total out of pocket for your Medicare prescription drugs in 2026. Once you hit that limit, your drugs are free for the rest of the year. This is a huge change — before this law, some people paid tens of thousands of dollars annually on expensive medications.

The Inflation Reduction Act created a $2,100 annual out-of-pocket cap on Medicare Part D prescription drug costs, effective January 1, 2025, and continuing in 2026.

If you use insulin covered by Medicare Part D, you'll pay no more than $35 per month for each insulin product, no matter what it costs. The same $35 limit applies if you use an insulin pump (that's covered by Part B). This applies from the very first prescription — you don't have to meet a deductible first.

The Inflation Reduction Act caps Medicare Part D insulin costs at $35 per month per covered insulin product. The cap also applies to insulin covered under Part B (for insulin pumps) since July 2023.

Thanks to the Inflation Reduction Act, vaccines covered by your Medicare drug plan (Part D) are now completely free — no copay, no deductible. This is especially important for the shingles vaccine (Shingrix), which used to cost $50–$200 per dose but is now $0. Flu and pneumonia shots remain free under Part B as they always were.

Yes. The IRA eliminated cost-sharing for all adult vaccines recommended by ACIP and covered under Medicare Part D, making them available at $0 cost to Part D enrollees as of January 1, 2023.

For the first time ever, Medicare can now negotiate drug prices directly with drug companies. In 2026, 10 major drugs have new lower negotiated prices — saving beneficiaries and Medicare billions. More drugs will get negotiated prices in 2027 and 2028. The savings can be significant: one diabetes drug went from $527 to $113 per month.

The Inflation Reduction Act gave CMS the authority to directly negotiate drug prices with manufacturers for selected high-cost medications. For 2026, 10 Part D drugs have negotiated Maximum Fair Prices (MFPs).

Ten major Medicare drugs got negotiated price cuts in 2026. The biggest examples: Januvia (diabetes) dropped from $527 to $113/month — a 79% cut. Eliquis (blood clots) went from $521 to $231/month — a 56% cut. All 10 drugs treat serious conditions like diabetes, blood clots, heart failure, arthritis, and cancer. These new prices apply when you pick them up at the pharmacy.

The 10 Medicare-negotiated drugs effective January 1, 2026 are: Eliquis, Jardiance, Xarelto, Januvia, Farxiga, Entresto, Enbrel, Imbruvica, Stelara, and Fiasp/NovoLog (insulins).

If Medicare (or your Medicare plan) denies a claim you think should be covered, you have five chances to fight it. You start with a review by the original decision-maker, then escalate to independent reviewers, a judge, an appeals board, and finally federal court. Most cases are resolved at levels 1 or 2. To reach a judge's hearing, the disputed amount must be at least $200.

The 5 Medicare appeals levels are: (1) Redetermination by the plan or MAC, (2) Reconsideration by the QIC or IRE, (3) ALJ hearing (OMHA), (4) Medicare Appeals Council (MAC), and (5) Federal District Court.

The first step in a Medicare appeal is called a redetermination. You file it with whoever made the original decision — your plan (for MA or Part D) or the Medicare claims processor (for Original Medicare). You have 120 days from getting the denial to file. They must respond within 60 days normally, or 72 hours if it's urgent.

A redetermination is the first level of Medicare appeal, filed with the plan (MA/Part D) or Medicare Administrative Contractor (Original Medicare) within 120 days of receiving the denial. The plan has 60 days (standard) or 72 hours (expedited) to respond.

If your first appeal didn't work, Level 2 sends your case to a completely independent review organization. You have 180 days after the Level 1 decision to file. They're required to respond within 30 days (for Medicare Advantage) or 60 days (for Original Medicare). This independent review often catches errors that the original decision-maker missed.

Level 2 is a reconsideration by an independent review entity — the QIC (Qualified Independent Contractor) for Original Medicare or the IRE (Independent Review Entity) for MA and Part D. You have 180 days from the Level 1 decision to file.

Level 3 is a formal hearing before an independent federal judge. To get there, the amount you're fighting for must be at least $200 in 2026. You file within 60 days of the Level 2 denial. You can present evidence and testimony, and the judge makes an independent decision. This is a serious legal proceeding — consider getting SHIP counseling or legal help.

Level 3 is a hearing before an Administrative Law Judge at the Office of Medicare Hearings and Appeals (OMHA). In 2026, the amount in controversy must be at least $200 to request an ALJ hearing.

If the judge at Level 3 still rules against you, you can ask the Medicare Appeals Council (Level 4) to review the case. You have 60 days to file. This is a high-level review board within the federal health department. There's no minimum dollar amount required at this level. Both you and CMS can appeal the judge's decision here.

The Medicare Appeals Council (MAC), part of the HHS Departmental Appeals Board, reviews ALJ decisions. Beneficiaries can request MAC review within 60 days of an unfavorable ALJ decision.

Think of it on a spectrum: fraud is deliberate cheating, like making up services that never happened. Abuse is acting carelessly or against accepted practices in a way that costs Medicare money. Waste is simply being inefficient — ordering unnecessary tests, for example. All three harm Medicare and ultimately taxpayers.

Fraud is intentional deception for unauthorized benefit (e.g., billing for services never rendered). Waste is overutilization without intent to deceive. Abuse is practices inconsistent with sound medical or business practices that cause unnecessary costs.

The most common scams include billing for care you never got, inflating what care you did get, splitting bills to overcharge, paying doctors for referrals, and using your Medicare number to commit identity theft. Always review your Medicare statements and question any charges for care you don't remember receiving.

The most common Medicare fraud schemes include phantom billing (billing for services never provided), upcoding (billing for more expensive services than delivered), unbundling (billing separately for bundled services), kickbacks, and identity theft using Medicare numbers.

If you think someone is cheating Medicare, call 1-800-Medicare right away, or call the fraud hotline at 1-800-447-8477. You can also contact your local Senior Medicare Patrol (SMP) for free help. Reports can be anonymous, and in some cases, reporting fraud can result in a financial reward for the person who reports it.

Call 1-800-MEDICARE (1-800-633-4227) or the OIG hotline 1-800-HHS-TIPS (1-800-447-8477). You can also report online at oig.hhs.gov or get free assistance from your local Senior Medicare Patrol (SMP) by calling 1-877-808-2468.

The Senior Medicare Patrol is a free program run by trained volunteers who help Medicare beneficiaries detect and report fraud. They can meet with you one-on-one to review your Medicare statements, teach you what to watch for, and help you report anything suspicious — all at no cost.

The Senior Medicare Patrol (SMP) is a federally-funded program that empowers Medicare beneficiaries through trained volunteers to prevent, detect, and report Medicare fraud, waste, and abuse — available in all 50 states at no cost.

The Anti-Kickback Statute means you can't pay for patient referrals or receive payments for steering clients to certain plans or providers. As an agent, this also means your gifts to clients must be small — generally $15 or less per item, up to $75 total per year. Violating this law can end your Medicare career.

The Anti-Kickback Statute (AKS) prohibits offering, paying, soliciting, or receiving anything of value to induce or reward referrals of Medicare business. Violations can result in criminal penalties, civil fines up to $100,000+ per violation, and exclusion from Medicare.

If you're under 65 and get Social Security disability payments, Medicare starts automatically after 2 years of receiving those payments. You don't have to apply — Medicare enrollment is automatic once you've been on SSDI for 24 months. The 2-year wait is one of the toughest aspects of the system for people with serious disabilities.

Individuals under 65 qualify for Medicare after receiving Social Security Disability Insurance (SSDI) benefits for 24 consecutive months. They receive the same Medicare benefits as those 65 and older.

If you need regular dialysis or have had a kidney transplant, you can get Medicare at any age — not just after 65. There's a short 3-month wait for dialysis patients. Medicare covers the dialysis, the transplant surgery, and the medications needed to keep a transplanted kidney working.

Individuals with ESRD (permanent kidney failure requiring regular dialysis or transplant) qualify for Medicare regardless of age, after a 3-month waiting period from the start of regular dialysis, or immediately upon receiving a kidney transplant.

If you or a loved one is diagnosed with ALS, Medicare starts right away once Social Security disability payments begin — there's no 2-year wait like with other disabilities. This special rule was created because ALS progresses so quickly that waiting 2 years for coverage would be devastating.

People diagnosed with ALS receive Medicare immediately upon approval of SSDI benefits — there is no 24-month waiting period. ALS is the only disability with this immediate Medicare eligibility provision.

VA benefits and Medicare don't work together — they're two completely separate systems. When you go to a VA facility, use your VA card. When you go to a non-VA doctor or hospital, use your Medicare card. Medicare won't pay for anything at the VA, and the VA won't pay for anything outside the VA system. It's best to have both.

VA benefits and Medicare are completely separate — they do not coordinate benefits. Veterans must present their Medicare card at non-VA facilities and their VA card at VA facilities. Medicare will not pay for care received at VA facilities.

TRICARE for Life is a fantastic Medicare supplement for military retirees — it acts just like a Medigap plan, but free (you just pay the Part B premium). Medicare pays first and TRICARE picks up most of the rest, so your out-of-pocket costs are usually $0. You also keep your TRICARE pharmacy coverage instead of needing a Part D plan.

TRICARE for Life (TFL) is Medicare wrap-around coverage for military retirees who are Medicare-eligible. Medicare pays first; TRICARE for Life pays most remaining costs including deductibles and coinsurance, with most covered services costing $0 out-of-pocket.

Original Medicare lets you see any doctor or hospital in the country that accepts Medicare — no referrals needed — but has no cap on your costs, so a serious illness could cost tens of thousands. Medicare Advantage has network restrictions like a regular insurance plan but caps your annual out-of-pocket spending (average $6,153 in 2026) and often includes dental, vision, and hearing — usually at $0 monthly premium.

Original Medicare (Parts A and B) is a government fee-for-service program with nationwide provider access but no OOP maximum, while Medicare Advantage (Part C) is delivered through private insurers with network restrictions, a built-in OOP maximum (average $6,153 in 2026), and typically extra benefits.

Medigap is like a premium insurance plan on top of Medicare — you pay more each month but have little to no bills when you use it, and you can see any Medicare doctor anywhere. Medicare Advantage costs much less per month and often includes dental and vision, but it has network restrictions. It's a trade-off between predictability/freedom and lower upfront costs.

Medigap + Original Medicare offers maximum provider freedom and predictable costs (fixed monthly premium, low or zero cost-sharing), while Medicare Advantage offers lower premiums and extra benefits but with network restrictions. The right choice depends on your health, finances, and provider preferences.

With Original Medicare and a Medigap plan, you can see virtually any doctor or specialist in the country without permission — no referrals needed. Medicare Advantage HMO plans lock you into a network and typically require referrals to see specialists. If seeing your specific doctors or having unrestricted access matters most to you, Medigap wins on this dimension.

Original Medicare and Medigap have no network restrictions — any of the 94%+ of U.S. physicians who accept Medicare are available. Medicare Advantage HMOs restrict you to a network; PPOs allow out-of-network at higher cost.

If you split your time between Florida and New York, or travel internationally, Original Medicare with a Medigap plan is the better choice. You can see any Medicare doctor anywhere in the country. MA HMO plans only cover routine care within their local network — if you're in another state and need a specialist, you're mostly on your own.

Original Medicare + Medigap is best for frequent travelers — Medigap Plan G covers care at any Medicare provider nationwide and some plans (like C and F, for pre-2020 enrollees) cover limited foreign travel emergency care. MA HMO plans only cover non-emergency care in-network.

Original Medicare doesn't cover your regular prescription drugs — you need to add a Part D plan, which costs around $46.50/month on average. Medicare Advantage plans usually include drug coverage built in. Either way, your drug out-of-pocket costs are capped at $2,100 in 2026, and 10 major drugs now have lower negotiated prices.

Original Medicare (Parts A+B) has no drug coverage — you need a standalone Part D plan (avg. $46.50/month in 2026). Medicare Advantage with drug coverage (MA-PD) bundles drugs into the plan. The 2026 Part D OOP cap is $2,100 regardless of plan type.

The Scope of Appointment is a form you must have every Medicare client fill out before a sales meeting. It lists what Medicare products they agreed to hear about. You need it 48 hours before the meeting unless it's a walk-in or within the last 4 days of AEP/OEP. Keep these forms for 10 years — CMS can audit them.

A Scope of Appointment is a CMS-required form documenting which Medicare plan types a beneficiary agrees to discuss with an agent, and must be completed at least 48 hours before a personal marketing meeting (with limited same-day exceptions).

As a Medicare agent, CMS has strict rules you must follow: never cold call beneficiaries, always use the TPMO disclaimer (which lists how many plans you represent), collect the SOA 48 hours before meetings, never turn educational events into sales events, and record your marketing calls. Violations can result in fines, suspension, or loss of your ability to sell Medicare plans.

CMS 2026 marketing rules prohibit cold calling (unsolicited contact), require TPMO disclaimers on all marketing materials, mandate the 48-hour SOA rule, prohibit conducting sales at educational events, and require recording of all marketing calls made by TPMOs.

AEP is your most important selling season. Start your prep in August by getting certified and reviewing plan changes. When AEP opens on October 15, call your existing clients first — they're your easiest retention and cross-sell. Hold educational events mid-season to generate new leads. Try to complete most enrollments before Thanksgiving so you're not scrambling in the final days.

Effective AEP strategy (Oct 15 – Dec 7) focuses on current client reviews first (retention), systematic prospecting starting August-September, front-loading appointments early in AEP, using compliant digital and community marketing, and having all contracting and plan materials ready before Oct 15.

During January through March (OEP), Medicare Advantage members can switch plans once, but you as an agent cannot actively market or recruit switches. If a client calls you wanting to change their MA plan, you can absolutely help them. But don't use OEP as an excuse to call clients and push them to switch — that's a CMS violation.

During OEP (Jan 1 – Mar 31), agents can assist current MA enrollees who want to switch plans or return to Original Medicare, but cannot proactively market or solicit switches. OEP is for inbound inquiries only — not an opportunity to proactively prospect.

A good needs assessment is like a health and lifestyle interview before recommending a Medicare plan. Ask about their current coverage, monthly budget, their specific doctors and medications, how healthy they are, whether they travel a lot, and what extras (like dental) matter most to them. Then match those answers to the best plan options available in their area.

A comprehensive Medicare needs assessment covers: (1) current coverage and budget; (2) doctors and hospitals preferred; (3) prescription medications; (4) health status and anticipated needs; (5) geographic factors; and (6) desired extra benefits — then maps findings to available plan options.