Medicare Frequently Asked Questions

Medicare is the federal health insurance program for people age 65 or older, and for certain younger people with disabilities or end-stage renal disease. It has several parts: Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage), and Part D (prescription drug coverage).

Original Medicare (Parts A and B) is run directly by the federal government and lets you see any provider that accepts Medicare nationwide. Medicare Advantage is run by private insurers, typically uses a network, often bundles in Part D and extra benefits, and may have lower out-of-pocket costs in exchange for network restrictions.

A Medigap (Medicare Supplement) plan is private insurance that works alongside Original Medicare to help pay costs Medicare doesn't cover, such as copayments, coinsurance, and deductibles.

Original Medicare generally doesn't cover routine dental, vision, or hearing care, most long-term custodial care, and care received outside the United States. Many of these gaps can be addressed through Medicare Advantage plans or supplemental coverage.

The Annual Enrollment Period runs October 15 through December 7 each year. During AEP 2026, you can switch Medicare Advantage plans, switch Part D plans, or move between Original Medicare and Medicare Advantage for coverage effective January 1, 2027.

The standard Part B premium in 2026 is $202.90 per month. Some higher-income beneficiaries pay more due to IRMAA (Income-Related Monthly Adjustment Amount).

Costs vary by the coverage you choose, but in 2026 the standard Part B premium is $202.90/month, and many Medicare Advantage plans have a $0 premium while Medigap premiums and Part D premiums vary by plan and location. Your total monthly cost depends on whether you pair Original Medicare with a Medigap and Part D plan, or choose a Medicare Advantage plan instead — a licensed agent can estimate your realistic total based on your specific situation.

You can generally change plans during the Annual Enrollment Period (October 15 – December 7) for coverage starting January 1, or during the Medicare Advantage Open Enrollment Period (January 1 – March 31) if you're already in a Medicare Advantage plan. Outside those windows, changes are usually limited to Special Enrollment Periods triggered by qualifying life events like moving or losing other coverage.

Original Medicare generally does not cover routine dental, vision, or hearing care, such as cleanings, eye exams for glasses, or hearing aids. Many Medicare Advantage plans do include some level of dental, vision, and hearing benefits as an added perk, so if these matter to you, it's worth comparing plans that specifically include them rather than assuming all Medicare coverage includes them.

You don't need an agent physically nearby — licensed independent agents like Kayla Price at Price Services Group work with clients by phone and video across the states they're licensed in, which often means faster, more flexible scheduling than an in-person-only local office. You can book a free, no-obligation consultation directly through our schedule page if you're located in one of our 10 licensed states.

Part A is hospital insurance. It helps cover inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care. Most people don't pay a monthly premium for Part A because they or a spouse paid Medicare taxes while working.

Part B is medical insurance. It helps cover doctor visits, outpatient care, preventive services, durable medical equipment, and some home health care. In 2026, the standard Part B premium is $202.90 per month, and the annual deductible is $283.

Medicare Advantage is an alternative way to get your Medicare Part A and Part B benefits through a private insurance company approved by Medicare. Many Medicare Advantage plans also include Part D drug coverage and extra benefits like dental, vision, and hearing.

Part D is prescription drug coverage, offered through private insurance companies approved by Medicare. You can get it as a standalone Prescription Drug Plan (PDP) alongside Original Medicare, or bundled into a Medicare Advantage plan (MA-PD).

You're generally eligible at age 65 if you or your spouse worked and paid Medicare taxes for at least 10 years (40 quarters). People under 65 may qualify due to certain disabilities, ALS, or end-stage renal disease (ESRD).

If you're already receiving Social Security benefits when you turn 65, you're typically enrolled automatically in Parts A and B. If not, you'll need to actively sign up through the Social Security Administration during your Initial Enrollment Period.

Your IEP is a 7-month window centered on your 65th birthday — 3 months before your birthday month, your birthday month, and 3 months after. This is your first chance to enroll in Medicare, and missing it can lead to permanent late enrollment penalties.

OEP runs January 1 through March 31 each year. If you're already enrolled in a Medicare Advantage plan, you can use this window to switch to a different Medicare Advantage plan or drop back to Original Medicare (with or without a standalone Part D plan) one time.

The General Enrollment Period runs January 1 through March 31 each year. It's for people who missed their Initial Enrollment Period and didn't qualify for a Special Enrollment Period. Coverage typically begins the month after you enroll, and late enrollment penalties may apply.

A Special Enrollment Period lets you enroll in or change Medicare coverage outside the usual windows due to a qualifying life event — such as losing employer coverage, moving out of your plan's service area, or losing Medicaid eligibility.

You may have to wait until the General Enrollment Period (January 1 – March 31) to enroll, and you could face a permanent late enrollment penalty on Part B and/or Part D premiums, unless you qualify for a Special Enrollment Period.

Generally only during the Medicare Advantage Open Enrollment Period (Jan 1 – Mar 31) or if you qualify for a Special Enrollment Period. Otherwise, changes are limited to the Annual Enrollment Period.

If you enroll in the 3 months before your birthday month or during your birthday month, coverage generally starts the first day of your birthday month. Enrolling in the 3 months after can delay your start date.

This is a one-time, 6-month window that starts the month you're both 65 and enrolled in Part B. During this period, you can buy any Medigap plan sold in your state without medical underwriting, regardless of health conditions.

Generally no, unless you qualify due to a qualifying disability, ALS, or end-stage renal disease. Otherwise, age-based Medicare eligibility begins at 65.

A Medicare Advantage plan is a Medicare-approved plan from a private company that provides your Part A and Part B benefits, and often Part D and extra benefits like dental, vision, hearing, and fitness programs, usually through a network of providers.

HMO plans generally require you to use in-network providers and get referrals to see specialists. PPO plans offer more flexibility to see out-of-network providers, usually at a higher cost, and typically don't require referrals.

Most do. HMO and PPO Medicare Advantage plans typically use a network of doctors, hospitals, and pharmacies. Staying in-network usually means lower out-of-pocket costs.

Many Medicare Advantage plans include benefits Original Medicare doesn't cover, such as routine dental, vision, hearing aids, fitness programs (like SilverSneakers), and sometimes transportation or over-the-counter allowances. Specific benefits vary by plan.

A Special Needs Plan is a type of Medicare Advantage plan designed for people with specific needs — such as certain chronic conditions (C-SNP), those who live in an institution (I-SNP), or those dually eligible for Medicare and Medicaid (D-SNP).

Many Medicare Advantage plans have a $0 monthly premium, but you still pay your Part B premium, and you may have copays, coinsurance, and an annual out-of-pocket maximum. "Free" refers only to the plan premium, not all costs.

No. Medigap plans are designed to work with Original Medicare, not Medicare Advantage. It's not legal for someone to sell you a Medigap policy if they know you're enrolled in a Medicare Advantage plan.

A Private Fee-for-Service (PFFS) plan is a type of Medicare Advantage plan that determines how much it pays providers and how much you pay when you get care, rather than using a traditional network model.

Medigap plans help pay for costs that Original Medicare doesn't fully cover, such as Part A and Part B coinsurance, copayments, and deductibles. Coverage details depend on which standardized plan letter you choose.

In most states, Medigap plans are standardized into lettered plans (like Plan G or Plan N). Each lettered plan offers the same basic benefits no matter which insurance company sells it — pricing and customer service can differ between carriers.

Outside your Medigap Open Enrollment Period or a guaranteed issue right, insurers can generally use medical underwriting and may deny coverage or charge more based on your health history.

No. Medigap plans sold today do not include prescription drug coverage. You'd need a separate standalone Part D plan for drug coverage alongside a Medigap plan.

A guaranteed issue right means an insurance company must sell you a Medigap policy, cover your pre-existing conditions, and can't charge you more due to health problems — this typically applies in specific situations, such as losing other coverage involuntarily.

Yes, but outside your initial Medigap Open Enrollment Period or a guaranteed issue situation, you may be subject to medical underwriting when switching, and could be denied or charged more.

Plan G covers Part B coinsurance in full but not the Part B deductible. Plan N generally has a lower premium but includes copays for some office and ER visits and doesn't cover Part B excess charges. The right choice depends on your budget and expected usage.

It depends on the pricing method your insurer uses — some plans use community-rated, issue-age-rated, or attained-age-rated pricing, which affects whether and how premiums rise as you get older.

Part D is optional, but if you go without it (or other creditable prescription drug coverage) when you're first eligible, you may face a lifelong late enrollment penalty if you enroll later.

A formulary is the list of prescription drugs a Part D or Medicare Advantage plan covers. Formularies are organized into tiers, and each plan's formulary can differ, so the drugs you take should be checked against a specific plan's list.

In 2026, Part D plans can charge a deductible of up to $615 before coverage kicks in, though many plans offer lower or no deductible — this varies by plan.

For 2026, once you reach $2,100 in out-of-pocket prescription drug costs, you enter catastrophic coverage and pay $0 for covered Part D drugs for the rest of the year.

The donut hole (coverage gap) was a former phase of Part D coverage with higher cost-sharing. As of recent redesign changes, Part D now has a simplified structure — deductible, initial coverage, then catastrophic coverage — with an annual out-of-pocket cap.

Prior authorization means your plan requires approval before it will cover certain medications, confirming the drug is medically necessary and appropriate before you fill the prescription.

Step therapy requires you to try a lower-cost or preferred drug first before the plan will cover a more expensive alternative, unless the first drug doesn't work or isn't appropriate for you.

If you go 63 or more consecutive days without Part D or other creditable drug coverage after becoming eligible, you may owe a permanent monthly penalty added to your Part D premium for as long as you have Part D coverage.

The annual Part B deductible in 2026 is $283. After you meet it, Medicare generally pays its share of Part B-covered services.

The Part A inpatient hospital deductible in 2026 is $1,676 per benefit period. This isn't an annual deductible — it applies each time a new benefit period begins.

IRMAA (Income-Related Monthly Adjustment Amount) is an extra amount added to your Part B and Part D premiums if your income is above a certain threshold, based on your tax return from two years prior.

No, Original Medicare (Parts A and B) has no annual out-of-pocket maximum, which is one reason many people add a Medigap plan or choose Medicare Advantage, which are required to have an annual out-of-pocket limit.

Extra Help (also called the Low-Income Subsidy or LIS) is a federal program that helps people with limited income and resources pay for Part D premiums, deductibles, and copays.

A benefit period begins the day you're admitted to a hospital or skilled nursing facility and ends after you've been out for 60 consecutive days. A new benefit period — and a new Part A deductible — can start if you're readmitted after that.

Yes — programs like Medicare Savings Programs (MSP) and Extra Help/LIS can help eligible beneficiaries with limited income and resources cover premiums, deductibles, and drug costs.

It depends on the size of your employer and your coverage. If you have creditable coverage through a large employer (generally 20+ employees), you may be able to delay Part B without penalty. Smaller employer plans often work differently — check with your plan administrator and a licensed agent.

Creditable coverage is health or drug coverage that's considered at least as good as Medicare's coverage. Having creditable coverage can let you delay Medicare enrollment without facing a late enrollment penalty later.

Generally not, if your employer coverage is creditable and from a large employer. But if your coverage isn't creditable, or your employer is small, delaying could expose you to late enrollment penalties.

When you (or your spouse) stop working or lose employer group coverage, you typically get an 8-month Special Enrollment Period to sign up for Medicare Part A and/or B without a late enrollment penalty.

Since Part A is usually premium-free, many people enroll in Part A at 65 even while working, as long as they're not contributing to a Health Savings Account (HSA), which has specific rules that can conflict with Part A enrollment.

Which plan pays first — Medicare or your employer plan — depends on employer size and other factors, a concept called coordination of benefits. A licensed agent or your employer's benefits office can help you sort out which coverage is primary.

Medicare Advantage plan availability and pricing in North Carolina vary by county and change from year to year, so there's no single answer that applies statewide. A licensed agent can pull up the specific plans available in your ZIP code and compare them side by side.

Yes. Price Services Group is based in Wilmington, North Carolina, and Kayla Price is a licensed independent insurance agent serving clients across the entire state, with free, no-obligation Medicare reviews available by phone or video.

Yes — North Carolina is our home state and primary service area. We help clients throughout North Carolina compare Medicare Advantage, Medigap, and Part D options and navigate enrollment timelines.

Plan availability and pricing for Medicare Advantage in Texas vary widely by county, since Texas covers a huge and diverse service area. A licensed agent can review the specific plans available where you live rather than relying on generic statewide figures.

Yes. Kayla Price is a licensed independent insurance agent in Texas, and Price Services Group offers free Medicare plan reviews by phone or video to residents anywhere in the state.

Yes — Texas is one of the 10 states where Price Services Group is licensed to help with Medicare Advantage, Medicare Supplement, Part D, and related insurance products.

Florida has one of the largest Medicare populations in the country, and plan options, premiums, and extra benefits vary significantly by county. A licensed agent can look up the actual plans available in your specific area.

Yes. Price Services Group is licensed to serve Florida residents with free, independent Medicare plan reviews — comparing Medicare Advantage, Medigap, and Part D options across carriers.

Yes — Florida is one of our 10 licensed states, and we work with Florida residents on Medicare, life insurance, and annuity planning.

Medicare Advantage plan availability in Georgia depends on your county, and the specific carriers and benefits offered can change annually. A licensed agent can pull current options for your area rather than guessing based on statewide averages.

Yes. Kayla Price is licensed to help Georgia residents with Medicare Advantage, Medicare Supplement, and Part D plan comparisons, with free consultations available by phone or video.

Yes — Georgia is one of the 10 states where Price Services Group is licensed to provide Medicare and insurance guidance.

As in every state, Medicare Advantage options in South Carolina vary by county and change from year to year. A licensed agent can review the specific plans available in your area, including carrier networks and extra benefits.

Yes. Price Services Group is licensed in South Carolina and offers free, no-obligation Medicare reviews to residents throughout the state.

Yes — South Carolina is one of our 10 licensed states, alongside our home state of North Carolina, for Medicare and related insurance services.

Yes — Virginia is one of the 10 states where Price Services Group is licensed to help with Medicare Advantage, Medicare Supplement, Part D, and related insurance products.

Medicare Advantage, Medigap, and Part D plan availability in Virginia varies by county and changes from year to year, so there's no single answer that applies statewide. A licensed agent can review the specific options available in your ZIP code.

Kayla Price is a licensed independent insurance agent in Virginia, and Price Services Group offers free, no-obligation Medicare plan reviews by phone or video to residents anywhere in the state.

Yes — Maryland is one of the 10 states where Price Services Group is licensed to provide Medicare and insurance guidance.

Plan availability and pricing for Medicare Advantage, Medigap, and Part D in Maryland vary by county. A licensed agent can pull the specific plans available where you live rather than relying on generic statewide figures.

Yes, Price Services Group is licensed to serve Maryland residents with free, independent Medicare plan reviews — comparing Medicare Advantage, Medigap, and Part D options across carriers.

Yes — Michigan is one of the 10 states where Price Services Group is licensed to help with Medicare and related insurance products.

Medicare Advantage and Part D plan options in Michigan depend on your county, and the specific carriers and benefits offered can change annually. A licensed agent can pull current options for your area.

Kayla Price is licensed to help Michigan residents with Medicare Advantage, Medicare Supplement, and Part D plan comparisons, with free consultations available by phone or video.

Yes — Kansas is one of the 10 states where Price Services Group is licensed to provide Medicare and insurance guidance.

As in every state, Medicare Advantage and Part D options in Kansas vary by county and change from year to year. A licensed agent can review the specific plans available in your area, including carrier networks and extra benefits.

Price Services Group is licensed in Kansas and offers free, no-obligation Medicare reviews to residents throughout the state, by phone or video.

Yes — Ohio is one of the 10 states where Price Services Group is licensed to help with Medicare Advantage, Medicare Supplement, Part D, and related insurance products.

Medicare Advantage plan availability and pricing in Ohio vary by county and change from year to year, so there's no single answer that applies statewide. A licensed agent can pull up the specific plans available in your ZIP code and compare them side by side.

Kayla Price is a licensed independent insurance agent in Ohio, and Price Services Group offers free Medicare plan reviews by phone or video to residents anywhere in the state.

There's no single "best" Medicare Advantage plan — the right one depends on your specific doctors, medications, budget, and travel habits. A plan that's a great fit for one person can be a poor fit for another, which is why comparing your actual options rather than a generic ranking matters most. A licensed agent can review the plans available in your ZIP code against your doctors and prescriptions to find the best fit for you specifically.

Medicare Supplement (Medigap) is generally worth considering if you want predictable costs, the freedom to see any provider who accepts Medicare nationwide, and you're willing to pay a higher fixed monthly premium in exchange for lower costs when you use care. If you travel frequently, see specialists outside a local network, or simply want to minimize surprise bills, Medigap alongside Original Medicare and a standalone Part D plan may be a better fit than Medicare Advantage.

If you don't have other creditable coverage (such as from a large employer) and don't sign up during your Initial Enrollment Period, you may face permanent late enrollment penalties on Part B and/or Part D, and you may have to wait until the General Enrollment Period to sign up. It's important to confirm whether your other coverage counts as creditable before deciding to delay.

Medicare is a federal health insurance program mainly for people 65 and older or with certain disabilities, regardless of income. Medicaid is a joint federal and state program that provides health coverage based on financial need, and eligibility and benefits vary by state. Some people qualify for both programs at once, known as being "dual eligible."

If Medicare or your plan denies a claim or service, you have the right to appeal — the process and deadlines depend on whether you have Original Medicare or a Medicare Advantage plan, and instructions are included in the denial notice you receive. A licensed agent can help you understand the specific appeal steps for your situation, though the formal appeal itself is filed with Medicare or your plan directly.