Question 1

What is Medicare?

Accepted Answer

Medicare is the federal health insurance program primarily for people age 65 and older, and for certain younger people with qualifying disabilities or End-Stage Renal Disease (ESRD). It is administered by the Centers for Medicare & Medicaid Services (CMS) and is divided into parts that cover different types of care: hospital insurance, medical insurance, private plan alternatives, and prescription drug coverage.

Question 2

What are the different parts of Medicare (A, B, C, and D)?

Accepted Answer

Medicare has four parts. Part A is hospital insurance, covering inpatient hospital stays, skilled nursing facility care, hospice, and some home health care. Part B is medical insurance, covering doctor visits, outpatient care, preventive services, and durable medical equipment. Part C, also called Medicare Advantage, is an alternative offered by private insurers that bundles Part A and Part B (and usually Part D) into one plan. Part D is prescription drug coverage offered through private plans.

Question 3

What is the difference between Original Medicare and Medicare Advantage?

Accepted Answer

Original Medicare refers to Part A and Part B administered directly by the federal government; you can see any provider that accepts Medicare, and you can add a separate Part D drug plan and a Medigap supplement. Medicare Advantage (Part C) is offered by private insurance companies approved by Medicare and bundles your coverage into one plan, often with extra benefits and a provider network. Each approach has different tradeoffs in cost structure, provider access, and flexibility. Neither is universally better; the right fit depends on your individual health needs, budget, and preferences.

Question 4

Who is eligible for Medicare?

Accepted Answer

Most people qualify for Medicare at age 65 if they are U.S. citizens or lawful permanent residents who have lived in the country for at least five years. People under 65 can qualify if they have received Social Security Disability Insurance (SSDI) for 24 months, have ESRD, or have ALS (Lou Gehrig's disease). Eligibility for premium-free Part A generally depends on whether you or your spouse paid Medicare taxes for at least 10 years (40 quarters).

Question 5

What is the difference between Medicare and Medicaid?

Accepted Answer

Medicare is a federal health insurance program based mainly on age or disability, regardless of income. Medicaid is a joint federal and state program that provides coverage based on income and need, with eligibility rules that vary by state. Some people qualify for both programs and are called 'dual-eligible'; in those cases, the two programs work together to cover costs, with Medicare generally paying first.

Question 6

When can I enroll in Medicare?

Accepted Answer

Most people first enroll during their Initial Enrollment Period (IEP), a 7-month window that begins three months before the month you turn 65, includes your birthday month, and ends three months after. If you miss it, you may be able to sign up during the General Enrollment Period (January 1 to March 31 each year) or a Special Enrollment Period if you qualify.

Question 7

What is the Initial Enrollment Period (IEP)?

Accepted Answer

The Initial Enrollment Period is the 7-month window around your 65th birthday when you can first sign up for Medicare Parts A and B. It starts three months before the month you turn 65, includes your birthday month, and continues for three months after. Signing up during the first three months helps ensure your coverage starts the month you turn 65.

Question 8

What is the Medicare Annual Election Period (Open Enrollment)?

Accepted Answer

The Annual Election Period (AEP), also called Medicare Open Enrollment, runs from October 15 to December 7 each year. During this window you can join, switch, or drop a Medicare Advantage plan or a Part D prescription drug plan, and changes take effect January 1 of the following year. It is a good idea to review your Annual Notice of Change, which your plan sends in September, to see what is changing before you decide.

Question 9

What is the Medicare Advantage Open Enrollment Period?

Accepted Answer

The Medicare Advantage Open Enrollment Period runs from January 1 to March 31 each year. If you are already enrolled in a Medicare Advantage plan, you can use this period to switch to a different Medicare Advantage plan or return to Original Medicare (and add a Part D plan). You can make only one change during this window, and it does not apply to people enrolled in Original Medicare.

Question 10

What is a Special Enrollment Period (SEP)?

Accepted Answer

A Special Enrollment Period lets you enroll in or change Medicare coverage outside the normal windows when certain life events occur, such as losing employer coverage, moving out of your plan's service area, or qualifying for Extra Help. The rules and timeframes depend on the specific event. SEPs are designed so that major life changes do not leave you without an opportunity to adjust your coverage.

Question 11

Do I have to sign up for Medicare at 65 if I am still working?

Accepted Answer

Not necessarily. If you or your spouse have qualifying coverage through a current employer, you may be able to delay enrolling in Part B without a late penalty and sign up later through a Special Enrollment Period. The rules can depend on the size of the employer and the type of coverage, so it is worth confirming your specific situation before deciding to delay. Many people still enroll in premium-free Part A at 65 even while working.

Question 12

How much does Medicare Part A cost in 2026?

Accepted Answer

Most people pay no monthly premium for Part A because they or their spouse paid Medicare taxes for at least 10 years. If you do not qualify for premium-free Part A, the 2026 monthly premium is $311 for those with 30 to 39 quarters of coverage and $565 for those with fewer than 30 quarters. The Part A inpatient hospital deductible for 2026 is $1,736 per benefit period.

Question 13

How much is the Medicare Part B premium in 2026?

Accepted Answer

The standard Medicare Part B premium for 2026 is $202.90 per month, and the annual Part B deductible is $283. After you meet the deductible, you typically pay 20% of the Medicare-approved amount for most covered services. Some higher-income beneficiaries pay more than the standard premium because of an income-related surcharge called IRMAA.

Question 14

What is IRMAA and how does it affect my premium?

Accepted Answer

IRMAA stands for Income-Related Monthly Adjustment Amount. It is an extra charge added to your Part B and Part D premiums if your income is above certain thresholds. For 2026, IRMAA generally applies to single filers with modified adjusted gross income above $109,000 or joint filers above $218,000, based on your tax return from two years earlier (2024 for 2026). For affected beneficiaries, total Part B premiums in 2026 range from $284.10 up to $689.90 per month depending on income. IRMAA affects roughly 8% of beneficiaries.

Question 15

How much does Medicare Part D cost in 2026?

Accepted Answer

Part D premiums vary by plan and are set by the private insurers that offer them. The maximum Part D deductible for 2026 is $615, though some plans set a lower deductible. Higher-income beneficiaries may also pay a Part D IRMAA surcharge in addition to their plan premium. Because premiums and covered drugs differ from plan to plan, it is worth comparing options each year during Open Enrollment.

Question 16

Is there a cap on what I pay for prescription drugs in 2026?

Accepted Answer

Yes. In 2026 there is a $2,100 annual cap on out-of-pocket spending for covered prescription drugs, which applies to both stand-alone Part D plans and Medicare Advantage plans that include drug coverage. Once your out-of-pocket spending on covered drugs reaches $2,100, you pay $0 for those covered medications for the rest of the calendar year. The cap includes deductibles, copays, and coinsurance, but not your monthly premium.

Question 17

What is the Medicare Prescription Payment Plan?

Accepted Answer

The Medicare Prescription Payment Plan lets you spread your out-of-pocket prescription drug costs across the calendar year in monthly payments instead of paying the full amount at the pharmacy each time. It does not reduce your total drug costs, but it can make budgeting easier, especially if you have high costs early in the year. Starting in 2026, enrollment can renew automatically each year unless you opt out.

Question 18

Are there programs that help pay Medicare costs if I have a limited income?

Accepted Answer

Yes. Medicare Savings Programs can help pay Part B premiums and, in some cases, deductibles and coinsurance for people whose income and resources fall below certain limits. The Extra Help program (the Part D Low-Income Subsidy) helps with prescription drug costs. Eligibility and application processes vary, and you typically apply through your state Medicaid office or the Social Security Administration.

Question 19

What does Medicare Part A cover?

Accepted Answer

Part A covers inpatient hospital stays, care in a skilled nursing facility (following a qualifying hospital stay), hospice care, and some home health care. It generally does not cover long-term custodial care, such as ongoing help with daily activities, when that is the only care you need.

Question 20

What does Medicare Part B cover?

Accepted Answer

Part B covers medically necessary services and preventive care, including doctor visits, outpatient care, lab tests, durable medical equipment, mental health services, and many screenings and vaccines. It typically pays 80% of the Medicare-approved amount for covered services after you meet the annual deductible, leaving you responsible for the remaining 20%.

Question 21

What is Medigap (Medicare Supplement Insurance)?

Accepted Answer

Medigap, or Medicare Supplement Insurance, is private insurance that helps pay some of the out-of-pocket costs Original Medicare leaves behind, such as copayments, coinsurance, and deductibles. Medigap policies are standardized into lettered plans, and the same lettered plan offers the same basic benefits regardless of which company sells it. Medigap works only with Original Medicare, not with Medicare Advantage.

Question 22

When is the best time to buy a Medigap policy?

Accepted Answer

The Medigap Open Enrollment Period is generally the best time to buy. It lasts six months and starts the month you are 65 or older and enrolled in Part B. During this window, insurers cannot deny you coverage or charge more based on your health. If you apply after this period, insurers in most states can use medical underwriting, which may affect your eligibility or premium.

Question 23

Does Medicare cover dental, vision, and hearing?

Accepted Answer

Original Medicare generally does not cover routine dental care, eye exams for glasses, or hearing aids, though it covers some related services in specific medical situations. Many Medicare Advantage plans include extra benefits for dental, vision, and hearing, but coverage varies widely by plan. If these benefits matter to you, it is worth reviewing the specific details of any plan you are considering.

Question 24

Does Medicare cover prescription drugs?

Accepted Answer

Original Medicare (Parts A and B) covers only a limited set of drugs, mainly those administered in a clinical setting. For most prescription medications you take at home, you need Part D coverage, either as a stand-alone plan added to Original Medicare or as part of a Medicare Advantage plan that includes drug coverage. Each plan has its own list of covered drugs, called a formulary.

Question 25

What is a formulary?

Accepted Answer

A formulary is the list of prescription drugs a Part D or Medicare Advantage drug plan covers. Plans organize covered drugs into tiers that affect how much you pay, and formularies can change from year to year. Because a drug that is covered by one plan may not be covered by another, checking whether your medications are on a plan's formulary is an important step when comparing options.

Question 26

How do I appeal a Medicare coverage decision or denial?

Accepted Answer

If Medicare or your plan denies coverage or payment for a service, you have the right to appeal. The process has several levels, beginning with a redetermination or reconsideration request, and each level has its own deadline and form. Your Medicare Summary Notice or plan denial letter explains how and when to file. Keeping copies of your medical records and any supporting documentation from your doctor can strengthen your appeal.

Question 27

Can I appeal an IRMAA surcharge?

Accepted Answer

Yes. If you believe your IRMAA determination is wrong, or if you had a life-changing event such as retirement, the death of a spouse, marriage, or divorce that lowered your income, you can ask the Social Security Administration to reconsider. You generally file Form SSA-44 along with documentation of the event. You typically have 60 days from the date of the IRMAA notice to file a standard appeal.

Question 28

What is the Part B late enrollment penalty?

Accepted Answer

If you do not sign up for Part B when you are first eligible and you do not qualify for a Special Enrollment Period, you may owe a late enrollment penalty. The penalty adds 10% to your standard Part B premium for each full 12-month period you could have had Part B but did not. In most cases this penalty is permanent, so it is important to understand your enrollment timing.

Question 29

What is the Part D late enrollment penalty?

Accepted Answer

You may owe a Part D late enrollment penalty if you go 63 or more days in a row without Part D or other creditable prescription drug coverage after your Initial Enrollment Period ends. The penalty is added to your monthly Part D premium and generally lasts as long as you have Part D coverage. Maintaining creditable drug coverage is the way to avoid it.

Question 30

I qualify for both Medicare and Medicaid. How does that work?

Accepted Answer

People who qualify for both programs are called dual-eligible, and the two programs coordinate to cover costs. Medicare generally pays first for covered services, and Medicaid may help with costs Medicare does not cover, such as certain premiums, deductibles, and coinsurance, as well as some services Medicare excludes. Some dual-eligible individuals can enroll in special plans designed to coordinate both kinds of coverage. Your state Medicaid office can explain how the programs work together in your state.

Question 31

Where can I get free, unbiased help with Medicare?

Accepted Answer

Every state has a State Health Insurance Assistance Program (SHIP) that offers free, unbiased counseling to people with Medicare and their families. You can also contact Medicare directly at 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048), available 24 hours a day, 7 days a week, or visit Medicare.gov. These resources can help you understand all of your options at no cost.

Question 32

What is the Health Insurance Marketplace?

Accepted Answer

The Health Insurance Marketplace, created under the Affordable Care Act, is where individuals and families who do not have coverage through an employer, Medicare, or Medicaid can shop for and buy health insurance. Plans are organized into metal tiers (Bronze, Silver, Gold, and Platinum) that reflect how costs are shared, and many people qualify for income-based subsidies that lower their premiums.

Question 33

Can I have both a Marketplace plan and Medicare?

Accepted Answer

In general, once you are eligible for and enrolled in Medicare, you are not meant to keep a Marketplace plan, and it is usually not advisable to do so. The Marketplace is designed for people who do not have other qualifying coverage. If you have a Marketplace plan and become eligible for Medicare, it is important to understand how and when to transition to avoid gaps, penalties, or paying for coverage you no longer need.

Question 34

I have a Marketplace plan and I am turning 65. What should I do?

Accepted Answer

When you become eligible for Medicare, you generally should enroll during your Initial Enrollment Period and end your Marketplace plan so that your Medicare coverage starts without overlap. If you receive premium subsidies through the Marketplace, those typically end once you are eligible for premium-free Medicare Part A. Timing the change carefully helps you avoid a Part B late enrollment penalty and prevents paying for two plans at once.

Question 35

Can I keep my Marketplace subsidy after I become eligible for Medicare?

Accepted Answer

Generally no. Once you are eligible for premium-free Medicare Part A, you usually no longer qualify for Marketplace premium tax credits. Continuing to receive a subsidy after you are eligible for Medicare could mean you have to repay it later. This is one reason it is important to plan the transition from Marketplace coverage to Medicare around your 65th birthday.

Question 36

I am under 65 and on a Marketplace plan. When does Medicare come into play?

Accepted Answer

If you are under 65 and receiving Social Security Disability Insurance, you generally become eligible for Medicare after 24 months of disability benefits. As that date approaches, you will want to understand how moving from a Marketplace plan to Medicare affects your coverage and any subsidies. The transition rules for people who qualify through disability are similar in principle to those for people turning 65.

Medicare & Marketplace, answered plainly.

Medicare Basics

Eligibility & Enrollment

Medicare Costs (2026)

Coverage & Plan Types

Claims, Appeals & Advocacy

Marketplace & Medicare Overlap

Important