What Is Medicare, and How Does It Work?

Quick Definition – but there is sooo much more to it!

Medicare is federal health insurance mainly for:

• People 65 and older
• Some people under 65 with certain disabilities
• People with End-Stage Renal Disease (ESRD) or ALS

Medicare is not the same as Medicaid. Medicare is federal. Medicaid is state-based and income-based. (Call 2-1-1 from any phone to find out how to apply for Medicaid. 2-1-1 is a United Way program that offers many resources.)

Part A (Hospital Insurance)
Usually covers:

• Inpatient hospital stays
• Skilled nursing facility care (after a qualifying hospital stay)
• Hospice
• Some home health care

Most people don’t pay a premium for Part A if they (or a spouse) paid Medicare taxes long enough (40 quarters- ask if a spouse can share their quarters!).

Part B (Medical Insurance)
Usually covers:

• Doctor visits
• Outpatient care
• Labs, x-rays
• Preventive services
• Durable medical equipment (like walkers)

Part B usually has a monthly premium, and you typically pay some costs when you use services (like deductibles/coinsurance).

Part C (Medicare Advantage) – Has a maximum annual out of pocket (MOOP)

Medicare Advantage plans are offered by private insurance companies approved by Medicare. They replace Original Medicare (A and B) and usually include:

• Part A + Part B coverage
• Often Part D (prescriptions)
• Often extra benefits (varies by plan) like dental/vision/hearing, fitness, etc.

You still must keep paying your Part B premium to Medicare even if you choose a Medicare Advantage plan. Sometimes you can choose a plan that helps you pay for part B. Ask your agent if this is important to you.

Part D (Prescription Drug Coverage) – You must have part D or “credible” drug coverage or you will be penalized.

Part D helps cover outpatient prescription drugs. Plans are offered by private companies approved by Medicare. Costs and covered drugs vary by plan (formulary).

Option 1: Original Medicare (Part A + Part B)
You must add:

• Part D (drug plan) or have “credible” drug coverage or you will be penalized by Medicare.

You can add:

• Medigap (Medicare Supplement) to help pay gaps like coinsurance/deductibles

Good for people who want flexibility with travel & doctors that accept Medicare (nationwide, possibly worldwide access in many cases).

Option 2: Medicare Advantage (Part C)

You get coverage through a private plan that replaces Original Medicare for how you receive benefits. Usually includes:

• A provider network (HMO/PPO varies)
• Set copays/coinsurance for services
• Can include Part D

Good for people who prefer a plan-style approach and want extra benefits, with attention to network and rules.

A Medicare Supplement is a private plan that works with Original Medicare to help pay costs that Medicare doesn’t fully cover (like deductibles and coinsurance).

Key points:

• You generally pay a monthly premium
• Usually no networks (you can see any provider that accepts Medicare)
• You’ll add a separate Part D plan for prescriptions

Initial Enrollment Period (IEP) — when you first become eligible

This is your first major enrollment window around turning 65 (or when you first qualify due to disability). This is when many people:

• Start Part A and Part B
• Choose Part D and/or Medigap
• Or choose Medicare Advantage

Annual Enrollment Period (AEP): Oct 15 – Dec 7

Each year you can:

• Switch Medicare Advantage plans
• Move from Medicare Advantage to Original Medicare (and add Part D)
• Switch Part D drug plans

Changes typically start January 1.

Medicare Advantage Open Enrollment Period: Jan 1 – Mar 31

If you are already in a Medicare Advantage plan, you can:

• Switch to another Medicare Advantage plan, or
• Drop Medicare Advantage and go back to Original Medicare (and add Part D)

Special Enrollment Periods (SEP)

Certain life events can open a special window (examples: moving, losing other coverage, qualifying for certain assistance programs, natural disasters, etc.).

Medicare costs depend on what you choose and your situation. Common cost types include:

• Premium: what you pay monthly
• Deductible: what you pay before coverage kicks in (for certain services)
• Copay/Coinsurance: your share when you receive care

Typical examples in 2026:

• Part A is often $0 premium for people who paid Medicare at least 40 quarters and usually has a deductible of $1,736 deductible per benefit period (not per year). There are many caveats to Part A. Ask your agent for more details.
• Part B has a Standard premium: $202.90 per month for most people and higher-income individuals pay IRMAA surcharges, with total premiums ranging roughly $284.10 – $689.90/month depending on income and an Annual deductible of $283 per year before Part B begins paying. After you meet the deductible Medicare pays: 80% of the Medicare-approved amount and You pay: 20% coinsurance (no cap under Original Medicare).
• Medicare Advantage may have an additional premium (sometimes $0), but you still pay Part B to Medicare.
• Part D usually has a premium (varies)
• Medigap usually has a premium (varies)

1. Doctors & hospitals you want to use
2. Prescriptions you take (and preferred pharmacy)
3. Budget (monthly premium vs. pay-as-you-go costs)
4. Travel / time away from home
5. Comfort level with networks and referrals (plan rules)

If you want me to help you compare options, have:

• Your Medicare card
• A list of medications (name + dosage)
• Your preferred pharmacy
• Your main doctors and clinics
• Your current plan card (if you already have coverage)

If you want help understanding Medicare or comparing your options:

Agent: Denice Barton - Call or Text: 903-521-4570 • Email: [email protected]
(Call or TEXT me anytime!! TEXTING is fastest!) Save me in your phone as “DENICE the MEDICARE Helper”