Quick Guide to Medicare Basics for 2026
Understanding Medicare Basics
Medicare is the federal health insurance program designed for Americans aged 65 and older, as well as those with certain disabilities like end-stage renal disease, Lou Gehrig’s disease, or long-term Social Security disability. It comes in several parts:
- Part A (Hospital Insurance): Covers inpatient care. It’s usually free if you or your spouse worked 40 quarters (10 years).
- Part B (Medical Insurance): Covers outpatient services, doctor visits, and durable medical equipment. The base premium in 2025 is $185, but high-income earners may pay more due to IRMAA (Income-Related Monthly Adjustment Amount).
What the Different Parts Cover
- Part C (Medicare Advantage): Private insurance plans that replace Original Medicare, often bundling in extras like dental, vision, and hearing.
- Part D (Prescription Drug Coverage): Covers medications, either as a standalone plan or built into Advantage plans.
- Medigap (Supplemental Insurance): Private plans such as Plan G or Plan N that cover gaps in Original Medicare like deductibles, coinsurance, and excess charges.
The Gaps in Original Medicare
Medicare doesn’t cover everything. Here’s what’s left for you to pay without supplemental insurance:
- Part A: $1,676 deductible per benefit period, plus daily costs for hospital or skilled nursing stays past a set number of days.
- Part B: $257 annual deductible, 20% coinsurance on outpatient care, and potential 15% excess charges from doctors who don’t accept Medicare assignment.
That’s where Medigap comes in:
- Plan G: Covers nearly everything except the Part B deductible. Premiums average $150–$200 per month.
- Plan N: Lower premiums ($90–$130/month) but includes small co-pays and may not cover excess charges.
Medicare Advantage (Part C) Pros and Cons
Advantage plans can look attractive with $0 monthly premiums, but they come with trade-offs:
- You’ll pay co-pays, deductibles, and co-insurance when you use services.
- Plans may require referrals or prior authorizations.
- Coverage is limited to local networks, except in emergencies.
- Benefits like dental, hearing, and wellness programs vary widely.
These plans reset every calendar year, so reviewing them annually is essential.
Enrollment Rules and Deadlines
- At 65: You must enroll if you don’t have employer coverage, COBRA, ACA/marketplace plans, or small-employer insurance (fewer than 20 employees).
- Automatic Enrollment: Happens if you already collect Social Security; your Medicare card arrives about 100 days before your 65th birthday.
- Initial Enrollment Period (IEP): A 7-month window around your 65th birthday.
- Special Enrollment Period (SEP): For those enrolling later due to employer coverage; lasts 8 months after losing that coverage.
Medigap Open Enrollment
The Medigap Open Enrollment Period is a one-time six-month window starting with your Part B effective date. During this period, you can purchase any Medigap plan without medical underwriting no health questions asked. This is the best time to secure coverage and lock in lower rates.
How to Apply for Medicare
You can sign up through:
- SSA.gov (online enrollment)
- Paper forms (L564 and CMS 40B for post-65 enrollment)
- Local Social Security offices
Why Professional Help Matters
Medicare is complicated. Missing deadlines or choosing the wrong plan can lead to lifelong penalties or higher costs. Services like Medicare School act as personal shoppers comparing carriers, explaining benefits, and guiding you through enrollment at no additional cost. Rates are standardized, so you don’t pay extra to use an expert, and you get ongoing support year after year.
Medicare is not one-size-fits-all. Knowing the basics of Parts A, B, C, and D and how Medigap or Advantage plans fit in can save you thousands and ensure peace of mind. With deadlines, penalties, and dozens of options, leaning on professional guidance can make all the difference.
