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Answer a few questions about your current coverage, benefits, age, and health situation. You will receive a clear next step.
Who can qualify for Medicare?
Age-Based Eligibility
Medicare generally begins around age 65 for people who meet citizenship or residency requirements. If your birthday is on the first day of a month, your coverage timing may shift to the prior month.
Disability Eligibility
People under 65 who receive Social Security disability benefits generally get Medicare automatically after 24 months of disability benefits.
ALS and ESRD
People with ALS generally get Medicare when disability benefits begin. End-Stage Renal Disease has separate eligibility and coverage-start rules tied to dialysis, transplant status, and work history.
Know your enrollment window before you delay.
Your Initial Enrollment Period usually lasts seven months: the three months before the month you turn 65, your birthday month, and the three months after.
If you receive Social Security or Railroad Retirement benefits at least four months before turning 65, enrollment in Parts A and B is generally automatic. Otherwise, you usually need to enroll through Social Security.
There are risks to signing up later, like a gap in your coverage or having to pay a penalty. However, in some cases, it might make sense to sign up later.
If you miss an enrollment period, you might qualify for a Special Enrollment Period.
If you must buy Part A and enroll late, the premium may increase 10%. The penalty generally lasts twice the number of years you delayed.
The premium generally increases 10% for each full 12-month period you could have had Part B but did not. For most people, it lasts as long as they have Part B.
Going 63 days or more without Part D or other creditable drug coverage can trigger a penalty based on 1% of the national base premium for each uncovered month.
Parts A and B form Original Medicare.
Hospital and facility coverage
Part A helps cover inpatient hospital care, skilled nursing facility care when Medicare requirements are met, hospice care, and certain home health services.
Most people pay no monthly Part A premium
$1,736 inpatient deductible for each benefit period in 2026
Hospital coinsurance begins after day 60
Skilled nursing coinsurance begins after day 20
Medical and outpatient coverage
Part B helps cover doctors and other providers, outpatient services, durable medical equipment, many preventive services, and certain home health services.
$202.90 standard monthly premium in 2026; higher-income beneficiaries may pay more
$283 annual deductible in 2026
Usually 20% coinsurance after the deductible
Original Medicare has no annual out-of-pocket maximum
Original Medicare covers a lot, but not everything.
Original Medicare has meaningful financial exposure because it does not cap your yearly Part A and Part B out-of-pocket costs. It also leaves some common services outside its standard benefits.
Without additional coverage, those costs can add up quickly, especially when care is ongoing or unexpected.
No Yearly Spending Limit
Part B usually leaves 20% coinsurance after the deductible, with no annual maximum under Original Medicare alone.
Prescription Drugs Are Separate
Original Medicare does not automatically include most outpatient prescription drugs. A separate Part D plan is generally needed.
Routine Extras Are Limited
Routine dental care, routine eye exams, hearing aids, and long-term custodial care generally are not covered.
Hospital Cost Exposure
Part A deductibles apply by benefit period, and longer hospital or skilled nursing stays can create daily coinsurance.
Limited Foreign Coverage
Original Medicare generally does not cover medical care outside the United States, except in limited circumstances.
Assignment Can Matter
A provider who does not accept Medicare assignment may be able to charge more where permitted.
How can I manage Original Medicare’s gaps and extra costs involved?
Medicare Supplement (Medigap)
Add Medigap and a separate Part D plan.
You keep Original Medicare for Parts A and B, add a Medicare Supplement policy with its own monthly premium to help with selected cost-sharing, and generally buy a separate Part D prescription drug plan with its own premium and costs.
Broad access to providers that accept Medicare
More predictable medical cost-sharing, depending on the Medigap plan
Separate monthly premiums for Medigap and a Part D plan
Medicare Advantage (Part C)
Receive Medicare benefits through one private plan.
A Medicare-approved private plan contracts with Medicare to provide your Part A and Part B benefits. Many plans include Part D, may offer extra benefits, and have a $0 monthly plan premium.
Annual out-of-pocket limit for covered Medicare services
Many plans include prescription drug coverage and may include routine dental, vision, or hearing benefits
Many plans offer a $0 monthly plan premium
Networks, referrals, and prior authorization vary
Medigap helps with certain Original Medicare costs.
Medigap policies are sold by private insurers and standardized by plan letter in most states. You pay a separate monthly premium for the Medigap policy, and premiums, pricing methods, availability, and service can differ by insurer.
What It Can Help Pay
Depending on the lettered plan, Medigap can help with Original Medicare deductibles, copayments, and coinsurance.
Six-Month Open Enrollment
The federal Medigap Open Enrollment Period lasts six months beginning when you are 65 or older and enrolled in Part B. During this window, health problems cannot be used to deny the policy or charge more.
Important Limitations
Medigap generally does not include Part D, routine dental, vision, hearing aids, or long-term care. Separate plans would need to be selected for coverage and each generally cost extra. You cannot use Medigap with Medicare Advantage.
Medicare Advantage combines Medicare benefits in a private plan that contracts with the federal government.
Medicare Advantage plans contract with Medicare and must cover medically necessary services covered by Original Medicare. Many plans include Part D and may offer a $0 monthly plan premium. Costs, provider networks, prior authorization, referrals, and extra benefits vary by plan and county.
HMO’s
HMO’s generally require in-network providers for non-emergency care, often require a primary care provider, and commonly require referrals for specialists. Exceptions apply for emergency care, urgent care, and temporary out-of-area dialysis.
PPO’s
PPO’s generally offer more out-of-network flexibility at a higher cost and often do not require referrals, though plan rules and prior authorization can still apply.
Original Medicare with Medigap versus Medicare Advantage.
This overview shows common structural differences. Exact premiums, provider access, benefits, cost-sharing, and enrollment rights must be checked for your location and situation.
Compare each topic
How coverage works
Original Medicare + Medigap
Original Medicare provides Parts A and B. Medigap helps with certain Original Medicare cost-sharing, but it has its own separate monthly premium.
Medicare Advantage
A private Medicare-approved plan provides your Part A and Part B benefits. Many plans have a $0 monthly plan premium.
Doctors and hospitals
Original Medicare + Medigap
Use any provider nationwide that accepts Medicare. Medigap generally has no provider network.
Medicare Advantage
Non-emergency care may need to stay within the plan network and service area. Rules vary by plan type.
Referrals and prior authorization
Original Medicare + Medigap
Original Medicare usually does not require referrals and generally uses less prior authorization.
Medicare Advantage
A plan may require referrals or prior authorization for certain services.
Out-of-pocket protection
Original Medicare + Medigap
Original Medicare alone has no yearly limit. A Medigap policy may help with selected deductibles, copayments, or coinsurance, depending on the policy and its separate premium.
Medicare Advantage
Every plan has a yearly limit for covered Medicare services. Copayments, coinsurance, and limits vary by plan.
Prescription drugs
Original Medicare + Medigap
A separate prescription drug plan is generally purchased and has its own premium and drug costs.
Medicare Advantage
Many plans include Part D drug coverage. Review the formulary, pharmacy network, premium, deductible, and drug costs.
Extra benefits
Original Medicare + Medigap
Medigap focuses on Original Medicare cost-sharing and generally does not include routine dental, vision, or hearing benefits. Separate coverage may be needed and can cost extra.
Medicare Advantage
Many plans may offer dental, vision, hearing, fitness, or other benefits. Benefits and limits vary by plan.
Premiums
Original Medicare + Medigap
Keep paying the Part B premium, plus a separate Medigap monthly premium and a separate Part D premium if you purchase drug coverage.
Medicare Advantage
Keep paying the Part B premium. Many plans have a $0 monthly plan premium, but copayments, coinsurance, deductibles, and other plan costs may apply.
Drug coverage depends on the plan’s formulary, tiers, and pharmacies.
Formulary and Tiers
Each plan has a formulary, or covered drug list. Lower tiers generally cost less, but each plan organizes its tiers differently and may use prior authorization, step therapy, or quantity limits.
2026 Cost Protection
The maximum Part D deductible is $615 in 2026. Covered Part D out-of-pocket spending is capped at $2,100 before catastrophic coverage begins.
Prescription Payment Plan
This voluntary option can spread drug costs across the calendar year. It can help manage cash flow, but it does not lower the total cost of prescriptions.
Extra Help can lower Medicare Part D costs.
Extra Help, also called the Part D Low-Income Subsidy or LIS, can help people with limited income and resources pay Part D premiums, deductibles, and prescription copayments. Some people qualify automatically through Medicaid, a Medicare Savings Program, or Supplemental Security Income; others can apply through Social Security.
Income and resource limits in 2026
In most cases, you must have income and resources below these limits. The limits may change each year.
- Individual
Income limit
$23,940
Resource limit
$18,090
- Married couple
Income limit
$32,460
Resource limit
$36,100
What you’ll pay under Extra Help in 2026
Plan premium: $0
Plan deductible: $0
Up to $5.10 for each generic drug at a participating pharmacy
Up to $12.65 for each brand-name drug at a participating pharmacy
Once total drug costs, including certain payments made on your behalf, reach $2,100, you’ll pay $0 for each covered drug.
Compare Medicare Advantage plans online, or review broader options with David.
Use the online tool to compare Medicare Advantage with Part D, Medicare Advantage without Part D (MA-only), and Special Needs Plans. Review plan costs, prescription costs, and provider networks side by side.
David de Jonge
Licensed Independent Insurance AgentReady To Talk Through Understanding Medicare?
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Send a MessageMedicare 101 FAQs
Questions that help the parts fit together.
Original Medicare is the federal health insurance program made up of Part A and Part B. You can use any doctor or hospital that accepts Medicare, but deductibles and coinsurance apply and there is no yearly out-of-pocket maximum under Original Medicare alone.
Original Medicare does not automatically include most outpatient prescription drugs, routine dental care, routine vision care, or hearing aids. It also leaves deductibles and coinsurance for you to pay and does not have a yearly out-of-pocket maximum.
Medigap works alongside Original Medicare and has its own monthly premium. Medicare Advantage is a private-plan way to receive Medicare benefits and many plans include Part D and extra benefits. Networks, costs, and plan rules differ, so the better fit depends on your doctors, prescriptions, travel, budget, and priorities.
Original Medicare does not automatically include most outpatient prescriptions. You can generally add a separate Part D plan, while many Medicare Advantage plans include Part D coverage.
No. A $0 plan premium does not remove other costs. Copayments, coinsurance, deductibles, out-of-network costs, and the Part B premium may still apply. Compare the likely total cost as well as the monthly plan premium.
With Original Medicare, you can generally use providers nationwide who accept Medicare. Medicare Advantage plans use provider networks and plan rules that vary, so always confirm your doctors and hospitals before enrolling.
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