Medicare
Medicare, explained in plain language
Medicare is the federal health insurance program for people 65 and older, and for some younger people with disabilities or End-Stage Renal Disease — it comes in four parts, and the parts you choose determine what you pay and which doctors you can see.
The four parts of Medicare
A
Hospital insurance
Inpatient hospital stays, skilled nursing facility care, hospice and some home health care. Most people pay no premium for Part A because they or a spouse paid Medicare taxes for about ten years.
B
Medical insurance
Doctor visits, outpatient care, lab work, durable medical equipment and preventive services. Part B has a monthly premium and an annual deductible, then you generally pay 20% coinsurance.
C
Medicare Advantage
A private plan that replaces how you get Parts A and B, usually with a network, an annual out-of-pocket maximum, and often drug coverage and extras built in.
D
Prescription drugs
Private drug coverage, either as a stand-alone plan next to Original Medicare or bundled into a Medicare Advantage plan. Each plan has its own list of covered drugs.
The one big decision
Nearly everything comes down to one fork in the road: Original Medicare (Parts A and B), usually with a Medigap policy and a stand-alone Part D plan — or a Medicare Advantage plan that bundles it together. Neither is universally better. It depends on your doctors, your prescriptions, how much you travel, and how you’d rather pay: steadier monthly premiums, or lower premiums with copays when you use care.
Who Medicare is designed for
- People turning 65, whether they’re retiring or still working
- People under 65 who have received Social Security Disability Insurance for 24 months
- People with End-Stage Renal Disease or ALS, who qualify on different timelines
- People leaving employer coverage after 65 and needing to start Part B without a penalty
What Original Medicare generally covers — and generally doesn’t
Generally covered
- Inpatient hospital and skilled nursing facility care
- Doctor visits, specialists and outpatient procedures
- Lab tests, imaging and durable medical equipment
- Preventive care: annual wellness visit, many screenings, flu shots
- Hospice care and limited home health care
Generally not covered
- Most prescription drugs you pick up at a pharmacy (that’s Part D)
- Routine dental, eye exams for glasses, and hearing aids
- Long-term custodial care in a nursing home or assisted living
- Most care outside the United States
- Cosmetic surgery and most routine foot care
Coverage is decided by Medicare and, for Part C and Part D, by each plan. Always confirm a specific service or drug against your plan’s documents or at Medicare.gov.
Eligibility considerations
Most people qualify for premium-free Part A at 65 based on their own or a spouse’s work history — roughly 40 quarters of Medicare-taxed employment. If you don’t have that history, Part A can still be purchased.
Part B always has a premium, and the standard amount is $202.90 per month in 2026, with a $283 annual deductible. Higher-income households pay an income-related surcharge (IRMAA) based on tax returns from two years earlier.
You must be enrolled in Part A and Part B to join a Medicare Advantage plan, and enrolled in Part A or Part B to join a stand-alone Part D plan. You also generally need to live in the plan’s service area.
Enrollment considerations
Initial Enrollment Period
A seven-month window: the three months before the month you turn 65, your birthday month, and the three months after.
Annual Enrollment, Oct 15 – Dec 7
Change Medicare Advantage or Part D plans for the coming year. Changes take effect January 1.
Medicare Advantage Open Enrollment, Jan 1 – Mar 31
If you’re already in a Medicare Advantage plan, you may make one change during this window.
Special Enrollment Periods
Losing employer coverage, moving, gaining Medicaid or Extra Help, and other life events can open a window outside the usual dates.
Important limitations
- Original Medicare has no annual out-of-pocket maximum. The 20% coinsurance on Part B services is open-ended unless you add a Medigap policy or choose a Medicare Advantage plan.
- Late enrollment in Part B or Part D can create a permanent monthly penalty. It is added to your premium for as long as you have the coverage.
- Medigap policies are only guaranteed-issue in certain windows. Outside them, an insurer may use medical underwriting in most states.
- Plan benefits, networks, formularies and premiums change every year. The plan that fit last year may not fit this year.
Frequently asked questions
Do I have to sign up for Medicare at 65?
Not always. If you’re still working and covered by a qualifying employer group health plan, you may be able to delay Part B without a penalty. Whether that’s true depends on the employer’s size and how the plan is structured, so it’s worth a phone call before you decide.
Is Medicare free?
Part A is premium-free for most people, but Part B has a monthly premium, both parts have deductibles and cost-sharing, and drug coverage costs extra. Programs like Extra Help and Medicare Savings Programs can reduce those costs for people with limited income.
What does your help cost me?
Nothing. Insurance carriers pay agents a set commission when someone enrolls, and those amounts are regulated — so the plan costs the same whether you enroll with us, on your own, or through a call center.
Can I change my mind later?
For Medicare Advantage and Part D, yes — each fall during Annual Enrollment, and sometimes at other times if you qualify for a Special Enrollment Period. Medigap is different: switching later can require medical underwriting depending on your state and timing.
Talk with James directly
James O’Neal
Licensed agent & broker · O'Neal Insurance Group
- No cost for our help — ever
- Independent — many carriers, not one
- You keep the same agent next year
- Plain answers, no pressure to switch
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