↳ Part A (Hospital Insurance)

– Payroll Taxes: The primary funding comes from a 1.45% Medicare payroll tax on earnings, paid by both employees and employers (2.9% total). Since the Affordable Care Act of 2010, high earners (individuals with income above $200,000 or couples above $250,000) pay an additional 0.9%. These taxes feed into the Hospital Insurance (HI) Trust Fund.

– Premiums: Most beneficiaries qualify for premium-free Part A based on 40 quarters of Social Security-covered employment (around 10 years of employment). Others pay premiums depending on work history.

– General Revenue: Federal general tax revenues supplement Part A costs, particularly for those not eligible for premium-free coverage.

↳ Part B (Medical Insurance)

– Beneficiary Premiums: Beneficiaries cover approximately 25% of Part B costs through monthly premiums. Higher-income beneficiaries pay additional income-related monthly adjustment amounts (IRMAA) based on income.

– General Revenue: The federal government funds the remaining ~75% through general tax revenues, primarily income taxes, deposited into the Supplementary Medical Insurance (SMI) Trust Fund.

↳ Part C (Medicare Advantage)

– Federal Payments: Medicare Advantage plans are funded through a blend of Part A and Part B funds. The federal government pays private insurers a per-person capitation rate, adjusted for beneficiary health status and regional costs.

– Beneficiary Premiums: Some plans charge additional premiums beyond the standard Part B premium, depending on the plan’s benefits and coverage.

↳ Part D (Prescription Drug Coverage)

– Beneficiary Premiums: Beneficiaries pay monthly premiums, varying by plan. High-income beneficiaries also pay IRMAA surcharges.

– General Revenue: Federal general revenues cover a significant portion of Part D costs, also through the SMI Trust Fund.

– State Contributions: States contribute via the “clawback” provision, reimbursing the federal government for Part D costs for dual-eligible beneficiaries (those enrolled in both Medicare and Medicaid).

↳ Initial Enrollment Period (IEP)

The Initial Enrollment Period (IEP) is your first opportunity to apply for Medicare benefits, typically beginning around your 65th birthday. Enrolling during this window ensures timely coverage and helps avoid penalties. Even if you or your spouse have qualifying group health coverage through an employer with 20 or more employees, enrolling in premium-free Part A during your IEP is usually recommended, as it can coordinate with your existing employer plan at no cost. You can delay Part B and Part D without penalty if your employer coverage is creditable.

• For Who: Individuals turning 65 who are not delaying Medicare
• Enrollment Timeframe: A 7-month window: 3 months before, the month of, and 3 months after your 65th birthday month
• Coverage Start Date:If you apply during the 1–3 months before your 65th birthday month, coverage begins on the first day of your birthday month. If you enroll during your birthday month or in the 3 months after, coverage begins on the first day of the month following your enrollment.
  • If your birthday falls on the 1st of the month, Medicare treats your birthday as if it were in the previous month—so your coverage starts one month earlier.
• Recommended Action: Apply during the first 3 months to ensure coverage starts the first day of your birthday month. Delayed enrollment may cause a 1–3 month coverage gap.
• Automatic Enrollment: If you’re already receiving Social Security benefits at least four months before your 65th birthday, you’ll be automatically enrolled in Medicare Parts A and B, with coverage starting the first day of your 65th birthday month.

↳ General Enrollment Period (GEP)

The General Enrollment Period (GEP) is for individuals who missed their IEP and do not qualify for a Special Enrollment Period (SEP). This includes people who delayed enrollment for reasons such as living abroad, misunderstanding eligibility, or simply choosing not to enroll at 65. While the GEP offers a second chance to sign up, it comes with consequences: you may incur late enrollment penalties, especially for Part B and Part D.

• For Who: Individuals who missed their IEP and don’t qualify for an Special Enrollment Period (SEP)
• Enrollment Timeframe: January 1 to March 31 each year
• Coverage Start Date: The first day of the month after you enroll
• Note: Missing the IEP without creditable coverage can result in higher costs and delays in coverage. Always verify your eligibility for an SEP before relying on the GEP.

↳ Special Enrollment Period (SEP)

The Special Enrollment Period (SEP) applies to individuals who delayed enrolling in Medicare because they or their spouse had creditable group health coverage through an employer with 20 or more employees. This SEP allows you to sign up for Parts A and/or B without penalties once the employment or health coverage ends.

• For Who: Individuals who delayed enrollment due to employer-based group health insurance (20+ employees)
• Enrollment Timeframe: 8 months starting the month after employment or group health coverage ends—whichever comes first
• Coverage Start: The first day of the month after you enroll
• Recommended Action: Enroll as soon as possible after losing employer coverage to avoid a coverage gap. You will need to submit proof of prior coverage, usually via Form CMS-L564.

↳ Part C & Part D Enrollment

Medicare Advantage (Part C) and Medicare Prescription Drug Plans (Part D) are available through private insurers approved by Medicare. Part D covers prescription medications, while Part C bundles Parts A and B—and often Part D—into one plan. You must be enrolled in Part A or Part B to join a Part D plan. You must be enrolled in both Part A and Part B to join a Medicare Advantage (Part C) plan. Enrollment for these plans (Part C & Part D) can occur during:

1. Initial Enrollment Period (IEP): 7-months (3 months before, during, and after your 65th birthday)
   • If you apply during the 1–3 months before your 65th birthday month, coverage begins on the first day of your birthday month. If you enroll during your birthday month or in the 3 months after, coverage begins on the first day of the month following your enrollment.
2. Annual Enrollment Period (AEP): October 15 – December 7
   • Join, switch, or drop a Medicare Advantage (Part C) or Part D (prescription drug) plan. Switch from Original Medicare to Medicare Advantage or vice versa.
     • Coverage typically begins on January 1 of the following year
3. Special Enrollment Period (SEP): Usually 2 months after a qualifying event.
   • Such as losing employer health or drug coverage, moving out of your plan’s service area or your plan ends it contract with Medicare.
     • Coverage usually begins the first day of the month following the month you enroll
4. Medicare Advantage Open Enrollment Period (MA-OEP): January 1–March 31; Only for people already enrolled in a Medicare Advantage (Part C) plan.
   • Key time to switch Part C plans or return to Original Medicare (and enroll in a Part D (drug) plan if returning to Original Medicare)

↳ If Employed By A Large Employer (20 + employee)

When you or your spouse are covered by a group health plan through an employer with 20 or more employees, you have flexibility in deciding how to coordinate that coverage with Medicare—especially if the plan is creditable (meaning it offers coverage equal to or better than Medicare). This is a common scenario for individuals who work past age 65 or whose spouse has robust employer-sponsored benefits.

With a large employer, the group plan typically serves as the primary payer, with Medicare as secondary if enrolled, allowing you to tailor your enrollment strategy to your financial and healthcare needs. You can choose to rely solely on your employer plan, transition fully to Medicare, or combine both for enhanced coverage, particularly by enrolling in premium-free Part A. Each option has implications for costs, benefits, and enrollment timing. Making an informed decision requires confirming your plan’s creditable status, understanding coordination of benefits, and planning enrollment to avoid penalties or coverage gaps

Options For Coverage

1. Rely on Employer Coverage and Delay Medicare
   • Continue with your employer’s group plan and delay enrolling in Medicare Parts A, B, and/or D (or a Part C Medicare Advantage plan). This strategy avoids Medicare premiums as long as the employer coverage is creditable (especially for prescription drugs and outpatient care).
2. Decline Employer Coverage and Enroll in Medicare:
   • Drop your employer plan and enroll in Medicare Parts A, B, and/or D (or a Part C Medicare Advantage plan). This may be beneficial if your employer plan is expensive or has limited coverage.
3.  Combine Employer Coverage with Medicare
   • A common approach: enroll in premium-free Part A during your Initial Enrollment Period (IEP) to supplement hospital costs, while delaying Parts B and D (or a Part C Medicare Advantage plan) until you retire or lose coverage. Part A is typically free for most, making this a cost-effective supplement to your employer plan.

Important Considerations and Action Steps

• Confirm Creditable Coverage: Request a Notice of Creditable Coverage from your employer or HR department (provided annually). This confirms your health and drug plans meet Medicare’s minimum standards, allowing you to delay Medicare Part B & D enrollment without facing penalties.
• Enroll in Part A During IEP: If you’re eligible for premium-free Part A, consider enrolling during your Initial Enrollment Period.
  • Exception: If you have a Health Savings Account (HSA) and wish to continue contributing, delay all parts of Medicare (even Part A), as Medicare enrollment disqualifies you from making HSA contributions.
• Enroll in Parts B and D During SEP: When employment or coverage ends, apply for Parts B and/or D during the Special Enrollment Period (SEP), submitting Form CMS-L564 (proof of group coverage, signed by your employer).
  • Alternatively, you can enroll in Part B and then Part C Medicare Advantage plan which may includes Part D. However, the SEP timeframe for Part C is only 2-months after losing creditable coverage.

↳ If Employed By A Small Employer (less than 20 employee)

If you are still working and covered by a group health plan from an employer with fewer than 20 employees, your Medicare enrollment decisions are more constrained compared to those with large employer coverage. For small employers, Medicare is always the primary payer, meaning it covers eligible healthcare costs first, while your employer’s plan, if retained, serves as secondary coverage, paying only for services Medicare doesn’t cover. This dynamic makes enrolling in Medicare Parts A and B during your Initial Enrollment Period (IEP) critical to avoid significant out-of-pocket expenses, as your employer plan may deny claims Medicare would have covered.

Options for Coverage

1. Enroll in Medicare and Keep Employer Coverage as Secondary:
   • Enroll in Parts A and B during your IEP, using Medicare as your primary coverage. Retain your employer’s plan as secondary if the employer allows it, which may cover costs like copayments or non-Medicare services (e.g., dental, depending on the plan). Add a Part D plan for prescription drugs (if your employer’s drug coverage is not creditable) or consider a Part C Medicare Advantage plan.
2. Enroll in Medicare and Replace Employer Coverage:
   • Enroll in Parts A and B during your IEP and drop your employer’s plan. Add a Part D plan for prescription drugs (if your employer’s drug coverage is not creditable) and consider a Medigap policy or a Part C plan.

Important Considerations and Action Steps

• Enroll in Parts A and B During IEP – If you work for a small employer, you should enroll in Medicare Parts A and B during your Initial Enrollment Period (IEP).
• Confirm Employer Coverage Status: Contact your employer’s HR department to determine if their plan can remain secondary to Medicare. Some small employers may discontinue coverage or limit it to non-Medicare services once you’re eligible for Medicare.
• Evaluate Drug Coverage: Request a notice of creditable coverage from your employer to verify if their prescription drug plan meets Medicare Part D standards. If not creditable, enroll in Part D during your IEP to avoid a late enrollment penalty.
  • Alternatively, consider a Medigap policy or a Part C plan during the IEP after enrolling in Part A & Part B if you plan on dropping employer coverage or the current drug coverage is not creditable.

↳ Part A & B

To apply for Part A and/or Part B, you’ll go through the Social Security Administration (SSA). Enrollment is available whether you’re newly eligible at 65 or qualifying through a Special Enrollment Period (SEP) after losing employer coverage. Below details your enrollment options:

1. By Online (Fastest & Easiest)
   • Go to: ssa.gov/medicare
   • Click “Apply for Medicare Only”
   • You can apply for Part A, Part B, or both
   • Application takes approximately 10–30 minutes
2. By Phone
   • Call Social Security at 1-800-772-1213 (TTY: 1-800-325-0778)
   • Hours: Monday–Friday, 8 AM–7 PM
   • Have your Social Security number and identity documents ready.
3. In Person 
   • Visit your local Social Security office
   • Appointments are strongly recommended
   • Find your nearest office: secure.ssa.gov/locator
   • Bring your Social Security number, proof of identity, and if applying during a Special Enrollment Period (SEP), bring Form CMS-L564 (completed by your employer to verify coverage)

↳ Part C & D

To enroll in a Part C (Medicare Advantage) or Part D (Prescription Drug Plan), you’ll work with a private insurance company approved by Medicare, not through Social Security. These plans vary in cost, coverage, and provider networks, so it’s important to compare options. Below details your options on how to enroll:

1. Online via Medicare Plan Finder
   • Go to: medicare.gov/plan-compare
   • Enter your ZIP code and current medications (for Part D)
   •  Compare:
     • Premiums
     • Copays
     • Drug coverage (for Part D)
     • Extra benefits (for Part C plans, like dental/vision/hearing/fitness)
     • Network of doctors and pharmacies
   • Select a plan and click “Enroll
2. By Phone (with the Plan)
   • Call the plan provider directly
   • A licensed representative can help you complete the enrollment over the phone

↳ Inpatient Hospital Stays

Inpatient hospital stays refer to medical care provided when you’re formally admitted to a hospital with a doctor’s order, typically for serious conditions requiring overnight or extended treatment. This type of care is typically for more serious conditions, surgeries, or procedures that necessitate continuous monitoring and treatment.

• Coverage: Covers semi-private rooms, meals, general nursing, medications during your stay, and other hospital services. Includes care in acute care hospitals, critical access hospitals, and inpatient rehabilitation facilities.
• Conditions: Requires a doctor’s order for medically necessary care.

↳ Skilled Nursing Facility (SNF) Care

Skilled nursing facility care involves short-term, intensive nursing or rehabilitation services in a specialized facility for patients recovering from a hospital stay, such as after surgery or illness. SNFs are designed to bridge the gap between hospital care and returning home, offering a more structured environment for recovery. 

• Coverage: Covers semi-private rooms, meals, skilled nursing, and rehabilitative services (e.g., physical therapy) after a qualifying 3-day inpatient hospital stay.
• Conditions: Must be medically necessary, ordered by a doctor, and provided in a Medicare-certified SNF. Does not cover custodial care (e.g., help with daily activities like bathing).

↳ Hospice Care

Hospice care provides compassionate, comfort-focused care for terminally ill patients with a life expectancy of 6 months or less, emphasizing quality of life over curative treatment.

• Coverage: Covers medical and support services, including pain relief, symptom management, counseling, and respite care for caregivers. Provided in your home, a hospice facility, or another setting.
• Conditions: Requires a doctor’s certification of terminal illness and enrollment in a Medicare-certified hospice program.

↳ Home Health Care

Home health care delivers part-time medical services to homebound patients recovering from illness or injury, allowing them to receive care without staying in a hospital or facility.

• Coverage: Covers part-time or intermittent skilled nursing, physical therapy, occupational therapy, and other services for homebound beneficiaries.
• Conditions: Requires a doctor’s order, a care plan, and services from a Medicare-certified home health agency. Does not cover 24-hour care or non-medical services (e.g., meal delivery).

↳ Doctor and Outpatient Medical Services

Doctor and outpatient medical services encompass visits to physicians, specialists, and other healthcare providers for diagnosis, treatment, or management of medical conditions, typically in an outpatient setting like a doctor’s office or clinic. These are services that do not require a hospital stay—patients typically receive care and return home the same day.

• Coverage: Covers medically necessary services, including office visits, consultations, second opinions, and outpatient procedures (e.g., minor surgeries, diagnostic tests). Includes services from primary care doctors, specialists (e.g., cardiologists), and other providers like nurse practitioners.
• Conditions: Services must be medically necessary and provided by Medicare-approved providers. Some procedures require prior authorization.

↳ Preventive Services

Preventive services include screenings, vaccines, and counseling aimed at preventing illness or detecting health issues early to improve outcomes and reduce healthcare costs.

• Coverage: Covers annual wellness visits, screenings (e.g., mammograms, colonoscopies, prostate cancer screenings), vaccinations (e.g., flu, pneumococcal, hepatitis B), and counseling (e.g., smoking cessation, diabetes self-management). Most preventive services are free if provided by Medicare-approved providers.
• Conditions: Must follow Medicare’s schedule (e.g., annual, biennial) and be performed by providers accepting Medicare assignment.

↳ Outpatient Hospital Services

Outpatient hospital services involve medical care provided in a hospital or facility without formal admission, such as emergency room visits, observation care, or same-day surgeries. This refers to medical care provided to patients who typically do not require overnight admission to the hospital.

• Coverage: Covers emergency department visits (without admission), observation services (e.g., monitoring without overnight stay), outpatient surgeries, diagnostic tests (e.g., X-rays, MRIs), and treatments (e.g., chemotherapy, dialysis for ESRD). Includes services in hospital outpatient departments or ambulatory surgical centers.
• Conditions: Services must be medically necessary and provided in Medicare-certified facilities. Some services require prior authorization.
• Observation Status Trap: If you’re in a hospital bed but not formally admitted (e.g., under “observation”), all services are outpatient (Part B), and Part A doesn’t apply, which can lead to unexpected costs.

↳ Inpatient Hospital Care (Physician and Related Services)

Refers to the professional services provided by doctors, surgeons, and other healthcare providers during a hospital stay where you’re formally admitted as an inpatient (typically overnight or longer). Part A covers the facility costs of an inpatient stay, such as the hospital room, nursing, meals, and general hospital operation but Part B covers covers the professional services during that stay.

• Coverage: Covers doctor visits (e.g., a cardiologist checking on you), surgeries performed by a surgeon, consultations, diagnostic tests (e.g., lab tests, X-rays), and other medical services provided by physicians or practitioners during an inpatient hospital stay. Includes services in acute care hospitals, critical access hospitals, or inpatient rehabilitation facilities.
• Conditions: Services must be medically necessary and provided by Medicare-approved providers. Part B covers only professional services, not facility costs (covered by Part A). Some services may require prior authorization.

↳ Home Health Care (Limited)

Home health care under Part B provides limited medical services for homebound patients who need ongoing care but do not qualify for Part A’s more extensive home health coverage.

• Coverage: Covers part-time or intermittent skilled nursing or therapy services (e.g., physical, occupational) for those not qualifying under Part A (e.g., no prior hospital stay). Includes medical social services and home health aide services in limited cases.
• Conditions: Requires a doctor’s order, a care plan, and services from a Medicare-certified home health agency. Does not cover 24-hour care or non-medical services.

↳ Durable Medical Equipment (DME)

Durable medical equipment refers to reusable medical devices prescribed for home use to manage health conditions, such as wheelchairs, oxygen equipment, or diabetic supplies.

• Coverage: Covers medically necessary DME (e.g., walkers, hospital beds, nebulizers) when prescribed by a doctor and supplied by Medicare-approved providers. Includes related supplies (e.g., glucose test strips).
• Conditions: Equipment must meet Medicare’s durability and medical necessity criteria. May require prior authorization for certain items.

↳ Ambulance Services

Ambulance services involve emergency or medically necessary transportation to healthcare facilities for treatment or diagnostics when other transport is not feasible.

• Coverage: Covers ground or air ambulance transport to the nearest appropriate facility (e.g., hospital, dialysis center) when medically necessary (e.g., emergency, non-emergency for bedridden patients).
• Conditions: Must be ordered by a doctor or deemed medically necessary. Non-emergency transport requires prior authorization.

↳ Inpatient Services (Equivalent to Part A)

Inpatient services under Part C encompass a broad range of medically necessary care provided during a formal hospital admission or related institutional stay, including acute care, skilled nursing, limited home health, and inpatient psychiatric care. These services mirror Part A’s coverage but are managed through the Part C plan’s network and rules, offering coordinated care for serious health conditions requiring hospitalization or specialized recovery.

• Coverage: Managed through the plan’s rules (e.g., in-network hospitals, referral requirements). Includes hospital stays, skilled nursing facility (SNF) care, limited home health care (part-time skilled services), and inpatient psychiatric care.
• Conditions: Requires a doctor’s order for medically necessary care. Services typically must be provided by in-network, with potential prior authorization or referrals (e.g., for HMO plans).
• Note: Hospice care remains covered by Original Medicare, even if you are enrolled in a Medicare Advantage plan.

↳ Outpatient & Preventive Services (Equivalent to Part B)

Outpatient and preventive services under Part C include a wide array of medical care provided without hospital admission, such as doctor visits, diagnostic tests, outpatient procedures, and preventive screenings, as well as physician services during inpatient stays. These services replicate Part B’s coverage but are coordinated through the Part C plan’s network, emphasizing early detection, treatment, and management of health conditions to maintain or improve health outcomes.

• Coverage: Provided through in-network providers. Includes doctor visits, lab tests, outpatient procedures, ambulance services, preventive screenings (e.g., annual wellness visits, mammograms, diabetes screenings), durable medical equipment (DME, e.g., wheelchairs, oxygen), and more. Examples include X-rays, chemotherapy, dialysis, and emergency ambulance transport.
• Conditions: Services must be medically necessary and provided by in-network. Some services (e.g., outpatient surgeries, DME) may require prior authorization or referrals, especially in HMO plans. Preventive services are typically free if provided by in-network providers following Medicare’s schedule.

↳ Prescription Drug Coverage (Most Plans Include Part D)

Prescription drug coverage under Part C, typically offered through Medicare Advantage Prescription Drug (MA-PD) plans, provides access to medications prescribed for treating or managing health conditions, integrating Part D benefits into the Part C plan for seamless drug coverage. This coverage mirrors standalone Part D plans but is managed within the Part C plan’s formulary and network, reducing the need for a separate Part D premium and coordinating drug benefits with medical care.

• Coverage: Drugs listed on the plan’s formulary (tiered by cost), including generics and brand-name medications.
• Conditions: Must use in-network pharmacies. Some drugs may require prior authorization or step therapy.

↳ Additional Benefits (Plan-Specific Extras)

These are not covered under Original Medicare but are often included in Part C plans.

• Examples:
  • Dental (e.g., exams, cleanings, fillings)
  • Vision (e.g., eye exams, glasses)
  • Hearing (e.g., exams, hearing aids)
  • Wellness (e.g., SilverSneakers gym memberships)
  • Transportation to appointments
  • Over-the-counter (OTC) allowances
• Limitations: Benefits vary by plan and may have caps (e.g., $500 annual dental limit) or referral requirements.

↳ Prescription Drugs (Formulary-Based)

Prescription drugs under Part D are medications prescribed by a healthcare provider to treat or manage medical conditions, dispensed through a plan’s formulary at participating pharmacies.

• Coverage: Includes generics, brand-name drugs, and specialty drugs listed in the plan’s formulary, covering treatments for chronic conditions (e.g., diabetes, heart disease), acute illnesses, and maintenance therapies.
• Conditions: Drugs must be medically necessary, prescribed by a Medicare-approved provider, and dispensed at in-network pharmacies. Some require prior authorization, step therapy (trying lower-cost drugs first), or quantity limits. Formularies may change annually.

↳ Vaccinations (Select Preventive Drugs)

Select vaccinations under Part D are preventive medications administered to protect against specific diseases, distinct from Part B-covered vaccines like flu or pneumococcal.

• Coverage: Covers vaccines not under Part B, such as shingles (herpes zoster) and tetanus-diphtheria-pertussis (Tdap), when prescribed and dispensed through the plan’s formulary.
• Conditions: Must be medically necessary, prescribed, and obtained from an in-network pharmacy or provider. May have tier-based copays or require prior authorization

↳ Supplies for Drug Administration

Supplies for drug administration under Part D are equipment or materials needed to deliver covered medications, such as syringes for insulin or inhalation devices for asthma drugs.

• Coverage: Includes needles, syringes, inhalers, or other supplies used with Part D-covered drugs (e.g., insulin, nebulized medications). Subject to formulary rules and tier-based copays.
• Conditions: Supplies must be medically necessary, linked to a covered Part D drug, and obtained from an in-network pharmacy or supplier. May require prior authorization.

↳ Eligibility

To be eligible for a Medigap policy, you must:

• Be enrolled in Original Medicare (Part A and Part B)
• Not be enrolled in a Medicare Advantage Plan (Part C)
• Reside in the state where the Medigap plan is offered. Medigap policies are regulated at the state level and can only be sold to residents of that state.

↳ Enrollment

(1) Medigap Open Enrollment Period (OEP) – The best time to enroll in a Medigap plan is during your six-month Medigap Open Enrollment Period, which begins the first day of the month in which you are both 65 or older and enrolled in Medicare Part B. During this period:

• Insurance companies cannot deny coverage or charge higher premiums based on pre-existing conditions.
• You have the widest selection of plans at standard rates.

Outside this period, you can still apply for a Medigap policy, but insurers may use medical underwriting to determine your eligibility and premiums. You could be denied coverage or charged more based on your health. You can only enroll in one Medigap plan at a time, and switching plans later may involve underwriting.

(2) Guaranteed Issue Rights (“Special Enrollment” Situations) – There are specific circumstances in which you may be granted guaranteed issue rights, which function like a Special Enrollment Period (SEP). These rights allow you to purchase a Medigap policy without medical underwriting, even outside your Open Enrollment Period. You typically have 63 days from the date your coverage ends (or from receiving notice) to enroll. You may qualify for guaranteed issue rights if:

• Your Medicare Advantage Plan stops serving your area or you move out of its service area
• You lose employer coverage that was supplementing Medicare
• You tried a Medicare Advantage Plan for the first time and decide to switch back to Original Medicare within 12 months (called a “trial right”).
• You dropped a Medigap plan to join a Medicare Advantage Plan, and now want to return within 12 months.

↳ Services/Coverage

Medigap plans are standardized into ten types: Plans A, B, C, D, F, G, K, L, M, and N. Each plan offers a different set of benefits, but all plans must follow federal and state laws designed to protect consumers. The benefits within each lettered plan are identical across insurers, although costs may vary. You can review Medigap benefits on the Medicare.gov website. Most Medigap plans help reduce or eliminate the following expenses:

• Medicare Part A coinsurance and hospital costs
• Medicare Part B coinsurance or copayments
• Blood transfusions (first 3 pints)
• Hospice care coinsurance (under Part A)
• Skilled nursing facility care coinsurance
• Foreign travel emergency care (in some plans)

This coverage can significantly lower your out-of-pocket expenses and provide greater cost predictability, particularly if you have frequent doctor visits or ongoing medical needs.

Note: Medigap does not cover prescription drugs, dental, vision, hearing aids, or long-term care. For drug coverage, you must enroll separately in a Medicare Part D plan.

↳ Cost

The cost of a Medigap plan varies widely depending on several factors, but one thing is certain: Medigap is not free, and it comes on top of what you already pay for Medicare. When you enroll in a Medigap plan, you pay a monthly premium to a private insurance company. This premium is in addition to your Medicare Part B premium (which is required in order to have Medigap). Premiums can vary greatly based on:

• The plan you choose: More comprehensive plans tend to have higher premiums.
• Your location: Premiums can differ by state, region, or even ZIP code.
• Your age: Depending on how the plan is priced, your age at enrollment—or your current age—can impact cost.
• When you enroll: If you apply outside your Open Enrollment Period, you may face higher premiums or be denied based on your health.
• The insurance company: Different insurers can charge different rates for the exact same plan.

Note: Premium prices may increase yearly based upon your age or inflation, depending upon the method the insurance company uses. It is important to understand which pricing method (community-rated, issue-age-related or attained-age-related) the insurer uses as it can significantly impact your long-term cost.