If you're approaching 65 or recently retired, you've probably realized that Medicare can feel like learning a new language. Parts A, B, C, D—supplements, advantage plans, enrollment periods—it's enough to make your head spin.
Here's the good news: Medicare doesn't have to be complicated.
I'm Steve Germain, and over the past 10 years, I've helped more than 3,000 people just like you navigate Medicare with confidence. My goal with this guide is simple: help you understand how Medicare works so you can choose the coverage that's right for you.
What Is Medicare?
Medicare is the federal health insurance program that covers:
- People age 65 and older
- People under 65 with certain disabilities
- People of all ages with End-Stage Renal Disease (permanent kidney failure)
Important to know: Medicare is individual coverage. Even if you and your spouse are both turning 65, you each need to enroll separately.
The 4 Parts of Medicare
Medicare has four main parts that work together to cover your healthcare needs:
Part A – Hospital Insurance
Part A covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health services. Most people get Part A premium-free if they or their spouse worked and paid Medicare taxes for at least 10 years.
Part B – Medical Insurance
Part B covers doctor visits, outpatient care, preventive services, lab tests, and medical equipment. Everyone pays a monthly premium for Part B—$202.90 in 2026 for most people. High-income earners pay additional IRMAA surcharges based on tax returns from two years prior.
Part C – Medicare Advantage
Medicare Advantage is a bundled plan offered by private insurance companies that includes Parts A and B, and usually Part D. Many plans also include extra benefits like dental, vision, and hearing coverage.
Part D – Prescription Drug Coverage
Part D helps cover the cost of prescription medications. You'll need to add this to Original Medicare (Parts A and B) or choose a Medicare Advantage plan that includes drug coverage.
Your Two Main Coverage Paths
Once you're enrolled in Original Medicare (Parts A and B), you have two paths forward:
Path 1: Original Medicare + Supplement + Part D
Best for: People who want maximum flexibility to see any doctor nationwide and prefer predictable costs.
Path 2: Medicare Advantage (Part C)
- Choose a Medicare Advantage plan that replaces Original Medicare
- Typically includes prescription drug coverage
- Often includes extra benefits (dental, vision, hearing, gym memberships)
Best for: People who prefer an all-in-one plan and are comfortable with network restrictions.
What Medicare Covers (and Doesn't Cover)
What Medicare Covers
- Hospital stays and surgeries
- Doctor visits and outpatient care
- Lab tests and X-rays
- Preventive care (screenings, vaccines, wellness visits)
- Skilled nursing facility care (with limitations)
- Home health care (if medically necessary)
- Hospice care
What Medicare Doesn't Cover
- Routine dental care
- Routine vision care (glasses, contacts)
- Hearing aids
- Long-term custodial care (nursing home)
- Cosmetic surgery
Many people choose supplemental coverage to fill these gaps.
The Medicare Gaps You Should Know About
Original Medicare (Parts A and B) has significant coverage gaps that can lead to substantial out-of-pocket costs:
Part A Gaps
- $1,736 deductible for each benefit period in 2026 (not per year)
- Skilled nursing coinsurance: $217/day for days 21-100
- Hospital stay costs: $434/day for days 61-90, $868/day for lifetime reserve days 91-150
- No coverage beyond 150 days per benefit period
Part B Gaps
- 20% coinsurance with no annual maximum
- Example: A $100,000 hip surgery means Medicare pays $80,000 and you pay $20,000
Most people choose either a Medicare Supplement plan or Medicare Advantage plan to fill these gaps and protect against unexpected medical costs.
Understanding Benefit Periods
A benefit period starts when you're admitted to a hospital and ends when you haven't received inpatient care for 60 consecutive days.
Why this matters: You pay the Part A deductible ($1,736 in 2026) for each benefit period, not once per year. If you're hospitalized twice with more than 60 days between discharges, you'll pay two separate deductibles.
Example: You're hospitalized in March, discharged in April, and rehospitalized in September. Because more than 60 days passed between stays, you would pay the deductible twice.
The Skilled Nursing Care Gap
One of Medicare's biggest coverage gaps is skilled nursing care. Medicare only covers up to 100 days in a skilled nursing facility per benefit period, and only under specific conditions:
- You must have a qualifying 3-day minimum inpatient hospital stay first
- The care must be for skilled services (physical therapy, IV medications, wound care)
- Days 1-20: Medicare covers fully
- Days 21-100: You pay $217/day in 2026 ($19,360 maximum)
- After day 100: Medicare pays nothing
Important: Skilled nursing care is different from long-term custodial care. If you need help with daily activities like bathing or dressing, Medicare doesn't cover it at any point.
Final Thoughts
Medicare doesn't have to be overwhelming. Understanding the four parts, knowing your coverage options, and enrolling on time are the foundations for making confident decisions about your healthcare.
At A&E Insurance Agency, we make Medicare simple. We'll compare plans in your area, explain your costs, and help you choose coverage that fits your needs—whether that's a Medicare Supplement, Medicare Advantage, or the right combination of supplemental policies. Schedule a free consultation to get started.
Frequently Asked Questions (FAQs)
Q1. What is Medicare, and who qualifies?
Medicare is a federal health insurance program designed primarily for people aged 65 and older. You may also qualify before 65 if you have been receiving Social Security Disability Insurance (SSDI) benefits for 24 months, or if you have been diagnosed with End-Stage Renal Disease (ESRD) or ALS (also known as Lou Gehrig's disease). Eligibility is based on age, work history, or qualifying medical conditions making it an essential healthcare lifeline for more than 67 million Americans.
Q2. What are the four parts of Medicare?
Medicare is made up of four parts, each covering different healthcare needs:
Part A (Hospital Insurance): Covers inpatient hospital stays, skilled nursing facility care following a qualifying hospital stay of at least 3 consecutive days, hospice care, and some home health services.
Part B (Medical Insurance): Covers doctor visits, outpatient care, preventive services, durable medical equipment, and medically necessary services. The standard 2026 Part B premium is $202.90/month with a $283 annual deductible.
Part C (Medicare Advantage): Private plans approved by Medicare that bundle Part A and Part B coverage, and usually include Part D prescription drug coverage often with added benefits like dental, vision, and hearing.
Part D (Prescription Drug Coverage): The federal program that helps cover the cost of prescription medications. In 2026, the annual out-of-pocket cap for Part D is $2,100 after which covered drugs cost $0 for the rest of the year.
Understanding how these four parts work together is the foundation for building the right coverage.
Q3. What is the difference between Original Medicare & Medicare Advantage?
Original Medicare includes Part A and Part B and allows you to see any doctor or hospital in the country that accepts Medicare with no network restrictions and no referral requirements. It offers broad flexibility but does not include prescription drug coverage or extra benefits by default, and has no annual out-of-pocket cap.
Medicare Advantage (Part C), offered through Medicare-approved private insurance companies, bundles hospital, medical, and usually prescription drug coverage into one plan. These plans often include extra benefits like dental, vision, and hearing, but typically require you to use a provider network. All Medicare Advantage plans include an annual in-network out-of-pocket maximum capped at $9,250 in 2026 a financial protection that Original Medicare alone does not provide.
Q4. Does Medicare cover everything?
No. While Medicare provides strong coverage for hospital and medical services, it does not cover routine dental, vision, hearing care, or long-term custodial care. Under Original Medicare, you are also responsible for deductibles, copayments, and coinsurance with no annual cap on what you can owe. In 2026, the standard Part B premium is $202.90/month and the annual Part B deductible is $283. This is why many beneficiaries choose to add a Medicare Supplement (Medigap) plan or enroll in Medicare Advantage to better control their out-of-pocket exposure.
Q5. Do I need a Medicare Supplement plan?
A Medicare Supplement (Medigap) plan is designed to fill the coverage gaps in Original Medicare helping pay for costs like deductibles, copayments, and coinsurance. These plans provide more predictable healthcare expenses and allow you to see any provider that accepts Medicare, anywhere in the country, with no network restrictions. Medigap plans are standardized under federal law and sold by private insurers regulated at the state level. They are especially valuable for beneficiaries who want broad provider access and protection from unexpected or high medical bills.
Q6. When should I enroll in Medicare?
You should enroll during your Initial Enrollment Period (IEP) a 7-month window that begins 3 months before your 65th birthday, includes your birth month, and ends 3 months after. If you are qualifying through disability, your IEP begins 3 months before your 25th month of receiving SSDI benefits. Enrolling on time is critical missing this window can result in permanently higher premiums and delayed coverage. If you have group health coverage through an active employer, a Special Enrollment Period (SEP) may apply when that coverage ends, allowing you to enroll without penalty.
Q7. How do I choose the right Medicare plan?
The right Medicare plan depends on your healthcare needs, preferred doctors, prescription drug usage, and budget. If you value flexibility and the freedom to see any Medicare-accepting provider nationwide without referrals, Original Medicare paired with a Medigap supplement may be the best fit.
If you prefer bundled, all-in-one coverage with lower monthly premiums and added benefits like dental and vision, a Medicare Advantage plan may work better. Working with a licensed, independent Medicare advisor like Steve Germain at A&E Insurance Agency means you get a clear, side-by-side comparison of every option available to you, with no pressure and at no cost to you.
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