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Medicare Deep Dive

Medicare Coverage and Costs Explained

Understand How Medicare Coverage, Costs and Choices Work Together

Medicare is not one single health insurance plan. It is a federal health insurance program made up of different parts, enrollment rules, costs and coverage choices. Understanding how those pieces work together can help you avoid penalties, unexpected medical bills and coverage that does not fit your doctors, prescriptions or healthcare needs.

This guide explains Medicare Parts A, B, C and D, what Original Medicare does and does not cover, how income may affect your premiums through IRMAA, and the decisions you may face when choosing between Medicare Advantage and Medicare Supplement coverage.

The Four Parts of Medicare at a Glance

Each part has a different role. Some are provided directly through the federal government, while others are offered by private insurance companies approved by Medicare.

A

Medicare Part A

Hospital Insurance

  • Inpatient hospital care
  • Skilled nursing facility care
  • Hospice services
  • Limited home healthcare
Explore Part A →
B

Medicare Part B

Medical Insurance

  • Doctor and specialist visits
  • Outpatient medical services
  • Preventive care
  • Durable medical equipment
Explore Part B →
C

Medicare Part C

Medicare Advantage

  • Alternative way to receive Parts A and B
  • Offered by private insurance companies
  • Often includes prescription coverage
  • Uses plan networks and cost-sharing
Explore Medicare Advantage →
D

Medicare Part D

Prescription Drug Coverage

  • Helps cover outpatient prescriptions
  • Uses formularies and drug tiers
  • Available as a standalone plan
  • May be included with Medicare Advantage
Explore Part D →

Understanding the letters is only the beginning

After enrolling in Medicare Parts A and B, you may still need to decide how you want to manage prescription coverage and the costs Original Medicare leaves behind. That is where Medicare Advantage, Medicare Supplement insurance and Part D coverage become important.

Common Medicare Mistakes to Avoid

Medicare decisions can have lasting financial and coverage consequences. These are some of the most common problems we see when helping people prepare for Medicare.

Mistake 1

Assuming everyone must enroll at age 65

Some people should enroll when they turn 65, while others may be able to delay Medicare because they have qualifying employer coverage. The correct timing depends on your employment, coverage and household situation.

Mistake 2

Thinking Original Medicare covers everything

Original Medicare does not cover every healthcare expense and does not include an annual out-of-pocket maximum. Understanding the gaps is essential before choosing how to supplement your coverage.

Mistake 3

Choosing coverage before checking doctors and prescriptions

Plan premiums are only one part of the decision. Your doctors, hospitals, prescriptions, travel needs and expected healthcare use can all affect which option fits you.

Mistake 4

Confusing marketing ability with Medicare expertise

A polished social media presence and a large audience do not automatically equal Medicare experience. Some professionals are Medicare agents who use social media to educate. Others are primarily content creators who also sell Medicare. Ask about experience, ongoing training, carrier representation and the service you will receive after enrollment.

Mistake 5

Ignoring Medicare coverage after enrollment

Plan networks, formularies, premiums and benefits can change. A proactive Medicare Annual Review can help confirm that your coverage still fits your doctors, medications and budget.

Mistake 6

Continuing HSA contributions without checking Medicare rules

Enrolling in Medicare affects your eligibility to contribute to a Health Savings Account. People working beyond age 65 should coordinate Medicare enrollment, Social Security, payroll and HSA contributions carefully.

Choosing the right agent is part of choosing the right coverage

Look beyond advertising and popularity. An experienced Medicare agent should take time to review your doctors, prescriptions, healthcare needs and budget, explain why a recommendation is being made, and remain available after your enrollment is complete.

Compare Types of Medicare Agents
Hospital Insurance

What Medicare Part A Covers and What It Costs

Medicare Part A primarily helps cover inpatient hospital care. It may also cover skilled nursing facility care, hospice and certain home healthcare services when Medicare's requirements are met.

Services Medicare Part A May Cover

Part A is often called hospital insurance, but coverage depends on the type of care you receive, where you receive it and whether Medicare's eligibility requirements are satisfied.

Inpatient hospital care after you are formally admitted
Qualifying skilled nursing facility care
Hospice care for eligible beneficiaries
Certain limited home healthcare services

2026 Medicare Part A Costs

Most Medicare beneficiaries qualify for premium-free Part A because they or their spouse worked and paid Medicare taxes long enough. However, Part A is not completely free. Hospital and skilled nursing facility costs are generally based on a benefit period.

Monthly Premium

Generally 40 or more work quarters Usually at least 10 years of paying Medicare taxes.
$0
30–39 work quarters
$311 per month
Fewer than 30 work quarters
$565 per month

Inpatient Hospital Costs

Part A deductible The deductible applies to each new benefit period—not necessarily only once per calendar year.
$1,736 per benefit period
Days 1–60
$0 daily coinsurance
Days 61–90
$434 per day
Days 91 and beyond Uses your available lifetime reserve days. Medicare beneficiaries generally have 60 lifetime reserve days.
$868 per day

Skilled Nursing Facility Costs

Days 1–20 of a Medicare-covered stay
$0 daily coinsurance
Days 21–100 of a Medicare-covered stay
$217 per day
After day 100
You pay all costs

These are 2026 Original Medicare amounts. Medicare Advantage plans may structure hospital and skilled nursing cost-sharing differently, but must provide at least the coverage required by Medicare.

Main Purpose Inpatient Care
Premium for Most People $0
2026 Deductible $1,736 Per Benefit Period
Medical Insurance

How Medicare Part B Covers Doctors and Outpatient Care

Medicare Part B helps cover medically necessary and preventive services received outside an inpatient hospital admission. This includes many of the services people use most often, such as doctors, specialists, testing, outpatient procedures and medical equipment.

Services Medicare Part B May Cover

Part B generally covers two broad categories: medically necessary services used to diagnose or treat a medical condition, and preventive services intended to help identify or prevent illness.

Primary care and specialist visits
Outpatient surgery and medical procedures
Diagnostic testing and laboratory services
Emergency room and ambulance services
Certain preventive screenings and vaccines
Durable medical equipment, such as qualifying walkers or oxygen equipment
Outpatient therapy and mental health care
Certain medications administered by a healthcare professional

2026 Medicare Part B Costs

Everyone enrolled in Part B generally pays a monthly premium. The amount may be higher for beneficiaries with higher modified adjusted gross income.

Standard Monthly Premium

Standard 2026 Part B premium Some beneficiaries pay more because of IRMAA, and certain beneficiaries may pay a late-enrollment penalty.
$202.90 per month

Annual Deductible and Coinsurance

2026 Part B deductible
$283 per year
Your share after the deductible For many covered services when the provider accepts Medicare assignment.
Usually 20%
Original Medicare annual out-of-pocket maximum
None

Some Part B preventive services may be covered without the deductible or 20% coinsurance when Medicare's requirements are met and the provider accepts assignment.

Standard Premium $202.90 Per Month
2026 Deductible $283 Per Year
Typical Coinsurance 20%

Part B is only one piece of your coverage

After enrolling in Medicare Parts A and B, you still need to decide how you will handle prescription drug coverage and the deductibles and coinsurance left by Original Medicare.

Use the Plan Selector Explore Medigap Explore Medicare Advantage
Medicare Advantage

How Medicare Part C Changes the Way You Receive Your Benefits

Medicare Part C, commonly called Medicare Advantage, is an alternative way to receive your Medicare Part A and Part B benefits through a private insurance company approved by Medicare.

What Is Medicare Advantage?

When you join a Medicare Advantage plan, you remain enrolled in Medicare and must continue paying your Part B premium. The private plan becomes responsible for administering your Medicare-covered Part A and Part B services.

Many plans also include Part D prescription drug coverage and may offer additional benefits that Original Medicare does not routinely cover. Benefits, provider networks, drug formularies, costs and service areas vary by plan.

Includes Medicare Part A hospital benefits
Includes Medicare Part B medical benefits
Often includes Part D drug coverage
May include additional dental, vision or hearing benefits
Uses plan-specific copayments and coinsurance
Includes an annual maximum out-of-pocket limit for covered Part A and Part B services

Two Ways to Receive Medicare Coverage

After enrolling in Medicare Parts A and B, most beneficiaries make a larger coverage decision: remain with Original Medicare or receive their benefits through Medicare Advantage.

Original Medicare

Medicare administers your Part A and Part B benefits directly.

  • Visit any provider in the country who accepts Medicare
  • Add a standalone Part D plan for prescription coverage
  • Consider Medigap to help cover deductibles and coinsurance
  • No built-in annual out-of-pocket maximum for Parts A and B

Medicare Advantage

A private insurance company administers your Medicare-covered services.

  • Usually uses an HMO or PPO provider network
  • Often includes prescription drug coverage
  • Uses plan copayments and coinsurance as care is received
  • Includes an annual maximum out-of-pocket limit for covered medical services
Use the Plan Selector Compare Both Paths

What Does Medicare Part C Cost?

Medicare Advantage costs are not standardized nationwide. The amount you pay depends on the specific plan, where you live, which services you use and whether providers are in the plan's network.

Costs to Review

Medicare Part B premium You generally continue paying this premium even when enrolled in a Medicare Advantage plan.
Still required
Additional plan premium Some plans have no additional monthly plan premium. Other plans charge an additional amount.
Varies by plan
Copayments and coinsurance
Vary by service
Annual medical out-of-pocket maximum This generally applies to covered Part A and Part B services, not monthly premiums or Part D drug costs.
Varies by plan

HMO and PPO Networks Can Work Differently

The plan's provider network is one of the most important parts of a Medicare Advantage decision. Never assume that every doctor, hospital or specialist accepts every plan from the same insurance company.

Medicare Advantage HMO Generally requires members to use in-network providers except for emergency care, urgent care and certain other limited circumstances. Some HMOs require referrals for specialist care.
Medicare Advantage PPO Generally allows both in-network and out-of-network care, but out-of-network services may cost more. Providers are not necessarily required to accept the plan simply because it offers out-of-network benefits.
Take the HMO or PPO Quiz View the HMO and PPO Comparison
Administered By Private Medicare Plan
Drug Coverage Often Included
Medical Spending Limit Included
Prescription Drug Coverage

How Medicare Part D Covers Your Prescriptions

Medicare Part D helps pay for covered outpatient prescription drugs. Coverage is offered through private insurance companies approved by Medicare, and every plan has its own premium, formulary, pharmacy network and cost-sharing structure.

Two Ways to Get Medicare Drug Coverage

Standalone Part D Plan

A separate prescription drug plan, commonly called a PDP, can be paired with Original Medicare.

  • Separate monthly plan premium
  • Plan-specific formulary and pharmacies
  • Commonly paired with Medigap
  • Does not cover Part A or Part B medical services

Medicare Advantage Drug Plan

Many Medicare Advantage plans combine Part A, Part B and Part D within one plan.

  • Often called an MAPD plan
  • Medical and prescription benefits are combined
  • Uses the plan's drug formulary
  • Uses the plan's pharmacy network

2026 Medicare Part D Costs

Part D premiums and prescription costs vary by plan. The following amounts are federal limits, not a promise that every plan will charge the maximum.

Premium and Deductible

Monthly plan premium Depends on the plan and service area. Higher-income beneficiaries may also pay Part D IRMAA directly to Medicare.
Varies by plan
Maximum permitted 2026 deductible A plan may charge a lower deductible, have no deductible or apply the deductible differently to certain drug tiers.
$615

Annual Out-of-Pocket Cap

2026 out-of-pocket limit for covered Part D drugs After reaching the applicable annual threshold, you pay no additional out-of-pocket costs for covered Part D drugs for the remainder of the year.
$2,100

The Part D out-of-pocket cap does not include monthly premiums, drugs that are not covered by your plan or purchases that do not count toward your Part D out-of-pocket spending.

How Part D Costs Build During the Year

Your exact costs depend on your plan and prescriptions, but Part D generally moves through the following stages.

1

Deductible Stage

When a deductible applies, you pay the plan's negotiated cost for applicable medications until the deductible is met. No Part D plan may have a deductible above $615 in 2026.

2

Initial Coverage Stage

After satisfying any applicable deductible, you pay the plan's copayment or coinsurance for covered medications.

3

Annual Out-of-Pocket Limit

Once your qualifying out-of-pocket costs for covered Part D drugs reach $2,100 in 2026, you pay no additional out-of-pocket costs for covered Part D prescriptions for the rest of that calendar year.

Why the Drug Formulary Matters

A formulary is the list of medications covered by a prescription drug plan. Two plans with similar premiums can produce very different annual costs depending on how they cover your prescriptions.

Drug Tier Plans group medications into different pricing levels. Higher tiers often have greater copayments or coinsurance.
Prior Authorization The plan may require approval before it will cover a medication.
Step Therapy The plan may require you to try another covered medication before covering the prescribed drug.
Quantity Limits The plan may limit the amount covered during a specific period.
Preferred Pharmacies Your medication may cost less at a pharmacy with preferred pricing.
Mail-Order Options Some plans offer different pricing for extended supplies obtained through mail-order services.
2026 Maximum Deductible $615
2026 Drug Spending Cap $2,100
Premium Varies by Plan

Prescription coverage should be reviewed every year

Your prescriptions may change, and plans may change their premiums, formularies, pharmacy arrangements, copayments and coverage rules. An annual review can identify whether your current plan is still a good fit for the coming year.

Start a Medicare Annual Review Book an Appointment
Higher-Income Medicare Premiums

How Income Can Increase Your Medicare Premiums

The Income-Related Monthly Adjustment Amount, commonly called IRMAA, is an additional amount some higher-income Medicare beneficiaries pay for Part B and Part D. It is not a separate insurance plan or a one-time fee.

1

Social Security Reviews Your Income

For 2026 premiums, Social Security generally reviews income reported on your 2024 federal tax return. If that return is unavailable, older tax information may sometimes be used.

2

Your Filing Status Determines the Bracket

The income thresholds differ for individual filers, married couples filing jointly and certain married people filing separately.

3

The Adjustment Is Added Monthly

Part B IRMAA increases your monthly Part B premium. Part D IRMAA is added to the premium charged by your prescription drug plan or Medicare Advantage drug plan.

2026 Medicare IRMAA Estimator

Enter the filing status and MAGI from the tax return generally used for 2026 Medicare premiums.

$
For 2026, this is generally your 2024 adjusted gross income plus tax-exempt interest.
$

Your estimate will appear here

The result will show the estimated Part B premium, Part D adjustment and combined annual amount.

Your Estimated 2026 Medicare Costs

Monthly Part B Premium $0.00 Includes the standard Part B premium and any estimated Part B IRMAA.
Monthly Part D IRMAA $0.00 Added to the premium charged by your drug plan. The plan premium is not included here.
Estimated Annual Part B Premium and Part D IRMAA $0.00 This does not include your Part D plan premium, Medigap premium, Medicare Advantage premium, deductibles, copayments or coinsurance.
Based on the information entered, your income does not appear to exceed the 2026 IRMAA threshold for this filing status. The standard Part B premium is still due.
Based on the information entered, an income-related adjustment may apply to both Part B and Part D. Social Security—not this calculator or Capstone Health—makes the official determination.
Important: This calculator provides an estimate only.

It is not a tax calculation, legal advice or an official determination of your Medicare premiums. Social Security makes the final IRMAA decision using information available from the IRS and other applicable records. Contact Social Security at 1-800-772-1213 or your local Social Security office to confirm your actual premium.

2026 IRMAA Brackets

These amounts are based generally on 2024 MAGI.

Individual MAGI Married Filing Jointly MAGI Total Part B Premium Part D IRMAA Added to Plan Premium
$109,000 or less $218,000 or less $202.90 $0
More than $109,000 through $137,000 More than $218,000 through $274,000 $284.10 +$14.50
More than $137,000 through $171,000 More than $274,000 through $342,000 $405.80 +$37.50
More than $171,000 through $205,000 More than $342,000 through $410,000 $527.50 +$60.40
More than $205,000 but below $500,000 More than $410,000 but below $750,000 $649.20 +$83.30
$500,000 or more $750,000 or more $689.90 +$91.00
Married filing separately has different brackets when the beneficiary lived with a spouse at some point during the tax year. The estimator above includes that filing status. Part D amounts shown are added to the premium charged by the beneficiary's prescription drug plan.

What if your income has decreased since the tax year Medicare reviewed?

A past tax return may not reflect your current financial situation. Social Security may consider a new IRMAA determination when certain life-changing events reduce your household income.

Marriage
Divorce or annulment
Death of a spouse
Work stoppage or retirement
Reduction in work hours
Loss of income-producing property
Loss of certain pension income
Employer settlement payment
Review Social Security's IRMAA Process View Form SSA-44
Medicare Enrollment Timing

When to Enroll—and When You May Be Able to Delay Medicare

Turning 65 does not create the same enrollment decision for everyone. Your Social Security status, current employment, employer coverage, spouse’s coverage, HSA contributions and retirement date can all affect when you should enroll.

Path One

You are retiring or do not have qualifying employer coverage

You will generally need to coordinate Medicare enrollment around your 65th birthday to prevent a lapse in coverage or possible late-enrollment penalties.

  • Confirm whether enrollment will be automatic.
  • Verify your requested Part A and Part B start dates.
  • Decide how you will receive your Medicare benefits.
  • Arrange prescription drug coverage when needed.
Path Two

You or your spouse will continue actively working

You may be able to delay Part B without a penalty when you are covered by a qualifying group health plan based on your or your spouse’s current employment.

  • Ask how the employer plan coordinates with Medicare.
  • Confirm whether the coverage is based on current employment.
  • Review the employer’s size and Medicare payer rules.
  • Discuss HSA contributions before enrolling in any part of Medicare.

Your Initial Enrollment Period

Your first Medicare enrollment window generally surrounds the month you turn 65.

The Initial Enrollment Period generally lasts seven months. It begins three months before your 65th-birthday month and ends three months afterward.

1 Three Months Before Enrollment window begins
2 Two Months Before Prepare coverage choices
3 One Month Before Confirm effective dates
65 Birthday Month Your Medicare eligibility month
5 One Month After Enrollment period continues
6 Two Months After Coverage may begin later
7 Three Months After Initial window ends

Special timing applies when your birthday falls on the first day of a month. Your Medicare eligibility and enrollment timeline may be treated as though your birthday occurred during the prior month.

Will Medicare Enrollment Happen Automatically?

Receiving Social Security before age 65 can change the application process.

Already receiving Social Security

People receiving qualifying Social Security or Railroad Retirement Board benefits before age 65 are often enrolled automatically in Medicare Part A and Part B.

Review all Medicare notices carefully, especially when you plan to keep working or contribute to an HSA.

Not receiving Social Security yet

Medicare enrollment may not happen automatically. You may need to submit an application through Social Security when you are ready to begin Medicare.

Do not assume that reaching age 65 alone completes the enrollment process.

Working Past 65: Questions to Ask Before Delaying Part B

“I have insurance through work” is not enough information to make a safe Medicare decision.

Before delaying Medicare, speak with the employer benefits administrator and get clear answers to the following questions.

Is the coverage based on current employment?

Retiree coverage, COBRA and individual coverage are not treated the same as a group health plan based on active employment.

How many employees does the employer have?

Employer size may affect whether the group plan or Medicare pays first after you become Medicare eligible.

Does the plan require enrollment in Medicare?

Some employer or retiree plans reduce benefits or expect Medicare to pay first once you become eligible.

Is the prescription coverage creditable?

Ask for the annual creditable-coverage notice and keep it with your records in case you delay Part D.

Will enrolling in Part A affect HSA contributions?

Enrollment in any part of Medicare can make you ineligible to contribute to an HSA.

What happens when employment ends?

Ask when the employer plan terminates and how early Medicare applications should be submitted to avoid a coverage gap.

Part B Special Enrollment Period

When you delay Part B because you or your spouse are actively working and you have qualifying group health coverage, you may generally enroll while that coverage continues or during the eight-month Special Enrollment Period after employment or coverage ends, whichever occurs first.

Employment or qualifying job-based coverage ends
Eight-Month Part B Enrollment Window Waiting until the end of this period can still create a gap in coverage. Apply early enough to coordinate the requested Medicare start date.

Not All Coverage Lets You Safely Delay Medicare

The source of your health insurance matters.

Active Employer Group Coverage
Coverage based on your or your spouse’s current employment may support a Part B Special Enrollment Period when Medicare’s requirements are met.
COBRA
COBRA continuation coverage does not extend the eight-month Part B Special Enrollment Period. That window generally starts when employment ends or active-employment coverage ends, whichever occurs first.
Retiree Coverage
Retiree health insurance is generally not treated as coverage based on current employment. Many retiree plans expect Medicare to pay first.
Marketplace Coverage
Individual Marketplace insurance does not generally create the same Part B Special Enrollment Period as qualifying active-employer group coverage.
VA Benefits
VA healthcare and Medicare are separate systems. VA coverage alone does not automatically protect someone from every Medicare late-enrollment consequence.

Medicare and Health Savings Accounts

HSA timing requires special care when Medicare enrollment is delayed beyond age 65.

1

Medicare enrollment ends contribution eligibility

Beginning with the first month you are enrolled in Medicare, your allowable HSA contribution limit is generally zero.

2

Part A may begin retroactively

When someone applies for premium-free Part A after age 65, coverage may be backdated by as much as six months, but not earlier than the first month of Medicare eligibility.

3

Retroactive coverage can create excess contributions

HSA contributions made for months later covered retroactively by Medicare may be considered excess contributions and can require tax correction.

4

Coordinate payroll and tax advice before applying

People applying for Medicare more than six months after turning 65 are commonly advised to review whether HSA contributions should stop at least six months before the Medicare application. Confirm your exact timing with payroll, the HSA administrator and a qualified tax professional.

Medicare Late-Enrollment Penalties

Delaying coverage without qualifying protection can create long-term costs.

Not every delay creates a penalty. The key question is whether you had coverage or circumstances that Medicare recognizes for delaying that specific part.

Part A Penalty

A penalty may apply if you must purchase Part A and did not enroll when first eligible.

The premium may increase by 10% for twice the number of years enrollment was delayed.

Part B Penalty

A penalty may apply when Part B was delayed without qualifying current-employment coverage or another valid enrollment right.

Generally 10% of the standard Part B premium for each full 12-month period of delay.

Part D Penalty

A penalty may apply after going 63 or more consecutive days without Part D or other creditable prescription coverage.

Generally calculated using 1% of the national base beneficiary premium for each uncovered month.

Common Forms When Leaving Employer Coverage

Social Security may require proof that your delayed Part B enrollment was based on qualifying employment coverage.

CMS-40B

Application for Enrollment in Medicare Part B. This form is used when requesting Part B outside of automatic enrollment.

CMS-L564

Request for Employment Information. This documents qualifying group health coverage based on current employment.

Visit Social Security’s Part B Application View Official Medicare Forms

What Original Medicare Does Not Routinely Cover

Medicare provides broad healthcare coverage, but it does not pay for every service or eliminate all medical costs.

Medicare Parts A and B cover many hospital, physician, outpatient and preventive services. However, beneficiaries still need to understand the services Medicare generally excludes and the deductibles and coinsurance they may be responsible for paying.

1

Routine Dental Care

Original Medicare generally does not cover routine cleanings, fillings, dentures or most routine dental services.

2

Routine Vision Care

Routine eye examinations for glasses and the cost of most eyeglasses or contact lenses are generally not covered.

3

Routine Hearing Services

Original Medicare generally does not cover routine hearing examinations or hearing aids.

4

Long-Term Custodial Care

Medicare does not generally pay for ongoing custodial assistance when skilled medical care is not required.

5

Most Care Outside the United States

Original Medicare provides only limited coverage outside the country under specific circumstances.

6

Annual Out-of-Pocket Limit

Original Medicare does not include a built-in annual maximum on what you may spend for covered Part A and Part B services.

Medicare Myth Versus Fact

Common Medicare Assumptions That Can Lead to Mistakes

Medicare decisions are easier when you separate common assumptions from how the program actually works.

Myth

Medicare is completely free.

Fact

Most people receive premium-free Part A, but Medicare can still include Part B premiums, Part D premiums, deductibles, copayments, coinsurance and income-related adjustments.

Myth

Everyone must enroll in every part at age 65.

Fact

Some people should enroll at 65, while others may be able to delay Part B or Part D because they have qualifying current-employment coverage.

Myth

I do not need Part D because I take no prescriptions.

Fact

Delaying Part D without other creditable drug coverage may create a late-enrollment penalty when you enroll later.

Myth

Every Medicare Advantage plan works the same way.

Fact

Provider networks, prescription coverage, copayments, benefits, service areas and plan rules can vary significantly.

Myth

The agent with the largest audience must be the most experienced.

Fact

Some experienced Medicare professionals use social media to educate. Others are primarily content creators who also sell Medicare. Evaluate experience, training, carrier access and ongoing client service—not popularity alone.

Myth

Once I choose a plan, I never need to review it again.

Fact

Plans may change their premiums, formularies, networks, benefits and cost-sharing. Your doctors, prescriptions and healthcare needs may also change.

Find Your Next Step

Continue Based on Where You Are in Your Medicare Journey

The right next step depends on whether you are approaching Medicare, comparing coverage or reviewing an existing plan.

1

Turning 65 or New to Medicare

Learn when to enroll, how Medicare starts and what decisions need to be made before your coverage begins.

Visit New to Medicare →
2

Unsure When to Enroll

Use the Medicare Enrollment Tool to review timing based on your birthday, employer coverage and Social Security status.

Use the Enrollment Tool →
3

Comparing Medigap and Medicare Advantage

Review the differences between the two coverage paths and use the Plan Selector for personalized education.

Use the Plan Selector →
6

Already Enrolled in Medicare

Complete a proactive annual review of your doctors, prescriptions, costs and plan changes.

Start an Annual Review →
Frequently Asked Questions

Answers to Common Medicare Questions

These general answers provide a starting point. Individual enrollment and coverage decisions can depend on your specific situation.

What is the difference between Original Medicare and Medicare Advantage?

Original Medicare is administered by the federal government and includes Part A and Part B. Medicare Advantage is an alternative way to receive those benefits through a private Medicare-approved plan.

The two paths differ in provider access, cost-sharing, prescription coverage and how annual spending is managed.

Does Medicare include prescription drug coverage?

Original Medicare Parts A and B do not provide comprehensive outpatient prescription coverage. Drug coverage is generally obtained through a standalone Part D plan or a Medicare Advantage plan that includes Part D.

Can I delay Medicare if I am still working?

You may be able to delay Part B when you have qualifying group health coverage based on your or your spouse's current employment. Employer size, payer rules, HSA contributions and the type of coverage all matter.

Do not rely only on the statement that you have workplace insurance. Confirm the details before delaying enrollment.

Is Medicare Part A always free?

Most beneficiaries qualify for premium-free Part A through their own or a spouse's work history. However, Part A still includes deductibles and coinsurance, and some people must pay a monthly premium to enroll.

What is IRMAA?

IRMAA is an income-related amount added to Medicare Part B and Part D costs for some higher-income beneficiaries. Social Security makes the official determination using applicable tax information.

Can I keep contributing to an HSA after enrolling in Medicare?

Enrollment in Medicare generally ends your eligibility to make new HSA contributions. Retroactive Part A coverage can also affect earlier contributions, so enrollment timing should be coordinated with payroll, the HSA administrator and a tax professional.

Does Original Medicare have a maximum out-of-pocket limit?

Original Medicare does not include a built-in annual maximum out-of-pocket limit for Part A and Part B services. Medicare Advantage plans include an annual medical spending limit, while Medigap can help pay certain costs left by Original Medicare.

Why should Medicare coverage be reviewed every year?

Medicare Advantage and Part D plans may change premiums, drug formularies, networks, copayments and benefits. Your medications, doctors, finances and healthcare needs can change as well.

Learn more about a proactive Medicare Annual Review .

Questions About Your Medicare Options?

Capstone Health is a family-owned independent Medicare agency in New Port Richey. We help you understand your choices, compare coverage and make an educated decision without relying on a call center.

1

Use a Medicare Decision Tool

Start with the tool that best matches the decision you are trying to make.

  • Enrollment Timing Tool
  • Medigap vs. Medicare Advantage Plan Selector
  • HMO or PPO Quiz
  • Plan G, Plan N and PPO Calculator
Use a Medicare Decision Tool
2

Meet Our Medicare Team

Meet the independent Medicare agents at Capstone Health and learn how our team supports clients before, during and after enrollment.

  • Independent Medicare guidance
  • Local and statewide support
  • Multiple experienced agents
  • Ongoing annual reviews
Meet Our Team
3

Value of Annual Medicare Reviews

Learn why reviewing your doctors, prescriptions, costs and plan changes each year can help keep your Medicare coverage aligned with your needs.

  • Review plan changes each year
  • Recheck doctors and prescriptions
  • Compare changing costs and benefits
  • Maintain year-round agent support
Value of Annual Reviews
Book a Medicare Appointment

Capstone Health is not connected with or endorsed by the United States government or the federal Medicare program. Information is educational and does not replace official guidance from Medicare, Social Security, the IRS or a qualified tax or legal professional.