Medicare & Insurance FAQ: 32 Common Questions Answered

What is Medicare?

Medicare is the U.S. federal health insurance program primarily for people age 65 and older, plus some younger adults with qualifying disabilities or conditions like End-Stage Renal Disease (ESRD) and ALS. It covers roughly 67 million Americans.

Who qualifies for Medicare?

U.S. citizens and legal residents of 5+ years qualify at age 65. People under 65 qualify if they have received Social Security Disability Insurance (SSDI) for 24 months, have ESRD and need dialysis or a transplant, or have been diagnosed with ALS.

What are the four parts of Medicare?

Part A is hospital insurance (inpatient care, skilled nursing, hospice). Part B is medical insurance (doctors, outpatient services, preventive care). Part C is Medicare Advantage — private plans that replace Parts A and B and usually include Part D. Part D is prescription drug coverage.

When can I enroll in Medicare?

Your Initial Enrollment Period (IEP) is a 7-month window: the 3 months before your 65th birthday, your birthday month, and the 3 months after.

Annual Enrollment runs October 15 through December 7 for Medicare Advantage and Part D changes. Medicare Advantage Open Enrollment runs January 1 through March 31, when you can switch MA plans or drop back to Original Medicare.

How much does Medicare cost in 2026?

Most people pay $0 for Part A. The standard Part B premium is $189.40/month in 2026, with a $240 annual deductible. Higher-income enrollees pay IRMAA surcharges on top of Part B and Part D. Part D and Medicare Advantage premiums vary by plan — many Advantage plans have $0 premiums.

Is Medicare Part A really free?

Part A has no monthly premium if you or your spouse worked 10+ years (40 quarters) paying Medicare taxes. It still has a deductible ($1,676 per benefit period in 2026) and coinsurance for longer hospital stays. Some people who haven't worked enough quarters pay a Part A premium of up to $518 per month.

What is IRMAA?

IRMAA is the Income-Related Monthly Adjustment Amount — an extra surcharge high-income beneficiaries pay on top of their Part B and Part D premiums. In 2026, IRMAA begins above $106,000 in modified adjusted gross income (MAGI) for singles and $212,000 for joint filers, based on 2024 tax returns.

Surcharges range from about $74 to $443 per month depending on income tier. If your income drops significantly due to a life event (retirement, divorce, death of spouse), you can appeal IRMAA using Form SSA-44.

Can I keep my employer coverage after 65?

Yes, if your employer has 20 or more employees, you can typically delay Medicare Part B without a late penalty and keep your employer plan. You qualify for a Special Enrollment Period when that employer coverage ends.

Employers with fewer than 20 employees generally require Medicare to be primary, so delaying Part B can leave you uncovered. Talk to your HR department and a licensed agent before deciding.

What is Medicare Advantage?

Medicare Advantage (Part C) is an alternative to Original Medicare offered by private insurance companies contracted with CMS. It bundles Parts A and B and usually includes Part D, plus often dental, vision, hearing, and fitness benefits. Many plans have $0 monthly premiums. About 54% of Medicare beneficiaries now choose Medicare Advantage over Original Medicare.

How is Medicare Advantage different from Original Medicare?

Original Medicare lets you see any provider nationwide that accepts Medicare, with no referrals needed. Medicare Advantage uses provider networks and often requires prior authorization for specialists and certain procedures.

Medicare Advantage usually has lower premiums but may have higher out-of-pocket costs if you use services heavily. Original Medicare paired with a Medigap supplement has more predictable costs but higher monthly premiums.

Can I switch Medicare Advantage plans?

Yes. During Annual Enrollment (Oct 15 – Dec 7), you can switch to a different Medicare Advantage plan, return to Original Medicare, or change Part D. During Medicare Advantage Open Enrollment (Jan 1 – Mar 31), you can switch MA plans or drop back to Original Medicare. Certain life events trigger Special Enrollment Periods.

What happens to my Medicare Advantage plan if I move?

Moving out of your plan's service area triggers a Special Enrollment Period. You'll have 2 months after the month you move (or tell your plan about the move) to enroll in a new Medicare Advantage plan, switch to Original Medicare, or add a standalone Part D plan.

What is Medigap?

Medigap (also called Medicare Supplement Insurance) is private insurance that fills gaps in Original Medicare, covering costs like copays, coinsurance, and deductibles. Medigap plans are standardized and labeled by letter (Plan G, Plan N, etc.). They work only with Original Medicare — not with Medicare Advantage.

Which Medigap plan is best?

Plan G is the most popular choice for new enrollees. It covers nearly everything except the Part B deductible ($240 in 2026). Plan N has lower premiums but requires small copays for some office visits and doesn't cover Part B excess charges. Plan F is only available to people who became Medicare-eligible before January 1, 2020.

The best plan depends on your budget, expected healthcare use, and state. A licensed agent can compare rates from multiple carriers for you at no cost.

What is the Medigap Open Enrollment Period?

Your one-time Medigap Open Enrollment Period is a 6-month window that starts the month you turn 65 AND are enrolled in Part B. During this window, you can buy any Medigap plan regardless of health status, and insurance companies can't charge you more or deny you for pre-existing conditions.

Outside this window, medical underwriting usually applies, meaning you could be denied or charged higher premiums based on your health history. Some states (like New York, Connecticut, Massachusetts, Maine) have guaranteed-issue rules that extend protections.

Can I change Medigap plans whenever I want?

You can apply to change Medigap plans at any time, but outside a guaranteed-issue period, insurance companies can require medical underwriting — meaning they can review your health history and deny you or charge more. Some states have annual Medigap switching windows (like California's birthday rule or Missouri's anniversary rule). Check with your licensed agent about your state's rules.

Does Medigap cover prescription drugs?

No. Medigap plans sold today do not include prescription drug coverage. You'll need to enroll in a standalone Medicare Part D plan for prescription coverage. The exception is some older Medigap policies sold before 2006 that had drug benefits — those are no longer available to new enrollees.

What is Medicare Part D?

Part D is prescription drug coverage offered by private insurance companies approved by Medicare. You can get Part D as a standalone plan alongside Original Medicare or built into a Medicare Advantage plan. Each Part D plan has its own formulary (list of covered drugs) and pricing tiers, so the best plan depends on your specific medications.

What is the $2,000 Part D out-of-pocket cap?

Starting in 2025, Medicare Part D enrollees pay no more than $2,000 per year out of pocket for covered prescription drugs. This cap was created by the Inflation Reduction Act and remains in effect for 2026. Once you hit $2,000 in covered drug costs, your plan pays 100% for the rest of the year.

Before this cap, some enrollees on specialty medications for conditions like cancer or autoimmune disease paid tens of thousands out of pocket annually.

What is the Part D late enrollment penalty?

If you go 63 or more consecutive days without Part D or other creditable drug coverage after first becoming eligible for Medicare, you may pay a late enrollment penalty for as long as you have Part D.

The penalty is 1% of the national base beneficiary premium ($36.78 in 2026) times the number of full uncovered months, added to your monthly Part D premium permanently. Even if you don't currently take prescriptions, many enrollees sign up for a low-cost Part D plan to avoid the penalty later.

What is the ACA Marketplace?

The Affordable Care Act (ACA) Marketplace — also called Healthcare.gov or an exchange — is where individuals and families under 65 can shop for health insurance. Plans are categorized by metal level (Bronze, Silver, Gold, Platinum) and must cover 10 essential health benefits. About 24.3 million Americans enrolled for 2025 coverage.

Am I eligible for ACA subsidies?

Most Marketplace enrollees qualify for a premium tax credit if their household income is between 100% and 400% of the Federal Poverty Level. For 2026, income above 400% FPL is no longer eligible for subsidies because the enhanced subsidies from the Inflation Reduction Act expired December 31, 2025.

Eligibility also requires being a U.S. citizen or lawfully present and not having access to affordable employer coverage. See our 2026 ACA Cheat Sheet for the full FPL chart and subsidy details.

When can I enroll in an ACA Marketplace plan?

Federal Marketplace Open Enrollment runs November 1 to January 15 each year. Some state-run marketplaces have later end dates. Outside Open Enrollment, you need a qualifying life event — like marriage, birth, job loss, divorce, or a move — to trigger a 60-day Special Enrollment Period.

What happened to the enhanced ACA subsidies?

The enhanced premium tax credits originally created by the 2021 American Rescue Plan and extended by the 2022 Inflation Reduction Act expired December 31, 2025. These enhancements capped premiums at 8.5% of income for all enrollees and removed the 400% FPL subsidy cliff. The One Big Beautiful Bill Act of 2025 did not extend them.

For 2026 plans, the older pre-ARPA subsidy formula returned, and CBO projected that roughly 4–5 million fewer Americans would have Marketplace coverage as a result.

What is the ACA subsidy cliff?

The "subsidy cliff" refers to the sharp loss of premium tax credits for households earning more than 400% of the Federal Poverty Level. Under the enhanced subsidies (2021–2025), there was no cliff — premiums were simply capped at 8.5% of income. Starting with Coverage Year 2026, the cliff returned: households above 400% FPL get no premium assistance, so they pay full-price premiums.

Can I have Medicare and an ACA plan at the same time?

No. It's illegal for an insurer or agent to knowingly sell a Marketplace plan to someone who has Medicare. If you're already on Medicare, you should drop your Marketplace plan when Medicare starts. You can keep a dental or vision plan from the Marketplace alongside Medicare.

What's the difference between Medicaid and Medicare?

Medicare is federal health insurance primarily for people 65+ and some with disabilities, with eligibility based on age or disability. Medicaid is a joint federal-state program for low-income individuals and families, with eligibility based on income.

Some people qualify for both ("dual eligibles") — roughly 12.5 million Americans — and get some costs covered by each program.

How does Medicaid expansion work?

The ACA gave states the option to expand Medicaid to all adults up to 138% of the Federal Poverty Level. As of 2026, 41 states plus D.C. have expanded. In non-expansion states (TX, FL, TN, AL, MS, SC, GA, WY, KS), adults without children typically can't qualify for Medicaid at any income, creating a "coverage gap" for low-income adults.

What is CHIP and how do I qualify?

CHIP (Children's Health Insurance Program) provides low-cost coverage for children in families who earn too much for Medicaid but not enough to afford private insurance. Income limits vary by state, typically ranging from 170% to 400% of the Federal Poverty Level. Some states also cover pregnant women through CHIP.

What does it cost to work with a Medicare or ACA insurance agent?

Nothing. Licensed insurance agents are paid commissions directly by the insurance carriers when you enroll in a plan. You pay the same premium whether you enroll on your own or with an agent's help. Using an agent doesn't add anything to your cost.

What is a TPMO?

TPMO stands for Third-Party Marketing Organization — a CMS term for any entity that markets, sells, or enrolls beneficiaries in Medicare Advantage or Part D plans on behalf of insurance carriers. CMS requires all TPMOs to provide a standardized disclaimer and follow specific marketing rules. Medicare Moms is a TPMO.

How do I find a Medicare agent near me?

You can:

Search Medicare.gov's Plan Finder to compare plans directly. Use the National Association of Insurance Commissioners lookup to verify an agent's licensing in your state. Contact your State Health Insurance Assistance Program (SHIP) for free unbiased counseling. Or contact Medicare Moms at (435) 246-1548 to speak with a licensed agent directly.

Always confirm an agent is licensed in your state and appointed with the carriers you're considering.

Does Medicare Moms have Spanish-speaking agents?

Yes. Medicare Moms has five bilingual Spanish/English licensed agents: Aidyl Semidey, Elizabeth Perez, Edmi Dominguez, Lissette Wong, and Magarely Sanchez. We also have a Japanese-speaking agent (Saya Murton) and a German-speaking agent (Michelle Bodin). You can reach our Spanish-language site at medicaremoms.com/es/.