Prime Integrity Insurance

Medicare Basics

Medicare, explained in plain English

Medicare is the federal health insurance program for people 65 or older, and for some younger people with a disability, End-Stage Renal Disease (ESRD), or ALS. This page walks through the parts, the two main ways to get coverage, and when you can sign up — in short sections you can skip around.

The details below follow Medicare.gov and CMS. Costs shown are for 2026 and can change each year. This is a summary, not a complete list of rules. For official information, use Medicare.gov or call 1-800-MEDICARE (1-800-633-4227). TTY: 711.

Start here

What Medicare is — and what it is not

Think of Medicare as a set of building blocks, not one single plan. Part A and Part B together are called Original Medicare. From there, you choose how to get that coverage, and whether to add drug coverage and extra help with out-of-pocket costs.

Medicare is different from insurance you might have had through work. It does not offer couple or family plans. You and your spouse each make your own choice. You also do not have to make the same choice.

Medicare is not Medicaid. Medicaid is a joint federal and state program for people who qualify based on income and other rules. If you qualify, you can have both. Medicare is also not a private insurance company — though private companies do offer Medicare Advantage, Part D, and Medigap policies that follow Medicare rules.

Who can get Medicare

  • Age 65 or olderMost people first become eligible at 65 if they meet citizenship or lawful residency rules.
  • Under 65 with a qualifying disabilityYou may get Medicare after receiving Social Security disability benefits for 24 months.
  • ESRD or ALSPeople with End-Stage Renal Disease or ALS (Lou Gehrig’s disease) may get Medicare earlier, with special timing rules.

Some people are enrolled automatically — usually if they already get Social Security or Railroad Retirement benefits at least 4 months before they turn 65. Others need to sign up. You sign up for Part A and Part B through Social Security, not through an insurance agent.

The building blocks

The four parts of Medicare

You do not pick “a Medicare” the way you pick a car model. You get Part A and Part B (or refuse Part B), then choose Original Medicare or a Medicare Advantage plan, and decide about drug coverage.

A

Part A

Hospital insurance

Helps pay if you are admitted to a hospital, or need certain follow-up care after a hospital stay.

What it helps cover

  • Inpatient hospital stays
  • Skilled nursing facility care after a qualifying hospital stay (with limits)
  • Hospice care
  • Some home health care

What you typically pay

Most people pay no monthly Part A premium if they or a spouse paid Medicare taxes long enough while working — generally at least 10 years. You can still owe a deductible and daily costs if you use hospital or skilled nursing care.

Good to know. Part A is one half of Original Medicare. It does not cover routine doctor visits. That is Part B.

B

Part B

Medical insurance

Helps pay for doctor visits, outpatient care, and many checkups that keep you healthy.

What it helps cover

  • Services from doctors and other health care providers
  • Outpatient care (including many hospital outpatient services)
  • Durable medical equipment, such as wheelchairs, walkers, and hospital beds
  • Many preventive services, including screenings, vaccines, and a yearly wellness visit
  • Some home health care

What you typically pay

Part B has a monthly premium. Most people pay the standard amount. People with higher incomes may pay more. There is also a yearly deductible. After that, you usually pay 20% of the Medicare-approved amount for many services.

Good to know. Original Medicare has no yearly cap on what you pay out of pocket unless you have other coverage, such as Medigap, Medicaid, or employer coverage.

C

Part C

Medicare Advantage

A private plan that is an alternative to Original Medicare. It bundles hospital and medical coverage, and usually drug coverage, into one plan.

What it helps cover

  • Part A and Part B benefits (almost all medically necessary services Original Medicare covers)
  • Usually Part D prescription drug coverage
  • All emergency and urgent care
  • Extra benefits on many plans, such as dental, vision, or hearing — these vary by plan and are not guaranteed

What you typically pay

You must keep paying your Part B premium. Some plans charge an extra premium; some do not. You usually pay copays when you use services. Plans have a yearly limit on out-of-pocket costs for Part A and Part B services.

Good to know. You generally must use doctors in the plan’s network for non-emergency care, and you may need a referral or prior approval. You cannot buy a Medigap policy while you are in a Medicare Advantage plan. You must have Part A and Part B to join.

D

Part D

Prescription drug coverage

Optional coverage that helps pay for prescription drugs and many recommended vaccines.

What it helps cover

  • Prescription drugs on the plan’s list (called a formulary)
  • Many recommended shots and vaccines
  • Drugs you get at a network pharmacy, or by mail if the plan offers it

What you typically pay

Premiums vary by plan. Higher-income people may pay an extra amount. Plans may have a deductible. In 2026, once you have paid $2,100 out of pocket for covered Part D drugs, you pay $0 for those covered drugs for the rest of the year. You still pay your premium. Covered insulin is also capped at a low monthly amount.

Good to know. You can get Part D as a standalone drug plan with Original Medicare, or through many Medicare Advantage plans. If you go 63 or more days in a row without Part D or other creditable drug coverage, you may owe a late enrollment penalty for as long as you have Part D.

More about Part D →

A simple choice

Two main ways to get your coverage

After you have Part A and Part B, you choose one path for your health coverage. You will have Original Medicare unless you join a Medicare Advantage plan.

Original Medicare

Part A + Part B

  • See any doctor or hospital that takes Medicare, anywhere in the U.S.
  • No plan network for routine care, and usually no referrals
  • Add a separate Part D drug plan if you want drug coverage
  • You can buy a Medigap policy to help with deductibles and the 20% coinsurance
  • No yearly cap on medical costs unless you have other coverage

Medicare Advantage

Also called Part C

  • One plan that includes Part A, Part B, and usually Part D
  • You generally use the plan’s doctor network, except in emergencies
  • Plans must cover emergency and urgent care
  • Yearly limit on out-of-pocket costs for Part A and Part B services
  • Many plans add extra benefits Original Medicare does not cover
  • You cannot use Medigap with this path

More about Medicare Advantage →

Neither path is “better” for everyone. The better fit depends on your doctors, prescriptions, travel, budget, and what is sold where you live. We do not offer every plan in your area.

When you can sign up

Timing matters. Missing a window can mean waiting, and it can mean a late enrollment penalty that lasts as long as you have that coverage.

  1. 1. Your first chance — Initial Enrollment Period

    This 7-month window starts 3 months before the month you turn 65, includes your birthday month, and ends 3 months after. If you are already getting Social Security, you may be enrolled automatically. If not, you sign up with Social Security.

  2. 2. Each fall — October 15 to December 7

    This is Open Enrollment. You can join, switch, or drop a Medicare Advantage plan or a Part D drug plan. Changes usually start January 1. You can also switch between Original Medicare and Medicare Advantage during this window.

  3. 3. January 1 to March 31 — two different windows

    If you missed signing up for Part A or Part B, the General Enrollment Period is January 1–March 31. Coverage starts the month after you sign up, and a penalty may apply. Separately, if you are already in a Medicare Advantage plan, you can make one change during this same date range — switch to another Advantage plan, or go back to Original Medicare.

  4. 4. Special situations

    You may get a Special Enrollment Period if you move, lose other coverage, qualify for Extra Help, or have certain other life changes. If you (or your spouse) are still working and have job-based insurance, you may be able to delay Part B without a penalty. Marketplace or COBRA coverage is not treated the same as current employer coverage.

2026 snapshot

What things cost this year

These are official 2026 figures from CMS and Medicare.gov. Your own costs can be different. Always check the current numbers at Medicare.gov.

Part A premium
Usually $0 if you or a spouse paid Medicare taxes long enough. If you buy Part A, it can be up to $565 a month in 2026.
Part A hospital deductible
$1,736 per benefit period in 2026, then daily coinsurance if you have a long stay.
Part B premium
Standard amount is $202.90 a month in 2026. Higher-income people pay more. Social Security tells you your amount.
Part B deductible
$283 per year in 2026, then usually 20% for many doctor and outpatient services.
Part D drugs
Plan premiums vary. In 2026, out-of-pocket costs for covered Part D drugs are capped at $2,100 for the year. Insulin on Part D has a low monthly cap.
Medicare Advantage
Varies by plan. Compare copays, networks, and the plan’s yearly out-of-pocket maximum. You still pay Part B.

Help paying costs may be available through Extra Help (for drug costs), Medicare Savings Programs, and Medicaid if you qualify. Ask Medicare.gov or your state, or talk with a licensed agent.

What Original Medicare usually does not cover

Original Medicare covers a lot of medically necessary care. It generally does not cover:

  • Most routine dental care and dentures
  • Eyeglasses and routine eye exams for glasses
  • Hearing aids and exams for fitting them
  • Long-term custodial care (help with bathing, dressing, or eating)
  • Most care outside the United States
  • Most cosmetic surgery and routine foot care

Some Medicare Advantage plans include extra dental, vision, or hearing benefits. Those extras vary by plan and location. Read the plan’s documents. You can also look at separate dental or vision policies. We do not offer every product in every area.

Want help applying this to your situation?

Prime Integrity Insurance is an independent agency. A licensed agent can walk through options available where you live — your doctors, drugs, and budget included. Requesting a review does not enroll you. You can also compare plans yourself at Medicare.gov.

Request a Plan ReviewRead common questions

Official sources: Medicare.gov, the Medicare & You 2026 handbook, and 1-800-MEDICARE (1-800-633-4227). TTY: 711.

Ready to review Medicare options?

Request a plan review from a licensed agent, or call us. Submitting a form does not enroll you. We do not offer every plan in your area.

Request a Plan ReviewCall (877) 273-0393