Welcome & IntroductionYou're in the right place
Welcome to Medicare 101. We're glad you're here.
This guide is designed specifically for people who are new to Medicare: turning 65 soon, recently retired, or just beginning to explore coverage options. Over the next several sections we'll walk through everything you need to know: what Medicare covers, how each part works, and most importantly, what your options are for filling in the gaps. By the end, our goal is for you to feel informed, confident, and ready to make the coverage decision that's right for you.
Who is Pinnacle Insurance Advisors
Pinnacle Insurance Advisors is a team of licensed Medicare specialists and dedicated advocates who focus exclusively on Medicare and the decisions that come with it. Our advisors guide you through every step of the enrollment process, from understanding your options to comparing coverage side by side. As an independent agency we are not limited to a single carrier. We represent every major insurance company and offer the full range of Medicare plans available in your state, which lets us shop the market on your behalf and advocate for your best interest, not an insurer's bottom line.
Medicare BasicsWhat it is & when to enroll
What is Medicare?
Medicare is the federal health insurance program for people age 65 or older, and for certain younger individuals with disabilities or specific conditions like End-Stage Renal Disease. It is administered by the Centers for Medicare & Medicaid Services (CMS).
When to enroll
Your Initial Enrollment Period (IEP) is the window surrounding your 65th birthday or your Medicare Part B effective date, in which you can enroll in a Medigap plan, Medicare A and/or B, and Part D.
Enrolling in Medigap (Medicare Supplement)
Your one-time Medigap open enrollment lasts 6 months from the day your Part B takes effect. Many carriers also accept applications up to 6 months before your Part B start date, so you can lock coverage in early. This is your golden window: inside it you cannot be denied or charged more for health reasons. Missing it can mean being denied for Medigap insurance or paying higher premiums.
Enrolling in Medicare A and/or B
A 7-month window starting 3 months before your 65th birthday month or intended Part B start date. It includes your birthday month and extends 3 months after. If you are drawing Social Security prior to age 65 you are automatically enrolled in Medicare A and B and can skip this step.
Enrolling in Part D
This step has the same 7-month window as Part A and B, but you must have a Medicare number before applying, so it must be done after step 2.
Past age 65 and leaving employer coverage
Special Enrollment Period (SEP): If you have employer coverage, you may delay Medicare A and/or B without penalty. When you decide to retire or drop your employer plan past 65, the same 3-step process applies to you.
The parts of Medicare at a glance
| Part | What it covers | Provider | Premium (2026) |
|---|---|---|---|
| Part A | Hospital, skilled nursing, hospice | Federal government | Usually $0 |
| Part B | Doctor visits, outpatient care | Federal government | $202.90/mo |
| Part C | Medicare Advantage (bundles A+B) | Private insurers | Often $0 |
| Part D | Prescription drugs | Private insurers | Varies by plan |
| Medigap | Fills gaps in Original Medicare | Private insurers | Varies by plan & age |
Not sure which windows apply to you?
Your enrollment dates are personal. They depend on your birthday, your work situation, and your spouse's coverage. In one free call we'll map your exact dates so nothing gets missed and no penalty sneaks up on you.
Or text us any question: (561) 287-8834
Part A: Hospital InsuranceUsually premium-free
Part A is your hospital coverage. For most people, those who worked and paid Medicare taxes for at least 10 years, Part A is premium-free. You have already paid into it throughout your working life.
What Part A covers
- Inpatient hospital stays: semi-private room, meals, nursing care, medications during your stay
- Skilled Nursing Facility (SNF) care: after a qualifying 3-day hospital stay
- Hospice care: for terminal illness, comfort-focused care
- Some home health care: medically necessary, part-time skilled nursing
- Inpatient mental health: psychiatric hospital stays
What Part A does NOT cover
- Long-term custodial care (assisted living, nursing home day-to-day)
- Private room upgrades
- Most dental, vision, and hearing
- Prescription drugs (that's Part D)
Part A costs in 2026
| Cost item | 2026 amount |
|---|---|
| Premium (if 40+ quarters worked) | $0 |
| Inpatient deductible (per benefit period) | $1,736 |
| Days 1-60 coinsurance | $0 |
| Days 61-90 coinsurance (per day) | $434/day |
| SNF days 1-20 | $0 |
| SNF days 21-100 (per day) | $217/day |
Part B: Medical InsuranceOutpatient & doctor coverage
Part B is your outpatient coverage, covering doctor visits, lab work, preventive care, and much more. Unlike Part A, Part B has a monthly premium that everyone pays. In 2026 the standard premium is $202.90 per month.
What Part B covers
- Doctor visits: primary care and specialist visits
- Preventive care: annual wellness visits, flu shots, cancer screenings, often at no cost
- Outpatient surgery: procedures that don't require an overnight stay
- Durable Medical Equipment (DME): wheelchairs, walkers, oxygen equipment
- Mental health services: outpatient therapy and counseling
- Ambulance services: when medically necessary
What Part B does NOT cover
- Routine dental, vision, and hearing
- Prescription drugs you take at home (that's Part D)
- Care received outside the U.S.
Part B costs in 2026
| Cost item | 2026 amount |
|---|---|
| Monthly premium (standard) | $202.90/month |
| Annual deductible | $283 |
| Coinsurance after deductible | 20% of approved amount |
| Out-of-pocket maximum | No limit with Original Medicare alone |
Part D: Prescription DrugsDrug coverage & formularies
Part D covers your prescription drugs, offered through private insurance companies approved by Medicare. Enrollment is optional, but if you don't sign up when first eligible and go without creditable drug coverage, you'll face a lifetime late enrollment penalty. Even if you don't take many medications today, it's often smart to enroll.
How Part D works
Part D plans use a formulary: a list of covered drugs divided into tiers. Lower tiers cost less, higher tiers cost more. You pay a monthly premium, an annual deductible, and then copays or coinsurance for your medications.
- Tier 1: Generic drugs, lowest cost
- Tier 2: Preferred brand-name drugs
- Tier 3: Non-preferred brand-name drugs
- Tier 4-5: Specialty drugs, highest cost
2026 Part D key numbers
| Item | 2026 amount |
|---|---|
| Deductible | Up to $615 (plan-specific) |
| Out-of-pocket cap | $2,100. Once hit, drugs are free for the year |
| Late enrollment penalty | 1% per month without coverage, added permanently |
Extra Help (Low Income Subsidy)
If you have a limited income, you may qualify for the Extra Help program, also called the Low Income Subsidy (LIS). This can dramatically reduce your Part D costs, sometimes to just a few dollars per prescription. Ask us about checking your eligibility.
Want to know what your medications would cost?
Read us your prescription list on a free call and we'll check every plan's formulary for you. It takes minutes and often finds hundreds of dollars in savings.
MedigapMedicare Supplement insurance
Medigap, also called Medicare Supplement Insurance, is private insurance that works alongside Original Medicare to pay costs that Medicare doesn't cover. Think of Medicare as the primary payor, and Medigap as the secondary payor that picks up what's left.
How Medigap works
- You keep Original Medicare (Parts A and B)
- You pay a monthly premium to a private insurer
- Medicare pays first, then Medigap pays its share
- See any doctor that accepts Medicare, nationwide, no networks
- No referrals needed to see specialists
- Benefits are identical from company to company
Most popular plans
Plan G
Covers almost everything except the $283 Part B deductible. The gold standard for new enrollees.
Plan N
Strong coverage with small copays (up to $20 office, $50 ER). Lower monthly premium than G.
Plan F
Covers everything including the Part B deductible. Only for those eligible before Jan 1, 2020.
High-Deductible G
Low premium with an annual deductible of $2,950. Full Plan G protection after that.
Initial enrollment: your best window
Your Medigap open enrollment is a one-time window that lasts 6 months from your Part B effective date. During this window insurers cannot deny you or charge more based on health. Many carriers also let you apply up to 6 months ahead of your Part B start date to lock in coverage early. After the window closes, they can deny you based on your health history. Timing matters enormously.
Medicare AdvantagePart C: private alternative
Medicare Advantage (Part C) is an all-in-one alternative to Original Medicare. Instead of receiving your Medicare benefits directly from the government, with Medicare Advantage you receive all your benefits through a private insurance company that is approved and paid by Medicare.
Medicare Advantage plans typically bundle Part A, Part B, and usually Part D drug coverage together. Many plans have $0 monthly premiums, though you still pay your Part B premium ($202.90/mo) to the government. Many also include extra benefits such as dental, vision, and hearing.
Types of plans
- HMO: Must use in-network providers. Requires a primary care doctor and referrals.
- PPO: Can see out-of-network providers at higher cost. More flexibility.
- SNP: Tailored for people with specific chronic conditions or dual Medicare/Medicaid eligibility.
Medigap vs. Medicare Advantage
| Feature | Medigap | Medicare Advantage |
|---|---|---|
| Monthly premium | Varies by plan type, age, gender, location | Often $0 (still pay Part B) |
| Networks | Any doctor accepting Medicare | In-network only |
| Referrals | Never needed | Required |
| Out-of-pocket max | Very low (Plan G: ~$283/yr) | Up to $9,250 in-network, $13,900 combined |
| Drug coverage | Separate Part D plan needed | Usually included |
| Extra benefits | Foreign travel coverage | Dental, vision, hearing, gym |
| Travel flexibility | Excellent, nationwide | Limited to service area |
| Paying claims | Covers everything medically necessary | Plan can deny claims |
Which side of this table fits your life?
The right answer depends on your doctors, your budget, your travel, and your health. A licensed advisor can tell you in one short call, with real quotes from every major carrier.
Or text us: (561) 287-8834
How to ChooseFinding the right coverage for you
Choosing the right Medicare coverage is not one-size-fits-all. The best plan depends on your health, finances, lifestyle, and the doctors you want to keep. Use this guide and the information presented today to help inform your decision.
Questions to ask yourself
- Do I have specific doctors I want to keep? Medigap offers the largest network available, allowing you to see any doctor or hospital that accepts Original Medicare. Advantage will require you to stay in-network.
- How often do I use medical care? Frequent users often benefit more from Medigap's predictable costs.
- Do I travel frequently? Medigap works nationwide. Most Advantage plans are regionally restricted.
- What's my budget? Advantage often has lower premiums but higher out-of-pocket exposure when you need care.
- Am I okay with taking risk? By opting for Medicare Advantage you risk not being able to see your doctors, having claims denied, and not being able to obtain a Medigap plan in the future.
Why work with an independent broker?
We offer a free, no-obligation one-on-one consultation where we review your specific situation: your doctors, medications, health history, and budget, and help you find the plan that makes the most sense for you.
As an independent broker we work with multiple carriers and offer all Medicare plans. We have no allegiance to any particular company. Our job is to find you the best coverage at the best price. Advisors are paid by the insurance carriers, never by you, and the price is identical whether you use an advisor or not.
Common QuestionsWhat people ask most
The Q&A below addresses the most common questions we hear from people new to Medicare. If you don't see your question here, reach out, we're happy to help.
I've had Blue Cross Blue Shield (or another carrier) for years and I'm scared to lose them.
This is a common concern, but once you understand how Medicare and a Medigap plan work, you'll feel at ease. Medicare will be your primary insurance, meaning you have access to over 90% of doctors, hospitals, and specialists nationwide. If you choose a Medigap plan, you can continue to keep your current network and gain access to an even larger network of doctors and facilities.
Can I be denied Medigap coverage?
During your open enrollment window: NO. Outside of that window, you can be denied due to medical history. This is why enrolling at 65 is so important.
What if I'm still working at 65?
You can delay Part B and Medigap if you have creditable employer coverage. Verify this before delaying.
Can I switch from Advantage to Medigap later?
Yes, but only if you are medically approved. In most states, insurers can deny you or charge more based on health conditions outside of your initial enrollment window.
Are my current doctors covered?
With Medigap: yes, because you keep Original Medicare as your primary insurance, you can use your Medigap plan at the 98% of doctors, hospitals, and specialists nationwide who accept Original Medicare. With Advantage, you are subject to network restrictions and referrals.
What does Medicare not cover at all?
Dental, vision, hearing, most long-term care, and care outside the U.S. Medigap plans will cover foreign travel emergencies, but do not include dental, vision, or hearing (DVH).
Is Medicare Advantage the same as Medicare?
No. Medicare Advantage (Part C) is not the same as Original Medicare (Parts A and B). Although you must be a Medicare recipient to participate, you are surrendering your Original Medicare for a private insurance plan and are subject to their rules and restrictions.
Is Medicare Advantage free?
Most Advantage plans have a $0 premium, but you must still pay your Part B premium ($202.90/mo) and are subject to copays and other out-of-pocket costs that may total up to $9,250 in-network, or $13,900 once out-of-network care is included.
Are there out-of-pocket costs with Medigap?
Yes, but very small. Today's most popular plan, Plan G, has an annual deductible of $283. Once that is met, there are no copays, coinsurance, or other out-of-pocket costs for anything medical. (DVH and Part D are separate.)
Which plan is more suitable for someone on a fixed income?
Whether income is fixed or unlimited, predictable monthly costs are important for budgeting. Only Medigap provides a fixed monthly premium, making it easy to budget and avoid the risk of the $9,250 yearly out-of-pocket maximum associated with Advantage plans.
Can my claims be denied?
If you have Original Medicare with a Medigap plan, all claims that are medically necessary are paid. No fights or exclusions, giving you a guarantee of coverage. If you opt in for Medicare Advantage, the private company that insures you has the power to deny your claims.
Is there a limit to what Medicare and Medigap will pay?
There is no annual or lifetime limit on claims. Whether the medical bill is $100 or $1,000,000, Medicare and Medigap will cover everything medically necessary after your annual deductible of $283. This includes all types of treatments and procedures, including ambulatory services and chemotherapy (the most commonly asked about).
Which insurance company offers the best Medigap policy?
All Medigap plans with the same letter are federally standardized. A Plan G from any company covers the exact same benefits, so you're simply shopping for the best rate. Although benefits are the same, some companies do have better track records on premiums, rate increases, and customer service. That's exactly what we compare for you.
Your Next StepYour 3-step enrollment guide
Enroll in your Medicare Supplement plan
This can be done up to 6 months before your 65th birthday month or your intended Medicare start date. Enrolling early locks in your coverage and guarantees acceptance during your open enrollment window, no medical underwriting required.
Enroll in Medicare Part A and Part B
This can be done up to 3 months prior to your 65th birthday month or intended Medicare start date. Your Part B effective date is what triggers your Medigap open enrollment and activates your Medigap coverage.
Enroll in Part D (prescription drug coverage)
This can be done 1 to 3 months prior to your Medicare start date. Your Medicare number is needed for this step. You will receive it once enrolled in Parts A and B. Even if you take few medications, enrolling avoids a lifetime late-enrollment penalty.
Medigap tips
Key reminders
- Medigap does not cover dental, vision, or hearing. Consider a separate DVH plan.
- Once your open enrollment closes, switching to Medigap requires medical underwriting. You can be denied.
- Your Medigap premium may increase slightly as you age, but your benefits never decrease.
- As independent brokers, we are not tied to any carrier. We work for you.
Ready to lock in your coverage?
Schedule your free one-on-one consultation with Pinnacle Insurance Advisors. We shop every major carrier, you get the best plan at the best price, and it costs you nothing. Pick a time below and a licensed advisor will call you.
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If it doesn't appear, open our booking page here or call 1-888-461-0184.
Prefer to handle it yourself?
If you already know the Medicare Supplement plan you want, you can complete the application online at your own pace. It takes about 10 minutes.
Tip: if you're unsure which plan letter or carrier to pick, a 15-minute call first means you only apply once. 1-888-461-0184
Already have Medicare and reviewing your current plan?
This guide is for people new to Medicare. If you already have a Medigap or Medicare Advantage plan, our Medicare Review guide was written for you.