Medicare plan selection

Medicare is the federal health insurance program for Americans aged 65+, those under 65 with certain disabilities, and people with End-Stage Renal Disease. The program is divided into four parts (A, B, C, D), and every beneficiary must make a fundamental choice: stay with Original Medicare (Parts A + B) or enroll in a Medicare Advantage plan (Part C).

43 steps across 12 sections

1. Determine Eligibility and Timeline

  • Turning 65? IEP starts 3 months before your birthday month
  • Already on Medicare? Review during AEP (Oct 15 - Dec 7)
  • Check if you have creditable employer coverage that lets you delay without penalty

2. Decide Original Medicare vs. Medicare Advantage

  • Do you want to see any doctor nationwide? —> Original Medicare
  • Do you want lower premiums and extra benefits? —> Medicare Advantage
  • Do you have complex health needs or travel frequently? —> Original Medicare + Medigap
  • Are you healthy and want to minimize monthly costs? —> Medicare Advantage

3. If Original Medicare - Choose Medigap and Part D

  • Compare Medigap plans (Plan G is most popular since Plan F closed to new enrollees after 2019)
  • Shop Part D plans on Medicare.gov Plan Finder using your drug list
  • Enroll during IEP for guaranteed issue (no medical underwriting for Medigap)

4. If Medicare Advantage - Compare Plans

  • Use Medicare.gov Plan Finder
  • Check: provider network (are your doctors in it?), drug formulary, out-of-pocket maximum, extra benefits, star rating
  • Call plans to verify specific doctors and drugs

5. Enroll

  • Online at Medicare.gov, by phone (1-800-MEDICARE), or through the plan directly
  • Keep confirmation documentation

6. Review Annually

  • Plans change every year - formularies, networks, premiums, benefits
  • Always review during AEP even if satisfied - your plan may have changed

7. Part A - Hospital Insurance

  • Covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care
  • Premium: Most people pay $0 (if they or a spouse paid Medicare taxes for 40+ quarters). Otherwise up to $565/month in 2026
  • Deductible: $1,736 per benefit period (2026)
  • Coinsurance: Days 1-60: $0 after deductible; Days 61-90: $434/day; Lifetime reserve days (60 total): $868/day

8. Part B - Medical Insurance

  • Covers doctor visits, outpatient care, preventive services, durable medical equipment, mental health services, ambulance services
  • Premium: $202.90/month standard (2026); higher-income beneficiaries pay more via IRMAA
  • Deductible: $283/year (2026)
  • Coinsurance: Typically 20% of Medicare-approved amount after deductible (no out-of-pocket maximum)

9. Part C - Medicare Advantage (MA)

  • Private insurance plans that bundle Part A + Part B (and usually Part D)
  • Must cover everything Original Medicare covers, often adds dental, vision, hearing, fitness
  • Uses provider networks (HMO, PPO, or PFFS)
  • Premium: Average $14.00/month in 2026 (on top of Part B premium); 67% of plans charge $0
  • Out-of-pocket max: Required by law (typically $3,000-$8,000 in-network)
  • 2026 market note: 231 fewer $0-premium plans than 2025; nearly 2.9 million enrollees forced to find new plans due to insurer exits; benefits generally leaner as insurers restore profitability

10. Part D - Prescription Drug Coverage

  • Covers outpatient prescription drugs
  • Available as standalone plans (with Original Medicare) or bundled into Medicare Advantage
  • Maximum deductible: $615 (2026)
  • Out-of-pocket cap: $2,000 (2026) - new under the Inflation Reduction Act
  • Coverage phases: Deductible > Initial Coverage > Out-of-Pocket Cap (no more "donut hole" catastrophic gap)

11. Initial Enrollment Period (IEP)

  • 7-month window around your 65th birthday: 3 months before, birthday month, 3 months after
  • Best time to enroll - guaranteed issue rights for Medigap
  • Late enrollment penalty if you delay Part B without creditable coverage

12. Annual Enrollment Period (AEP)

  • October 15 - December 7 each year
  • Switch between Original Medicare and Medicare Advantage
  • Join, drop, or switch Part D plans
  • Changes effective January 1

Common Mistakes

  • Missing the IEP
  • Choosing based on premium alone
  • Not checking the formulary
  • Assuming all MA plans are the same
  • Leaving Medigap without understanding re-entry risk

Pro Tips

  • Use SHIP counselors
  • Plan Medigap enrollment during IEP
  • Consider Plan G for Medigap
  • Check 5-star plans
  • Apply for Extra Help

Sources

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