Medigap FAQ: Your Questions Answered

Medicare is divided into Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage plans offered by private insurers), and Part D (prescription drug coverage). Many people also add a Medigap plan to cover out-of-pocket costs.

If you're already receiving Social Security or Railroad Retirement benefits, you'll be automatically enrolled in Medicare Parts A and B. Otherwise, you'll need to sign up during your Initial Enrollment Period, which begins three months before your 65th birthday.

Original Medicare includes Part A and Part B. Part A covers inpatient hospital stays, skilled nursing facilities, hospice care, and some home health services. Part B covers doctor visits, outpatient care, preventive services, and medical equipment.

Medicare doesn't cover long-term care (custodial care), most dental care, vision exams and glasses, hearing aids, cosmetic procedures, or routine foot care. You may need separate coverage or pay out of pocket for these services.

Medicare is a federal program primarily for people 65 and older or those with certain disabilities, regardless of income. Medicaid is a state and federal program that provides health coverage for people with low income and limited resources, regardless of age.

Yes. Many people have Medicare alongside employer insurance, retiree plans, Medicaid, or Medicare Supplement (Medigap) coverage. In these cases, Medicare may be the primary or secondary payer depending on your situation.

You can sign up for Medicare during your Initial Enrollment Period (IEP), which starts 3 months before the month you turn 65, includes your birthday month, and ends 3 months after. That gives you a 7-month window to enroll in Parts A and B.

If you're already receiving Social Security or Railroad Retirement benefits, you'll be enrolled in Medicare Parts A and B automatically. If not, you need to sign up manually through Social Security online, by phone, or at your local office.

If you miss your Initial Enrollment Period and don't qualify for a Special Enrollment Period, you'll need to wait until the General Enrollment Period (January 1 – March 31). Your coverage will then start on July 1. Late enrollment penalties may apply.

Yes. If you're still working and have creditable health coverage through your employer (or your spouse's), you can delay Medicare Part B without penalty. Once that coverage ends, you'll have an 8-month Special Enrollment Period to sign up.

A Special Enrollment Period lets you enroll in Medicare outside the usual windows if you've lost other coverage, moved, or experienced certain life events. Most people qualify for an SEP when they leave employer coverage after age 65.

The General Enrollment Period runs from January 1 to March 31 each year. If you missed your initial enrollment and don't qualify for a Special Enrollment Period, this is when you can sign up - but your coverage won't start until July 1.

You can sign up for Medicare online at ssa.gov/medicare, by calling Social Security at 1-800-772-1213, or by visiting your local Social Security office. Enrollment typically takes about 10–15 minutes online.

Yes. While full Social Security retirement age is 67 for those born in 1960 or later, your Medicare Initial Enrollment Period still starts at age 65. If you're working with creditable coverage, you can delay Part B and sign up during a Special Enrollment Period after ending that coverage.

Not necessarily. If you have employer coverage through a large employer, you can delay Part A and Part B without penalty. But since most people get Part A premium-free, many choose to enroll in it at 65 even if they delay Part B until their job ends.

You can change your Medicare Advantage or Part D drug plan once a year during the Annual Enrollment Period, from October 15 to December 7. Your new plan will begin January 1 of the following year.

Yes. You can drop a Medicare Advantage plan and return to Original Medicare during the Annual Enrollment Period (Oct 15–Dec 7), or during the Medicare Advantage Open Enrollment Period (Jan 1–Mar 31 each year). You may not be guaranteed a Medigap policy unless you're in a protected window.

Yes - but in most states, after your initial Medigap enrollment window ends, you may be subject to medical underwriting. This means the insurance company can deny you or charge more based on your health history. Some states offer limited "birthday rules" or switching windows - check locally.

If you tried a Medicare Advantage plan for the first time and decide it's not for you, you have a "trial right" to return to Original Medicare and buy a Medigap policy - usually within the first 12 months of joining the Advantage plan.

If you miss your enrollment window and don't qualify for a Special Enrollment Period, you'll need to wait for the next General or Annual Enrollment Period. Delays can mean gaps in coverage or even late penalties, so mark your calendar or get help early.

Starting in January 2026, Traditional Medicare is piloting prior authorization for 17 specific services and procedures in six states (AZ, NJ, OH, OK, TX, WA) under the WISeR model. Providers must get approval before you receive care, or risk denial of payment after.

No - the donut hole is officially closed. Your out-of-pocket prescription drug costs are capped at $2,100 per year in 2026, up from $2,000 in 2025, thanks to the Inflation Reduction Act.

Yes, slightly. The standard Part B premium increased to $202.90/month in 2026, with a deductible of $283.

Mostly stable. While premiums are expected to stay the same or drop slightly, some plans are cutting back on extra perks like dental or fitness benefits. Always review your plan details during open enrollment.

Yes. As of January 1, 2026, Medicare's negotiated prices take effect on 10 high-cost drugs including Eliquis, Jardiance, Januvia, Entresto, Enbrel, Imbruvica, Stelara, Fiasp/NovoLog, Farxiga, and Xarelto. More drugs will be added in subsequent years.

Medigap is private insurance that fills the "gaps" left by Original Medicare (Parts A & B), such as deductibles, coinsurance, and copayments. Plans are standardized (Plan A–N) and automatically renew each year as long as you pay your premium - even if your health changes.

Medicare Advantage is a private insurance alternative to Original Medicare. It combines Parts A and B, often includes Part D (prescriptions), and may offer extras like dental, vision, and gym memberships. You'll use a network of providers and have different rules than traditional Medicare.

No. You must choose one or the other. If you enroll in a Medicare Advantage plan, it is illegal for someone to sell you a Medigap policy.

Medicare Advantage may look attractive, but it comes with trade-offs: limited networks, prior authorizations for many procedures, annual plan changes, and higher out-of-pocket costs when you need care.

Medigap offers predictable, stable coverage with no networks - you can see any doctor or hospital that accepts Medicare nationwide. There are no prior authorizations and plans don't change annually.

In 2026, Medicare Advantage plan premiums average around $17/month, with many options as low as $0/month. Medigap plans - especially Plan G - can range from $65 to $450/month depending on your age, location, and the insurer.

Focus on what matters most to you: cost, doctor access, and predictability. Medigap offers freedom and consistency; Medicare Advantage offers extras but has rules, networks, and changes year to year.

Use the Medicare Plan Finder at medicare.gov/plan-compare. Check that your doctors are in-network, your prescriptions are covered, the out-of-pocket maximum fits your budget, and that extra benefits are useful to you.

All Medigap plans are standardized by law. Plan G from one company is the same as Plan G from another - only the monthly premium and service differ. Compare quotes from multiple insurers and check reviews for customer service and rate stability.

Yes - but they work differently. Medicare Advantage can change benefits, premiums, and provider networks every year. Medigap plans don't change coverage, but premiums can increase over time due to age or inflation.

You can use medicare.gov to compare plans directly, call your local State Health Insurance Assistance Program (SHIP) for free counseling, or work with a licensed, independent Medicare agent.

Most people pay $0/month for Part A if they worked and paid Medicare taxes for at least 10 years. In 2026, the hospital deductible is around $1,736 per benefit period.

In 2026, the standard monthly premium for Part B is $202.90. The annual deductible is $283. Higher-income individuals may pay more based on their tax return (IRMAA surcharges).

Some Medicare Advantage plans have premiums as low as $0/month, but you still pay your Part B premium and may have copays, coinsurance, or higher costs for out-of-network care.

Medigap plans vary by provider, location, age, and health. As a rough example, a 65-year-old may pay between $110–$250/month for Plan G. Always compare quotes from multiple insurers.

In 2026, drug costs are capped at $2,100 per year under any Part D plan. Average premiums dropped to about $34.50/month. Starting July 2026, GLP-1 weight-loss drugs are covered at a $50/month copay.

Yes. You may qualify for Medicare Savings Programs (helps pay Part A & B premiums), Extra Help (helps with Part D drug costs), or Medicaid. Apply through your state Medicaid office or ssa.gov.

WISeR (Wasteful and Inappropriate Service Reduction) is a CMS pilot program running January 2026 through December 2031 in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. If you live in one of these states, your Medicare provider may need prior authorization before performing any of 17 specific services - including certain spinal procedures, knee arthroscopy, nerve stimulation devices, and others. If approved, Medicare still covers the service normally.

The 17 WISeR service categories are: epidural steroid injections, cervical fusion, knee arthroscopy, spinal cord stimulators, vagus nerve stimulation, sacral nerve stimulation, phrenic nerve stimulation, hypoglossal nerve stimulation, deep brain stimulation (limited rollout), vertebral augmentation, skin substitutes, cellular and tissue-based products, incontinence devices, impotence treatment, induced nerve lesions, and PILD/percutaneous lumbar decompression (limited rollout).

Medigap covers your share of costs when Medicare approves a claim - it does not override prior authorization requirements. If a WISeR prior auth is denied, neither Medicare nor Medigap will pay. However, having a Medigap plan means that when care is approved, your out-of-pocket costs remain predictable and protected.

Starting in July 2026, Medicare Part D plans are required to cover FDA-approved GLP-1 medications (such as Wegovy/semaglutide) when prescribed for weight management. The standard copay is capped at $50/month. This is a significant expansion - previously Medicare only covered these drugs for diabetes management.

For the first time, Medicare's negotiated prices take effect January 1, 2026 on 10 high-cost drugs: Eliquis (blood thinner), Jardiance (diabetes/heart), Januvia (diabetes), Entresto (heart failure), Enbrel (autoimmune), Imbruvica (blood cancer), Stelara (autoimmune), Fiasp & NovoLog (insulin), Farxiga (diabetes/kidney), and Xarelto (blood thinner). These negotiated prices will lower out-of-pocket costs for beneficiaries on these medications.

Innovative Plan G is a new Medigap plan type available under the WISeR pilot. It is only available in the six WISeR pilot states (AZ, NJ, OH, OK, TX, WA) and is similar to standard Plan G but includes cost-sharing features aligned with the prior authorization model. Consult a licensed Medicare agent in your state for availability and pricing.

If your income is above $109,000 (individual) or $218,000 (joint filers) based on your 2024 tax return, you will pay a higher Part B premium in 2026. Surcharges range from an extra $81.20/month up to $487/month at the highest tier (income over $500,000 individual). Check the IRMAA table on this page for all brackets.

In 2026, the Part D out-of-pocket cap is $2,100 - up slightly from $2,000 in 2025. Once you reach this cap, your covered prescriptions cost $0 for the rest of the year. The maximum allowable Part D deductible is $615, and average Part D premiums dropped to approximately $34.50/month.