What Is Medicare? A Complete Guide for Seniors and Those Turning 65
If you are approaching age 65 or helping a loved one navigate their healthcare options, understanding Medicare is one of the most important steps you can take. As an independent Medicare insurance broker serving clients across New York, New Jersey, and nationwide, I help seniors understand and enroll in Medicare every day, completely free of charge. Here is everything you need to know.
What Is Medicare?
Medicare is the federal health insurance program administered by the Centers for Medicare and Medicaid Services (CMS). It provides health coverage to millions of Americans and is primarily designed for people aged 65 and older, though it also covers certain younger individuals with qualifying disabilities or conditions.
Who Is Eligible for Medicare?
You may be eligible for Medicare if you are:
- Age 65 or older — and a U.S. citizen or permanent legal resident who has lived in the U.S. for at least 5 years
- Under 65 with a qualifying disability — if you have received Social Security Disability Insurance (SSDI) for 24 months, you are automatically enrolled in Medicare
- Any age with End-Stage Renal Disease (ESRD) — permanent kidney failure requiring dialysis or a transplant
- Any age with ALS (Lou Gehrig’s Disease) — you are automatically enrolled in Medicare upon diagnosis
The Four Parts of Medicare
Medicare is divided into four parts, each covering different types of healthcare services:
Medicare Part A — Hospital Insurance
Medicare Part A covers inpatient care and hospital-related services, including:
- Inpatient hospital stays
- Skilled nursing facility (SNF) care — following a qualifying hospital stay
- Hospice care
- Some home health care services
Most people do not pay a monthly premium for Part A. If you or your spouse worked and paid Medicare taxes for at least 10 years (40 quarters), you receive Part A premium-free. The Part A inpatient deductible is $1,736 per benefit period in 2026.
Medicare Part B — Medical Insurance
Medicare Part B covers outpatient medical services, including:
- Doctor visits and specialist appointments
- Outpatient procedures and surgeries
- Diagnostic tests and lab work
- Durable medical equipment
- Preventive services — including annual wellness visits, screenings, and vaccines
- Mental health services
Part B requires a monthly premium — the standard Part B premium is $202.90 per month in 2026. Higher-income beneficiaries may pay more due to IRMAA surcharges. The annual Part B deductible is $257 in 2026. After meeting the deductible, Medicare Part B pays 80% of approved costs — leaving you responsible for the remaining 20%.
Medicare Part C — Medicare Advantage
Medicare Part C — also known as Medicare Advantage — is an alternative way to receive your Medicare benefits through a private insurance company approved by Medicare. Medicare Advantage plans must cover everything Original Medicare covers, and many offer additional benefits such as dental, vision, hearing, and prescription drug coverage.
Medicare Advantage plans are available as HMOs, PPOs, and other plan types — each with different network rules, costs, and benefits. Many plans have $0 monthly premiums beyond your Part B premium.
Medicare Part D — Prescription Drug Coverage
Medicare Part D provides prescription drug coverage through private insurance companies approved by Medicare. Part D is available as a standalone plan added to Original Medicare or as part of a Medicare Advantage plan.
Key Part D figures for 2026 include a maximum annual deductible of $590 and a new $2,000 annual out-of-pocket cap on drug costs — a significant improvement for seniors with high medication expenses.
Original Medicare vs Medicare Advantage
When you become eligible for Medicare, you have a fundamental choice to make:
- Original Medicare (Parts A and B) — the traditional government-administered program. You can see any doctor or hospital that accepts Medicare nationwide. Most people add a Medicare Supplement plan and a Part D plan to cover remaining costs.
- Medicare Advantage (Part C) — an all-in-one alternative that replaces Original Medicare through a private carrier. Typically includes drug coverage and extra benefits with lower or $0 monthly premiums — but restricts you to a network of providers.
Choosing between Original Medicare and Medicare Advantage is one of the most important decisions you will make at 65. As an independent broker, I help you evaluate both options based on your specific health needs, preferred doctors, budget, and lifestyle — with no pressure toward any particular plan or carrier.
When Should You Enroll in Medicare?
Most people become eligible for Medicare at age 65. Your Initial Enrollment Period (IEP) is a 7-month window starting 3 months before the month you turn 65, including your birthday month, and ending 3 months after.
Enrolling on time is critical — missing your enrollment window can result in permanent late enrollment penalties for both Part B and Part D. Use our Medicare Enrollment Period Calculator to find your specific enrollment dates.
What Does Medicare Cost?
Medicare costs in 2026 include:
- Part A premium: $0 for most people (if you have 40+ quarters of work history)
- Part B premium: $202.90/month standard (higher for higher-income beneficiaries)
- Part B deductible: $257 per year
- Part A deductible: $1,736 per benefit period
- Part D deductible: Up to $590 per year
- Part D out-of-pocket cap: $2,000 per year
Without additional coverage, Original Medicare leaves significant gaps, including the 20% coinsurance on all Part B services with no out-of-pocket maximum. A Medicare Supplement plan or Medicare Advantage plan can help cover these gaps.
Frequently Asked Questions — What Is Medicare?
Is Medicare free?
Most people receive Part A at no cost if they have at least 40 quarters of work history. Part B requires a monthly premium of $202.90 in 2026. Additional coverage through Medicare Advantage or Medigap plans may also have premiums depending on the plan you choose.
What does Medicare not cover?
Original Medicare does not cover dental care, routine vision, hearing aids, long-term custodial care, or most care outside the United States. Some Medicare Advantage plans offer dental, vision, and hearing benefits as extras. Long-term care requires separate coverage, such as long-term care insurance.
Can I have Medicare and employer insurance at the same time?
Yes — in many cases you can have both. Which coverage pays first depends on your employer’s size and other factors. I can help you navigate this decision if you are still working when you turn 65.
What is the difference between Medicare and Medicaid?
Medicare is a federal program primarily for people 65 and older, regardless of income. Medicaid is a joint federal and state program for people with limited income and resources. Some people qualify for both, known as dual eligibility.
Get Your Free Medicare Consultation
Navigating Medicare for the first time can feel overwhelming — but it does not have to be. As an independent Medicare broker, I walk you through every step of the process — from understanding your coverage options to enrolling in the right plan for your needs, completely free of charge.
I serve clients across New York, New Jersey, and nationwide by phone, video, or in person.
📞 Contact Craig Smith Insurance Group today at (917) 740-1895 for your free Medicare consultation. No pressure, no obligation — just straightforward guidance from an independent broker with over 25 years of experience in financial services.
