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Medicare Basics

A Simple Guide to Medicare Coverage

Understanding Medicare can be confusing, especially when trying to decide which coverage options are right for you. This guide provides a clear, easy-to-understand overview of Medicare, including what each part covers, who pays for it, enrollment periods, and supplemental coverage options.

Medicare Basics

A Simple Guide to Medicare Coverage

What Are the Different Parts of Medicare?

Medicare Part A helps cover inpatient hospital care and related services.

What Medicare Part A covers: - Inpatient hospital stays, skilled nursing facility care, hospice care, limited home health services

Who pays for Medicare Part A: Most people qualify for premium-free Part A if they or their spouse paid Medicare taxes for at least 40 quarters (10 years).

Medicare Part B covers medically necessary outpatient services and preventive care.

What Medicare Part B covers: - Doctor visits and specialist appointments, outpatient services, preventive care and screenings, lab work, imaging, and durable medical equipment

Who pays for Medicare Part B: Part B requires a monthly premium paid by the beneficiary. The premium is based on household income. Higher-income individuals may pay an additional amount called IRMAA (Income-Related Monthly Adjustment Amount).

https://www.cms.gov/newsroom/fact-sheets/2026-medicare-parts-b-premiums-deductibles

Important Part B Enrollment Notice:
If you do not enroll in Medicare Part B when you are first eligible and do not have creditable employer group health coverage, you may be subject to a late enrollment penalty. This penalty is added to your monthly Part B premium and generally lasts for as long as you have Part B.

Medicare Advantage plans (Part C) are offered by private insurance companies to help limit a member’s out-of-pocket liability under Medicare Part A and Part B.

What Medicare Advantage plans include: All benefits provided under Medicare Part A and Part B, and include Medicare Part D prescription drug coverage, creating a single, well-rounded health plan. Additional benefits can include dental, vision, hearing, fitness, wellness programs. Copays and out-of-pocket costs vary by plan.

Who pays for Medicare Advantage: Some plans have $0 or low monthly premiums. Members must continue to pay their Medicare Part B premium.

Network Access: HMO, POS, HMO

Medicare Part D helps cover the cost of prescription medications.

What Medicare Part D covers: - Outpatient prescription drugs

Who pays for Medicare Part D: Monthly premium paid by the member. Premiums vary by plan and carrier. Higher-income individuals may pay an income-based surcharge

*Part D coverage can be included with a Medicare Advantage plan or purchased as a stand-alone plan alongside Original Medicare.

Medicare Part D Late Enrollment Penalty: If you go without creditable prescription drug coverage for 63 days or longer after you are first eligible, you may have to pay a late enrollment penalty. This penalty is added to your Part D premium and generally applies for as long as you have Medicare drug coverage.

Medicare Supplement (Medigap) plans are designed to work alongside Original Medicare (Part A and Part B) to help reduce out-of-pocket expenses.

What a Medicare Supplement helps cover: Deductibles, coinsurance, copays that are not fully paid by Medicare.

Who pays for Medicare Supplement: Premiums are typically age-rated and may be gender-specific. Members must continue to pay their Medicare Part B premium. Copays and out-of-pocket costs vary by plan.

Network Access: Any provider who accepts Medicare.

*Medicare Supplement plans do not include prescription drug coverage.

Medicare Enrollment Periods Explained

Initial Enrollment Period (IEP)

  • Begins 3 months before your 65th birthday
  • Includes your birthday month
  • Ends 3 months after your birthday month

Enrolling during your Initial Enrollment Period helps avoid late enrollment penalties.

General Enrollment Period (GEP)

January 1 through March 31 each year

  • For individuals who did not enroll when first eligible
  • Coverage begins the month after enrollment
  • Late enrollment penalties may apply

Annual Enrollment Period (AEP)

October 15 through December 7 each year

  • Change Medicare Advantage plans
  • Switch Medicare Part D plans
  • Move between Original Medicare and Medicare Advantage

Special Enrollment Periods (SEP)

Special Enrollment Periods may be available if you experience a qualifying life event, such as: 

  • Loss of employer health coverage
  • Moving to a new service area
  • Other Medicare-approved circumstances

Medicare Plan Comparison


Medicare is a federal health insurance program for individuals age 65 and older. In some cases, you may qualify for Medicare before age 65 if you have a qualifying disability, End-Stage Renal Disease (ESRD), or ALS (also known as Lou Gehrig’s disease).

Below is a breakdown of the chart above. 

Comparison of Medicare Supplement (Medigap) and Medicare Advantage (Part C)
Plan Type Medicare Supplement (Medigap) Medicare Advantage (Part C)
How it works Works alongside Original Medicare (Part A & B) Replaces Original Medicare with a private plan
ID Card System
  • Original Medicare (Red, White and Blue)
  • Supplemental ID (Carrier ID)
  • Prescription Card (Carrier ID)
 Single ID Card (MA Carrier ID)
Coverage includes Helps cover deductibles, coinsurance, and copayments Includes Part A, Part B, and usually Part D
Prescription drug coverage Not included (separate Part D required) Usually included
Provider access Any provider nationwide who accepts Medicare Network-based (HMO, PPO, etc.)
Referrals required No May be required, depending on plan
Monthly premium Typically higher Often lower or $0 additional premium
Out-of-pocket costs Generally lower when care is used Copays apply; varies by service
Maximum out-of-pocket limit No Yes (annual limit required by Medicare)
Additional benefits None (medical coverage only) May include dental, vision, hearing, wellness
Enrollment rules Guaranteed issue only during certain periods Annual enrollment opportunities

How it works

Medicare Supplement (Medigap)

Works alongside Original Medicare (Part A & B)

Medicare Advantage (Part C)

Replaces Original Medicare with a private plan

ID Card System

Medicare Supplement (Medigap)

  • Original Medicare (Red, White and Blue)
  • Supplemental ID (Carrier ID)
  • Prescription Card (Carrier ID)

Medicare Advantage (Part C)

Single ID Card (MA Carrier ID)

Coverage includes

Medicare Supplement (Medigap)

Helps cover deductibles, coinsurance, and copayments

Medicare Advantage (Part C)

Includes Part A, Part B, and usually Part D

Prescription drug coverage

Medicare Supplement (Medigap)

Not included (separate Part D required)

Medicare Advantage (Part C)

Usually included

Provider access

Medicare Supplement (Medigap)

Any provider nationwide who accepts Medicare

Medicare Advantage (Part C)

Network-based (HMO, PPO, etc.)

Referrals required

Medicare Supplement (Medigap)

No

Medicare Advantage (Part C)

May be required, depending on plan

Monthly premium

Medicare Supplement (Medigap)

Typically higher

Medicare Advantage (Part C)

Often lower or $0 additional premium

Out-of-pocket costs

Medicare Supplement (Medigap)

Generally lower when care is used

Medicare Advantage (Part C)

Copays apply; varies by service

Maximum out-of-pocket limit

Medicare Supplement (Medigap)

No

Medicare Advantage (Part C)

Yes (annual limit required by Medicare)

Additional benefits

Medicare Supplement (Medigap)

None (medical coverage only)

Medicare Advantage (Part C)

May include dental, vision, hearing, wellness

Enrollment rules

Medicare Supplement (Medigap)

Guaranteed issue only during certain periods

Medicare Advantage (Part C)

Annual enrollment opportunities

Choosing the Right Medicare Coverage

Choosing the right Medicare coverage depends on several factors, including your health needs, travel habits, provider preferences, and budget. Medicare Advantage plans and Medicare Supplement plans each offer different benefits, and the best option varies from person to person.

At TMR & Associates, we help individuals understand Medicare, compare plan options, and make informed decisions with confidence. Whether you are new to Medicare or reviewing your current coverage, we are here to help guide you every step of the way.

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