Medicare Simplified

If you're approaching 65 or recently retired, you've probably realized that Medicare can feel like learning a new language. Parts A, B, C, D—supplements, advantage plans, enrollment periods—it's enough to make your head spin.

Here's the good news: Medicare doesn't have to be complicated.

I'm Steve Germain, and over the past 10 years, I've helped more than 3,000 people just like you navigate Medicare with confidence. My goal with this guide is simple: help you understand how Medicare works so you can choose the coverage that's right for you.

What Is Medicare?

Medicare is the federal health insurance program that covers:

• People age 65 and older
• People under 65 with certain disabilities
• People of all ages with End-Stage Renal Disease (permanent kidney failure)

Important to know: Medicare is individual coverage. Even if you and your spouse are both turning 65, you each need to enroll separately.

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The 4 Parts of Medicare

Medicare has four main parts that work together to cover your healthcare needs:

Part A – Hospital Insurance

Part A covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health services. Most people get Part A premium-free if they or their spouse worked and paid Medicare taxes for at least 10 years.

Part B – Medical Insurance

Part B covers doctor visits, outpatient care, preventive services, lab tests, and medical equipment. Everyone pays a monthly premium for Part B—$202.90 in 2026 for most people. High-income earners pay additional IRMAA surcharges based on tax returns from two years prior.

Part C – Medicare Advantage

Medicare Advantage is a bundled plan offered by private insurance companies that includes Parts A and B, and usually Part D. Many plans also include extra benefits like dental, vision, and hearing coverage.

Part D – Prescription Drug Coverage

Part D helps cover the cost of prescription medications. You'll need to add this to Original Medicare (Parts A and B) or choose a Medicare Advantage plan that includes drug coverage.

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Your Two Main Coverage Paths

Once you're enrolled in Original Medicare (Parts A and B), you have two paths forward:

Path 1: Original Medicare + Supplement + Part D

• Keep Original Medicare (Parts A and B)
• Add a Medicare Supplement (Medigap) plan to cover out-of-pocket costs
• Add a Part D prescription drug plan

Best for: People who want maximum flexibility to see any doctor nationwide and prefer predictable costs.

Path 2: Medicare Advantage (Part C)

• Choose a Medicare Advantage plan that replaces Original Medicare
• Typically includes prescription drug coverage
• Often includes extra benefits (dental, vision, hearing, gym memberships)

Best for: People who prefer an all-in-one plan and are comfortable with network restrictions.

What Medicare Covers (and Doesn't Cover)

What Medicare Covers

• Hospital stays and surgeries
• Doctor visits and outpatient care
• Lab tests and X-rays
• Preventive care (screenings, vaccines, wellness visits)
• Skilled nursing facility care (with limitations)
• Home health care (if medically necessary)
• Hospice care

What Medicare Doesn't Cover

• Routine dental care
• Routine vision care (glasses, contacts)
• Hearing aids
• Long-term custodial care (nursing home)
• Cosmetic surgery

Many people choose supplemental coverage to fill these gaps.

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The Medicare Gaps You Should Know About

Original Medicare (Parts A and B) has significant coverage gaps that can lead to substantial out-of-pocket costs:

Part A Gaps

• $1,736 deductible for each benefit period in 2026 (not per year)
• Skilled nursing coinsurance: $217/day for days 21-100
• Hospital stay costs: $434/day for days 61-90, $868/day for lifetime reserve days 91-150
• No coverage beyond 150 days per benefit period

Part B Gaps

• 20% coinsurance with no annual maximum
• Example: A $100,000 hip surgery means Medicare pays $80,000 and you pay $20,000

Most people choose either a Medicare Supplement plan or Medicare Advantage plan to fill these gaps and protect against unexpected medical costs.

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Understanding Benefit Periods

A benefit period starts when you're admitted to a hospital and ends when you haven't received inpatient care for 60 consecutive days.

Why this matters: You pay the Part A deductible ($1,736 in 2026) for each benefit period, not once per year. If you're hospitalized twice with more than 60 days between discharges, you'll pay two separate deductibles.

Example: You're hospitalized in March, discharged in April, and rehospitalized in September. Because more than 60 days passed between stays, you would pay the deductible twice.

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The Skilled Nursing Care Gap

One of Medicare's biggest coverage gaps is skilled nursing care. Medicare only covers up to 100 days in a skilled nursing facility per benefit period, and only under specific conditions:

• You must have a qualifying 3-day minimum inpatient hospital stay first
• The care must be for skilled services (physical therapy, IV medications, wound care)
• Days 1-20: Medicare covers fully
• Days 21-100: You pay $217/day in 2026 ($19,360 maximum)
• After day 100: Medicare pays nothing

Important: Skilled nursing care is different from long-term custodial care. If you need help with daily activities like bathing or dressing, Medicare doesn't cover it at any point.

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Final Thoughts

Medicare doesn't have to be overwhelming. Understanding the four parts, knowing your coverage options, and enrolling on time are the foundations for making confident decisions about your healthcare.

At A&E Insurance Agency, we make Medicare simple. We'll compare plans in your area, explain your costs, and help you choose coverage that fits your needs—whether that's a Medicare Supplement, Medicare Advantage, or the right combination of supplemental policies. Schedule a free consultation to get started.

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Frequently Asked Questions (FAQs)