Medicare ABCD Navigator

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Let's start here

Where are you with Medicare?

Choose the option that best describes your situation. We'll guide you through everything you need to know.

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Enrollment timing

Your Medicare timeline: When and how to enroll

Your Initial Enrollment Period (IEP): 7 months total — 3 months before your 65th birthday, your birth month, and 3 months after. This is your main window to sign up.

📆 Calculate your enrollment window:

When is your 65th birthday?

A

Enroll in Part A (Hospital)

Most people get this automatically and premium-free if they've worked 40+ quarters. If you're not getting Social Security yet, you'll need to actively enroll.
B

Decide on Part B (Medical)

Standard premium: $202.90/month in 2026. Higher if your income is above $109,000 (single) or $218,000 (married filing jointly).
C

Choose Part C OR Traditional + D

Medicare Advantage (Part C) OR stick with Original Medicare and add Part D drug coverage. You can't have both.

Insider Tip from Dr. Ed

Timing trick: Sign up during the first 3 months of your IEP for coverage to start on your 65th birthday. If you wait until your birth month or after, your coverage might not start until 1-2 months later. This can create dangerous gaps if you're leaving employer insurance.

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Special situation

Still working? You may be able to delay Part B

If you have "creditable coverage" through your employer, you can delay enrolling in Part B without penalty — but there are rules.

Good news: If you work for an employer with 20+ employees and you have group health insurance, you can delay Part B enrollment until you stop working or lose coverage.

Requirements for safe delay:

This is the key rule. If your employer has fewer than 20 employees, Medicare becomes your primary insurance at 65, and you should enroll in Part B on time. For 20+ employee companies, your employer insurance remains primary and Medicare becomes secondary.

You must be actively employed. COBRA coverage doesn't count as "creditable coverage" for delaying Part B. If you're on COBRA when you turn 65, enroll in Medicare during your IEP to avoid late penalties.

When you stop working or lose employer coverage, you have 8 months to enroll in Part B without penalty. This is your Special Enrollment Period (SEP). You'll need to provide proof of your employer coverage dates using Form CMS-L564.

Insider Tip from Dr. Ed

Pro move: Get Form CMS-L564 from your HR department BEFORE you leave work. This form proves when your employer coverage ended. Without it, Medicare might think you had a gap in coverage and charge you late penalties. HR departments are busy — get this while you're still employed.

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Important to know

Late Enrollment Penalties — How to Avoid Them

Miss your enrollment window without creditable coverage? You'll pay more for the rest of your life. Here's how much:

Part B penalty: 10% of the current Part B premium for each 12-month period you could have had Part B but didn't enroll. In 2026, that's 10% of $202.90 = $20.29 per year of delay.

Part D penalty: 1% of the national base premium ($38.99 in 2026) for each month you didn't have creditable drug coverage. That's about $0.39 per month of delay.

Penalty examples:

Delay Period	Part B Penalty (monthly)	Part D Penalty (monthly)
1 year late	$20.29	$4.68
2 years late	$40.58	$9.36
3 years late	$60.87	$14.04

Insider Tip from Dr. Ed

These penalties are permanent — you pay them every month for as long as you have Medicare. That's why it's critical to enroll on time OR make sure you have qualifying creditable coverage. A 2-year delay costs you over $600 extra every year for life.

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Part A: Hospital Insurance

What Part A covers and costs

Part A covers inpatient hospital care, skilled nursing facilities, hospice, and some home health services. Most people get it premium-free.

Premium-free if: You (or your spouse) worked and paid Medicare taxes for at least 40 quarters (10 years). About 99% of people qualify.

2026 Part A costs:

Work History	Monthly Premium	Why
40+ quarters	$0	You paid Medicare taxes
30-39 quarters	$295	Partially qualified
Under 30 quarters	$537	Full premium required

What you pay when you use Part A:

You pay $1,736 for each "benefit period" — which starts when you enter the hospital and ends when you've been out for 60 consecutive days. Days 1-60: covered in full after deductible. Days 61-90: $434/day coinsurance. Days 91+: $868/day (using lifetime reserve days).

First 20 days: covered in full. Days 21-100: $217/day coinsurance. After 100 days: you pay everything. Must be in a Medicare-approved facility and follow a qualifying hospital stay of 3+ days.

Home health services are covered in full if you meet Medicare's conditions. Hospice is covered in full except small copays for outpatient drugs and respite care. These are valuable benefits many people don't know about.

Insider Tip from Dr. Ed

Benefit periods reset: If you're out of the hospital for 60+ consecutive days, your next admission starts a new benefit period — which means a new $1,736 deductible. But it also resets your 90-day clock. This is why some people time non-urgent procedures strategically.

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Part B: Medical Insurance

Part B coverage, costs, and IRMAA (Income-Related Monthly Adjustment Amount)

Part B covers doctor visits, outpatient care, preventive services, durable medical equipment, and many other medical services.

2026 Part B costs: $202.90/month standard premium, $283 annual deductible, then 20% coinsurance for most services. But high earners pay much more.

Part B premiums by income (IRMAA):

2024 Income (Single)	2024 Income (Married)	2026 Monthly Premium
≤$109,000	≤$218,000	$202.90
$109,001-$137,000	$218,001-$274,000	$284.00
$137,001-$171,000	$274,001-$342,000	$405.20
$171,001-$214,000	$342,001-$428,000	$526.40
$214,001-$500,000	$428,001-$750,000	$647.60
>$500,000	>$750,000	$678.70

IRMAA uses 2-year-old tax returns: Your 2026 Medicare premiums are based on your 2024 income. If your income dropped due to retirement, death of spouse, or other life-changing events, you can appeal using Form SSA-44.

Insider Tip from Dr. Ed

Roth conversion warning: Large Roth IRA conversions can push you into higher IRMAA brackets for 2 years. A $100,000 conversion might cost you $2,000+ extra in Medicare premiums. Plan your conversions carefully, or spread them over multiple years to stay below the thresholds.

What Part B covers:

Doctor visits and outpatient care (20% coinsurance)
Preventive services like mammograms, colonoscopies (usually 100% covered)
Durable medical equipment — wheelchairs, oxygen, etc. (20% coinsurance)
Mental health services and some prescription drugs given in doctor's office
Ambulance services (20% coinsurance)
Physical therapy, occupational therapy (20% coinsurance with limits)

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Part C: Medicare Advantage

Medicare Advantage — Private alternative to Original Medicare

Medicare Advantage (Part C) plans are offered by private companies approved by Medicare. They combine Parts A, B, and usually D into one plan.

Key fact: You must keep paying for Part B ($202.90/month minimum) even if your Medicare Advantage plan has a $0 premium. The plan premium is IN ADDITION to your Part B premium.

How Medicare Advantage works:

All-in-one: Combines hospital (A), medical (B), and usually drug coverage (D)
Private networks: You must use doctors and hospitals in the plan's network (except emergencies)
Out-of-pocket maximum: Plans must have an annual limit on your costs (varies by plan)
Extra benefits: Many include dental, vision, hearing aids, wellness programs
Star ratings: Plans rated 1-5 stars based on quality and performance

Types of Medicare Advantage plans:

Must choose a primary care doctor. Need referrals to see specialists. Generally limited to your local area. Usually the lowest cost option but least flexibility. Good if you don't travel much and want coordinated care.

More flexibility — can see specialists without referrals. Some out-of-network coverage (but costs more). Better for people who travel or want more choice in doctors. Higher premiums than HMO plans.

Designed for people with chronic conditions (diabetes, heart failure, etc.) or dual eligible for Medicare and Medicaid. Tailored benefits and care coordination. May include transportation, meals, or other support services.

Insider Tip from Dr. Ed

Check the provider directory every year — and I mean actually call your doctors to confirm they're still in-network. Plans can drop doctors or hospitals with just 30 days' notice. What looks like a great plan in October might leave you without your oncologist in February. This is the #1 complaint I see.

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Part D: Prescription Drug Coverage

Medicare Part D — Drug coverage you need to understand

Part D covers prescription drugs through private plans. You need this unless you have creditable coverage elsewhere — and the late penalty lasts forever.

Big change for 2026: Thanks to the Inflation Reduction Act, your out-of-pocket maximum is capped at $2,100 per year. Once you hit this limit, you pay $0 for covered drugs for the rest of the year.

2026 Part D costs:

National base premium: $38.99/month (actual plan premiums vary)
Annual deductible: Up to $590 (varies by plan, many have $0 deductible)
Out-of-pocket maximum: $2,100 (new for 2025-2026)
Medicare Prescription Payment Plan: Spread costs over the year instead of paying all at once

How Part D coverage works:

You pay full price for drugs until you meet your plan's deductible (up to $590). Many plans have $0 deductible, especially for generic drugs. Once you meet the deductible, you enter the initial coverage phase.

You and your plan share costs based on the plan's formulary tiers. Generic drugs might be $5-15 copay. Brand-name drugs might be 25-50% coinsurance. This continues until your total drug costs reach the coverage gap threshold.

The "donut hole" has been largely eliminated. You pay no more than 25% for brand drugs and generics in the coverage gap. Plus, manufacturer discounts and your payments count toward getting you out of the gap faster.

Once you've spent $2,100 of your own money on covered drugs, you pay $0 for the rest of the year. This is a huge improvement from the old system where you still paid 5% forever.

Insider Tip from Dr. Ed

Don't pick a plan by premium alone. A $0 premium plan might put your critical medication on tier 4 or 5, costing you hundreds per month. Always use Medicare's Plan Finder tool with your exact medications and dosages. The cheapest premium often becomes the most expensive plan when you add in drug costs.

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Common Questions

Medicare FAQ

Your Initial Enrollment Period (IEP) is a 7-month window: 3 months before your 65th birthday month, your birthday month, and 3 months after. If you have employer coverage, you can delay without penalty and use the Special Enrollment Period (8 months after coverage ends).

The standard Part B premium is $202.90/month in 2026. Higher-income beneficiaries pay more through IRMAA (Income-Related Monthly Adjustment Amount) surcharges. The Part B deductible is $283/year.

Starting in 2025 (continuing in 2026), Medicare Part D has a $2,100 annual out-of-pocket maximum. Once you hit this cap, your plan covers 100% of drug costs for the rest of the year. You can also use the Medicare Prescription Payment Plan to spread costs monthly.

Income-Related Monthly Adjustment Amount. If your modified adjusted gross income exceeds $109,000 (single) or $218,000 (married filing jointly), you pay higher Part B and Part D premiums. IRMAA is based on your tax return from 2 years ago. You can appeal using Form SSA-44 if you've had a life-changing event.

It depends on your needs. Medicare Advantage: lower premiums, includes drug coverage, but has network restrictions and prior authorizations. Medigap: higher premiums, but covers most out-of-pocket costs, any doctor who accepts Medicare, great for travelers. Your best choice depends on your health, budget, and how much you travel.

Extra Help (also called Low Income Subsidy or LIS) helps pay Part D premiums, deductibles, and copays. You may qualify if your income is below 150% of the Federal Poverty Level ($23,940/year for an individual in 2026) and your resources are limited. Apply through SSA or your state Medicaid office.

Yes. During the Medicare Advantage Open Enrollment Period (January 1-March 31), you can switch back to Original Medicare and join a standalone Part D plan. You can also switch during the Annual Open Enrollment (October 15-December 7). Note: if you switch back, you may not have guaranteed Medigap enrollment rights.

Part A covers inpatient hospital stays, skilled nursing facility care (days 1-100), hospice care, and some home health services. Most people don't pay a premium for Part A if they or their spouse worked 40+ quarters. The 2026 deductible is $1,736 per benefit period.

Need to start over?

Go back to the beginning and choose a different path.

Where are you with Medicare?

Your Medicare timeline: When and how to enroll

📆 Calculate your enrollment window:

Enroll in Part A (Hospital)

Decide on Part B (Medical)

Choose Part C OR Traditional + D

Still working? You may be able to delay Part B

Requirements for safe delay:

Save Your Spot

Late Enrollment Penalties — How to Avoid Them

Penalty examples:

What Part A covers and costs

2026 Part A costs:

What you pay when you use Part A:

Part B coverage, costs, and IRMAA (Income-Related Monthly Adjustment Amount)

Part B premiums by income (IRMAA):

What Part B covers:

Medicare Advantage — Private alternative to Original Medicare

How Medicare Advantage works:

Types of Medicare Advantage plans:

Medicare Part D — Drug coverage you need to understand

2026 Part D costs:

How Part D coverage works:

Save your spot.

Medicare FAQ

Need to start over?