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Understanding Medicare Costs: Premiums, Deductibles, and Out-of-Pocket Expenses in 2026

Medical and Financial Disclaimer: This article provides educational information about Medicare costs and coverage options. It is not intended to replace professional medical advice, diagnosis, treatment, or financial planning guidance. Medicare enrollment decisions should be made in consultation with qualified healthcare providers, licensed insurance agents, and financial advisors based on your individual health status, financial circumstances, and coverage needs. All cost figures and program details are accurate as of publication (January 2026) but are subject to annual changes by the Centers for Medicare & Medicaid Services (CMS) and the Social Security Administration (SSA).

Introduction

Navigating Medicare costs can feel overwhelming, especially when you’re approaching retirement or helping a loved one enroll for the first time. With multiple components—Medicare Part A, Medicare Part B, Medicare Advantage (Part C), and Medicare Part D prescription drug coverage—each carrying different premiums, deductibles, and out-of-pocket costs, understanding your total healthcare expenses requires careful planning.

“One of the most common questions I hear from patients is, ‘How much will Medicare actually cost me?'” says Dr. Michael Curley, a board-certified Family Medicine physician with over 37 years of experience serving the Hemet, Murrieta, and Temecula communities through PromiseCare Medical Group. “The answer depends on several factors including your income, which Medicare options you choose, and whether you have supplemental coverage like Medigap or a Medicare Advantage plan.”

For 2026, the Centers for Medicare & Medicaid Services (CMS) has announced increases across Medicare premiums and deductibles. Understanding these costs and how they apply to your specific situation can help you make informed decisions about your healthcare coverage and budget effectively for medical expenses throughout the year.

This comprehensive guide breaks down every aspect of Medicare costs in 2026, including the latest premium amounts, deductible requirements, coinsurance responsibilities, and strategies to manage your out-of-pocket expenses. Whether you’re enrolling in Original Medicare for the first time during your Initial Enrollment Period, considering Medicare Advantage plans, or evaluating Medigap supplemental insurance options, you’ll find detailed cost information to support your healthcare planning.

Understanding the Four Parts of Medicare

Before diving into specific costs, it’s essential to understand how Medicare’s different components work together and what each covers.

Medicare Part A: Hospital Insurance

Medicare Part A covers inpatient hospital care, skilled nursing facility stays, hospice care, and some home health services. About 99% of Medicare beneficiaries don’t pay a monthly premium for Medicare Part A because they or their spouse paid Medicare taxes during at least 40 quarters (10 years) of employment, as determined by the Social Security Administration (SSA).

“Most of my patients who’ve worked their entire careers don’t pay anything for Part A coverage,” explains Dr. Edivina Gonzales, an Internal Medicine specialist with PromiseCare Medical Group. “However, Part A still has cost-sharing requirements when you actually use hospital services, which catches some people by surprise.”

For the minority who must purchase Part A coverage—typically individuals who haven’t worked enough quarters to qualify for premium-free coverage—the monthly costs for 2026 are:

Even with premium-free Part A, beneficiaries face substantial cost-sharing when receiving care:

2026 Part A Deductible: $1,736 per benefit period (an increase of $60 from 2025’s $1,676)

A benefit period begins when you’re admitted to a hospital or skilled nursing facility and ends when you haven’t received inpatient care for 60 consecutive days. If you’re hospitalized multiple times within 60 days, you only pay one deductible. However, if more than 60 days pass between hospital stays, each admission triggers a new deductible.

Additional Part A Cost-Sharing for 2026:

Medicare Part B: Medical Insurance

Medicare Part B covers physician services, outpatient care, preventive services, durable medical equipment, and certain diagnostic tests. Unlike Part A, nearly all Medicare beneficiaries pay a monthly premium for Part B coverage.

2026 Standard Part B Premium: $202.90 per month (an increase of $17.90 from 2025’s $185.00)

2026 Part B Deductible: $283 annually (an increase of $26 from 2025’s $257)

After meeting your annual deductible, Medicare Part B typically covers 80% of Medicare-approved amounts for covered services. You’re responsible for 20% coinsurance for most services and items, which can add up quickly without supplemental coverage.

“The 20% coinsurance under Part B is where many beneficiaries underestimate their costs,” notes Dr. David C. Stanford, an Internal Medicine physician with PromiseCare Medical Group. “For expensive treatments or ongoing specialist care, that 20% can represent significant out-of-pocket expenses over the course of a year.”

Importantly, Original Medicare (Parts A and B) has no maximum out-of-pocket limit, meaning your costs could theoretically continue indefinitely if you require extensive medical care. This is a critical consideration when comparing Original Medicare to Medicare Advantage plans or deciding whether to purchase Medigap supplemental insurance.

Medicare Part C: Medicare Advantage Plans

Medicare Advantage plans are offered by private insurance companies approved by Medicare. These plans must cover everything that Medicare Part A and Part B cover, but they often include additional benefits such as dental care, vision services, hearing aids, and prescription drug coverage.

Medicare Advantage plans work differently from Original Medicare regarding costs:

2026 Average Medicare Advantage Premium: $14 per month (down from $16.40 in 2025)

However, the majority of Medicare Advantage enrollees pay no additional premium beyond their Part B premium. In fact, approximately 25% of Medicare Advantage plans in 2026 pay at least a portion of enrollees’ Part B premiums, effectively reducing overall Medicare costs.

2026 Maximum Out-of-Pocket Limit: $9,250 for in-network services (a decrease of $100 from 2025’s $9,350)

This maximum out-of-pocket limit is a significant advantage over Original Medicare. Once you reach this annual cap, the Medicare Advantage plan pays 100% of covered services for the remainder of the year.

Medicare Advantage plans typically charge copayments for doctor visits rather than the 20% coinsurance under Part B. For example, you might pay a $15-$30 copayment for a primary care visit or $40-$60 for a specialist visit, making costs more predictable.

“Many of my patients prefer Medicare Advantage plans because they know exactly what they’ll pay for each visit,” says Dr. Ratan Tiwari, a cardiologist with PromiseCare Medical Group serving the Hemet area. “For someone managing a chronic condition like heart disease who sees multiple specialists regularly, those predictable copayments make budgeting easier.”

It’s important to understand that Medicare Advantage plans may have network restrictions. Most plans require you to use doctors and facilities within their network, except for emergency care. Some plans, particularly Health Maintenance Organizations (HMOs), may require referrals to see specialists. Preferred Provider Organizations (PPOs) typically offer more flexibility but at higher cost-sharing for out-of-network care.

Medicare Part D: Prescription Drug Coverage

Medicare Part D provides prescription drug coverage through private insurance companies. You can obtain Part D coverage either through a standalone prescription drug plan (PDP) paired with Original Medicare, or through a Medicare Advantage plan that includes drug coverage (MA-PD).

2026 Average Part D Premiums:

2026 Part D Deductible: Maximum of $615 (no plan may have a deductible higher than this amount, though some plans have no deductible)

The most significant change to Part D for 2025-2026 is the implementation of the Inflation Reduction Act’s out-of-pocket cap:

2026 Part D Out-of-Pocket Maximum: $2,100 annually

Once you’ve paid $2,100 in out-of-pocket costs for covered prescription drugs, you enter catastrophic coverage. During catastrophic coverage, you pay $0 for covered drugs for the remainder of the calendar year. This represents a transformational change for Medicare beneficiaries with high prescription drug costs, particularly those managing multiple chronic conditions.

“The Part D out-of-pocket cap has been life-changing for many of my patients who take expensive medications,” Dr. Curley emphasizes. “Previously, some patients were spending $5,000, $10,000, or more annually on prescriptions. Now their costs are capped at $2,100, which makes medications much more affordable.”

Part D plans use a formulary—a list of covered drugs organized into tiers. Generic medications typically fall into lower-cost tiers with smaller copayments or coinsurance, while brand-name and specialty medications occupy higher tiers with greater cost-sharing. When selecting a Part D plan, it’s crucial to verify that your current medications are covered and to understand which tier they occupy.

Income-Related Monthly Adjustment Amount (IRMAA)

One of the most misunderstood aspects of Medicare costs is the Income-Related Monthly Adjustment Amount, or IRMAA. This surcharge applies to Medicare Part B and Part D premiums for higher-income beneficiaries, based on Modified Adjusted Gross Income (MAGI) from your tax return filed two years prior.

“I explain IRMAA to patients as Medicare’s way of asking those who can afford to pay more to contribute a larger share toward their healthcare coverage,” says Dr. Gonzales. “It’s based on means-testing—your income determines how much you pay.”

For 2026, IRMAA thresholds and surcharges are:

2026 Part B IRMAA (Added to $202.90 standard premium)

Income (Individual) Income (Joint) Part B Premium Part B IRMAA
≤ $109,000 ≤ $218,000 $202.90 $0
$109,001 – $161,000 $218,001 – $322,000 $284.10 $81.20
$161,001 – $205,000 $322,001 – $410,000 $405.70 $202.80
$205,001 – $306,000 $410,001 – $612,000 $527.30 $324.40
$306,001 – $500,000 $612,001 – $750,000 $608.10 $405.20
> $500,000 > $750,000 $689.90 $487.00

2026 Part D IRMAA (Added to plan premium)

Income (Individual) Income (Joint) Part D IRMAA
≤ $109,000 ≤ $218,000 $0
$109,001 – $161,000 $218,001 – $322,000 $14.50
$161,001 – $205,000 $322,001 – $410,000 $37.40
$205,001 – $306,000 $410,001 – $612,000 $60.20
$306,001 – $500,000 $612,001 – $750,000 $83.10
> $500,000 > $750,000 $91.00

Approximately 7-8% of Medicare beneficiaries pay IRMAA surcharges. The Social Security Administration automatically calculates IRMAA based on IRS tax data and notifies affected beneficiaries by mail with the new premium amounts.

IRMAA Appeals and Life-Changing Events

If you’ve experienced a qualifying life-changing event that reduced your income, you may request an IRMAA reduction or elimination. Qualifying events include:

To request an IRMAA reconsideration, complete Form SSA-44 (Medicare Income-Related Monthly Adjustment Amount – Life-Changing Event) and submit it to the Social Security Administration within 60 days of receiving your IRMAA notice. Be prepared to provide documentation supporting your life-changing event and demonstrating your reduced income.

“I’ve helped several patients through the IRMAA appeal process after they retired mid-year,” Dr. Stanford shares. “If your income dropped significantly due to retirement but your IRMAA is based on tax returns from two years ago when you were still working full-time, you may qualify for a reduction.”

Medigap (Medicare Supplement Insurance)

Medigap policies are supplemental insurance plans sold by private companies to help cover the gaps in Original Medicare, such as deductibles, copayments, and coinsurance. Medigap policies work only with Original Medicare—you cannot use Medigap with a Medicare Advantage plan.

There are 10 standardized Medigap plan types (A, B, C, D, F, G, K, L, M, and N), each offering different levels of coverage. The benefits within each lettered plan are identical regardless of which insurance company sells it—the only difference is price.

Most Popular Medigap Plans:

Plan G: The most popular choice for new Medicare beneficiaries, Plan G covers:

The only gap Plan G doesn’t cover is the Part B deductible ($283 in 2026).

Plan F: Previously the most comprehensive Medigap plan, Plan F is no longer available to people who became eligible for Medicare on or after January 1, 2020. Those who enrolled in Plan F before this date can keep their coverage. Plan F covers everything Plan G covers, plus the Part B deductible.

Plan N: A lower-premium alternative to Plan G, with small copayments:

Medigap premiums vary significantly based on your location, age, tobacco use, and the insurance company selling the policy. Monthly premiums typically range from $100 to $400 or more, depending on these factors and which plan you choose.

“Medigap provides peace of mind because it dramatically reduces your out-of-pocket costs,” Dr. Curley notes. “With Plan G, my patients know they’ll only pay the Part B deductible each year, and Medigap covers nearly everything else. For people who want predictable healthcare costs, Medigap is excellent.”

Medigap Open Enrollment Period

The best time to purchase Medigap is during your six-month Medigap Open Enrollment Period, which begins the month you’re 65 or older and enrolled in Medicare Part B. During this period, insurance companies cannot:

Outside this enrollment period, insurers in most states can use medical underwriting to determine your eligibility and premium rates, potentially making Medigap significantly more expensive or even unavailable if you have serious health conditions.

Comparing Coverage Options: Making the Right Choice for Your Budget

Choosing between Original Medicare with Medigap, Original Medicare with standalone Part D, or Medicare Advantage requires evaluating your healthcare needs, budget, and personal preferences.

Original Medicare + Medigap + Part D

Total Monthly Costs:

Pros:

Cons:

Best for: People who travel frequently, want unlimited access to specialists, prefer predictable costs, have complex medical needs, or value flexibility above all else.

Medicare Advantage (Part C)

Total Monthly Costs:

Pros:

Cons:

Best for: Budget-conscious individuals comfortable with network restrictions, people who rarely travel outside their service area, those who value extra benefits like dental and vision, or individuals managing their healthcare needs with a primary care physician coordinating care.

Strategies to Reduce Medicare Costs

Even with careful planning, Medicare costs can strain budgets, particularly for those on fixed incomes. These strategies can help reduce your Medicare expenses:

1. Enroll on Time to Avoid Late Enrollment Penalties

Late enrollment penalties can permanently increase your Medicare costs. The Part B late enrollment penalty adds 10% to your premium for each 12-month period you were eligible but didn’t enroll. This penalty continues for as long as you have Part B coverage.

The Part D late enrollment penalty is calculated as 1% of the “national base beneficiary premium” ($38.99 in 2026) times the number of months you were without creditable prescription drug coverage. This penalty is also permanent.

“I always encourage patients to enroll during their Initial Enrollment Period or qualify for a Special Enrollment Period if they’re delaying due to employer coverage,” Dr. Tiwari advises. “Those penalties add up over the years and can’t be removed.”

2. Compare Plans Annually During Open Enrollment

Medicare Advantage plans and Part D prescription drug plans can change their benefits, premiums, formularies, and provider networks each year. The Annual Enrollment Period runs from October 15 to December 7, giving you the opportunity to switch plans for the following year.

Even if you’re satisfied with your current plan, review the Annual Notice of Change you receive each fall. Your medications may have moved to different formulary tiers, your preferred providers may have left the network, or better plan options may have become available in your area.

3. Apply for Financial Assistance Programs

Several programs help lower-income Medicare beneficiaries reduce costs:

Extra Help (Low-Income Subsidy): Assists with Part D premiums, deductibles, and copayments. To qualify for 2026, your annual income must be below $23,385 (individual) or $31,545 (couple), with resources below $17,220 (individual) or $34,360 (couple).

Medicare Savings Programs: Help pay Part B premiums and sometimes Part A premiums, deductibles, and coinsurance. Four programs exist based on income:

State Pharmaceutical Assistance Programs (SPAP): Some states offer additional prescription drug assistance beyond federal programs. Check with your State Health Insurance Assistance Program (SHIP) to see if your state provides SPAP benefits.

4. Review Prescription Drug Options

If you take multiple medications, generic alternatives can significantly reduce costs. Always ask your physician if generic versions are available and appropriate for your condition.

“When I prescribe medications, I’m always mindful of costs,” Dr. Gonzales explains. “Generic drugs work just as well as brand-name medications for most conditions and can cost 80-85% less. I encourage patients to have honest conversations about prescription costs so we can find effective, affordable treatment options.”

Many pharmaceutical companies offer patient assistance programs (PAPs) that provide free or low-cost medications to individuals who qualify based on income. Visit the Medicine Assistance Tool (medicineassistancetool.org) or contact drug manufacturers directly to explore available programs.

5. Maximize Preventive Care Benefits

Medicare Part B covers numerous preventive services at no cost when provided by participating providers, including:

Taking advantage of these preventive services can help detect health issues early when they’re more treatable and less expensive to manage.

“Preventive care is truly an investment in your health and your wallet,” Dr. Stanford emphasizes. “Many serious conditions—diabetes, heart disease, certain cancers—are much more manageable and less costly when caught early through routine screenings.”

6. Consider Health Savings Strategies Before Medicare

If you’re not yet on Medicare but approaching eligibility, consider these strategies:

Health Savings Account (HSA) Contributions: If you have a high-deductible health plan before age 65, maximize HSA contributions. Once you enroll in Medicare, you can no longer contribute to an HSA, but you can use accumulated funds tax-free for qualified medical expenses, including Medicare premiums (except Medigap), deductibles, and out-of-pocket costs.

Delay Part B Enrollment (If Working): If you’re still working at age 65 and have creditable coverage through your employer (generally employers with 20+ employees), you may delay Part B enrollment without penalty. This saves the Part B premium while you’re covered by employer insurance. Ensure you enroll during your Special Enrollment Period (8 months after employment or coverage ends) to avoid penalties.

Strategic Income Planning for IRMAA: Since IRMAA is based on income from two years prior, consider timing large income events (Roth conversions, home sales, retirement account withdrawals) to minimize IRMAA impact. Work with a financial advisor to strategize income distributions that keep you below IRMAA thresholds.

Special Situations and Qualifying Life Events

Certain life circumstances trigger Special Enrollment Periods (SEPs) that allow you to enroll in or change Medicare coverage outside standard enrollment windows:

Moving to a New Location

If you move outside your Medicare Advantage plan’s service area, you qualify for a Special Enrollment Period to join a new plan in your new location or return to Original Medicare. You have two months to make changes, starting the month you move.

Losing Other Coverage

When you lose employer coverage, COBRA, or other creditable coverage, you’re eligible for a Special Enrollment Period. For Part B, you have 8 months after employment or coverage ends. For Part D or Medicare Advantage, the window is 63 days from loss of creditable drug coverage.

Gaining Medicaid or Extra Help

If you become eligible for Medicaid or the Low-Income Subsidy (Extra Help), you can change Medicare Advantage or Part D plans once per calendar quarter during the first nine months of each year, with changes effective the first day of the following month.

Leaving a Nursing Home or Care Facility

Moving out of a skilled nursing facility, nursing home, or long-term care hospital qualifies you for a Special Enrollment Period to change Medicare Advantage or Part D plans. Your enrollment opportunity lasts two months following your move.

“Special Enrollment Periods provide critical flexibility when life circumstances change,” Dr. Curley notes. “The key is knowing your rights and acting within the timeframes. Your State Health Insurance Assistance Program can provide free, unbiased guidance during these transitions.”

Planning for Healthcare Costs in Retirement

Medicare provides essential health coverage, but it doesn’t cover everything. Understanding the full scope of healthcare expenses in retirement helps you budget appropriately and avoid financial surprises.

Costs Medicare Doesn’t Cover

Long-Term Care: Neither Original Medicare nor Medicare Advantage plans cover extended nursing home stays or custodial care (help with daily activities like bathing, dressing, eating). Consider long-term care insurance, hybrid life insurance policies with long-term care riders, or self-insuring through savings.

Dental, Vision, and Hearing: Original Medicare doesn’t cover routine dental care, eyeglasses, or hearing aids. Medicare Advantage plans often include these benefits, but coverage limits may apply. Budget for these expenses separately or explore standalone dental and vision insurance.

International Travel: Original Medicare provides limited coverage outside the United States. Some Medigap plans cover emergency care during foreign travel (up to 80% after a deductible), but coverage limits typically cap at $50,000 lifetime. Consider travel insurance for extended trips abroad.

Estimating Total Healthcare Costs

Financial planners often cite that the average couple retiring at age 65 will need approximately $315,000 to cover healthcare costs throughout retirement (excluding long-term care). This estimate includes Medicare premiums, out-of-pocket costs, prescription drugs, dental care, vision care, and hearing services.

Your individual costs will vary based on:

“I encourage patients to think holistically about healthcare costs in retirement,” says Dr. Gonzales. “Medicare is an excellent foundation, but planning for out-of-pocket expenses, supplemental coverage, and services Medicare doesn’t cover is equally important. Working with a financial advisor who understands healthcare costs can help you develop a comprehensive retirement healthcare strategy.”

Resources and Support for Medicare Beneficiaries

Navigating Medicare doesn’t have to be overwhelming. Numerous resources provide free, unbiased assistance:

State Health Insurance Assistance Program (SHIP): Every state offers SHIP, which provides free Medicare counseling. SHIP counselors can explain coverage options, help you compare plans, assist with enrollment, and answer questions about Medicare costs. Find your local SHIP at shiphelp.org or call 1-877-839-2675.

Medicare.gov: The official Medicare website offers plan comparison tools, cost calculators, coverage information, and educational resources. The Medicare Plan Finder tool (medicare.gov/plan-compare) lets you compare Medicare Advantage and Part D plans based on your medications, preferred pharmacies, and healthcare needs.

1-800-MEDICARE (1-800-633-4227): Call this toll-free number 24/7 for Medicare questions, enrollment assistance, and general information. TTY users can call 1-877-486-2048.

Social Security Administration: Contact SSA at 1-800-772-1213 for questions about Medicare enrollment, IRMAA appeals, or coordination between Social Security benefits and Medicare premiums. TTY users can call 1-800-325-0778.

PromiseCare Medical Group: As the Inland Empire’s largest Independent Physician Association network, PromiseCare offers comprehensive Medicare services through experienced physicians like Dr. Curley, Dr. Gonzales, Dr. Stanford, and Dr. Tiwari. Contact PromiseCare at (951) 390-2840 for Medicare-related healthcare questions or to schedule an appointment with a Medicare-accepting physician in Hemet, Murrieta, Temecula, or surrounding areas.

Conclusion

Understanding Medicare costs is essential for effective healthcare planning and financial security in retirement. From the 2026 Part B premium of $202.90 to the Part A deductible of $1,736, from IRMAA surcharges for higher-income beneficiaries to the transformational $2,100 out-of-pocket cap on Part D prescription drug costs, knowing these numbers helps you budget accurately and make informed coverage decisions.

Whether you choose Original Medicare with Medigap supplemental insurance, a Medicare Advantage plan with comprehensive benefits and maximum out-of-pocket protection, or another combination that suits your needs, the key is matching coverage to your health status, financial situation, and personal preferences.

“Medicare is not one-size-fits-all,” Dr. Curley emphasizes. “The ‘best’ Medicare option is the one that provides the coverage you need at a cost you can afford while offering access to the healthcare providers and services that matter most to you. Take time to research options, ask questions, and seek guidance from trusted resources.”

Remember these key takeaways as you navigate Medicare costs:

  1. Enroll on time to avoid permanent late enrollment penalties
  2. Compare plans annually during the Annual Enrollment Period (October 15 – December 7)
  3. Consider your total costs including premiums, deductibles, copayments, and out-of-pocket expenses
  4. Explore financial assistance programs if you have limited income and resources
  5. Take advantage of preventive services to maintain health and catch issues early
  6. Understand IRMAA and how your income affects Medicare premiums
  7. Know your Special Enrollment Period rights when experiencing qualifying life events
  8. Seek help from SHIP counselors and Medicare.gov resources

By understanding Medicare costs comprehensively and planning strategically, you can enjoy the healthcare security Medicare provides while managing expenses effectively throughout retirement. Your healthcare is an investment in your quality of life—make informed choices that support both your health and financial wellbeing.

Frequently Asked Questions

What is the monthly cost of Medicare in 2026?

The monthly cost depends on which Medicare components you choose. At minimum, most beneficiaries pay the Part B premium of $202.90. If you add Medigap supplemental insurance and Part D prescription drug coverage, total monthly costs typically range from $387 to $587. Medicare Advantage plans often cost less—sometimes just the Part B premium with no additional plan premium. Higher-income beneficiaries pay IRMAA surcharges on top of standard premiums.

Does Medicare Part A have a monthly premium?

Approximately 99% of Medicare beneficiaries receive premium-free Part A because they or their spouse paid Medicare taxes during at least 40 quarters of employment. The remaining 1% must purchase Part A coverage, paying either $311 monthly (30-39 quarters of coverage) or $565 monthly (fewer than 30 quarters) in 2026.

What is the Part B deductible for 2026?

The Medicare Part B deductible is $283 in 2026, an increase of $26 from the 2025 deductible of $257. You must meet this deductible before Part B begins paying its share of covered services. After meeting the deductible, Medicare typically pays 80% of Medicare-approved amounts, and you pay 20% coinsurance.

How does IRMAA affect my Medicare costs?

IRMAA (Income-Related Monthly Adjustment Amount) is a surcharge added to Medicare Part B and Part D premiums for beneficiaries with higher incomes. For 2026, individuals earning over $109,000 or couples earning over $218,000 (based on tax returns from two years prior) pay IRMAA. The surcharge ranges from $81.20 to $487 monthly for Part B and $14.50 to $91 monthly for Part D, depending on income level.

What’s the difference between Original Medicare and Medicare Advantage?

Original Medicare (Parts A and B) is traditional Medicare coverage directly from the federal government, allowing you to see any doctor who accepts Medicare nationwide. Medicare Advantage (Part C) is an alternative offered by private insurance companies that covers everything Original Medicare does, often with additional benefits like dental and vision, but typically with network restrictions. Medicare Advantage plans have maximum out-of-pocket limits ($9,250 in 2026), while Original Medicare has no cap on out-of-pocket costs.

Can I switch from Medicare Advantage back to Original Medicare?

Yes, you can switch from Medicare Advantage to Original Medicare during the Annual Enrollment Period (October 15 – December 7) each year, with changes effective January 1. You can also switch during the first three months of each year using the Medicare Advantage Open Enrollment Period. If you want Medigap supplemental insurance after leaving Medicare Advantage, you may face medical underwriting unless you qualify for guaranteed issue rights, which typically apply only within the first year of joining Medicare Advantage or during specific qualifying situations.

What does Medigap cover that Medicare doesn’t?

Medigap supplemental insurance helps pay for out-of-pocket costs that Original Medicare doesn’t cover, including Part A and Part B deductibles, Part B coinsurance (the 20% you typically pay), Part B excess charges, skilled nursing facility coinsurance, blood (first 3 pints), and foreign travel emergency care. The specific benefits depend on which Medigap plan (A through N) you choose. Medigap does not cover prescription drugs, dental care, vision care, hearing aids, or long-term care.

When can I enroll in Medicare?

You can enroll during your Initial Enrollment Period (7 months beginning 3 months before you turn 65), the Annual Enrollment Period (October 15 – December 7 each year), the General Enrollment Period (January 1 – March 31 for those who missed their Initial Enrollment Period), or during a Special Enrollment Period if you experience a qualifying life event such as moving, losing other coverage, or gaining Medicaid. Enrolling outside your Initial Enrollment Period without a Special Enrollment Period may result in late enrollment penalties.

What is the out-of-pocket maximum for Medicare in 2026?

Original Medicare (Parts A and B) has no maximum out-of-pocket limit—your costs could continue indefinitely depending on your healthcare needs. This is why many beneficiaries purchase Medigap supplemental insurance. Medicare Advantage plans are required to have maximum out-of-pocket limits, capped at $9,250 for in-network services in 2026. Once you reach this limit, the Medicare Advantage plan pays 100% of covered services for the rest of the year.

Are prescription drugs covered under Medicare?

Prescription drugs are covered under Medicare Part D, which is optional coverage provided by private insurance companies. You can obtain Part D through a standalone prescription drug plan paired with Original Medicare or through a Medicare Advantage plan that includes drug coverage. For 2026, the average Part D premium is $34.50 for standalone plans and $11.50 for Medicare Advantage plans with drug coverage. Part D includes a maximum out-of-pocket limit of $2,100 in 2026, after which you pay $0 for covered medications.

What happens if I don’t enroll in Medicare when I’m eligible?

If you don’t enroll in Medicare Part A or Part B when first eligible and don’t have creditable coverage from an employer, you may face late enrollment penalties. The Part B penalty is 10% of the premium for each 12-month period you were eligible but didn’t enroll, and it’s permanent. The Part D penalty is 1% of the national base beneficiary premium times the number of months without creditable drug coverage, also permanent. You may only be able to enroll during the General Enrollment Period (January 1 – March 31), with coverage starting July 1.

How do I qualify for Extra Help with prescription drug costs?

Extra Help (Low-Income Subsidy) assists with Medicare Part D premiums, deductibles, and copayments. To qualify for 2026, your annual income must be below $23,385 (individual) or $31,545 (couple), with resources below $17,220 (individual) or $34,360 (couple). Resources include savings and checking accounts, stocks, and bonds but exclude your home, car, personal possessions, and burial funds. Apply through the Social Security Administration online, by phone (1-800-772-1213), or at your local Social Security office.

Can I have both Medigap and Medicare Advantage?

No, you cannot have both Medigap supplemental insurance and Medicare Advantage coverage simultaneously. You must choose one or the other. Medigap works only with Original Medicare (Parts A and B), while Medicare Advantage replaces Original Medicare as your primary coverage. If you currently have Medigap and want to switch to Medicare Advantage, you can do so during enrollment periods, but you may not be able to return to Medigap later without facing medical underwriting, depending on your situation and timing.

What medical services does Medicare not cover?

Medicare does not cover long-term custodial care (nursing homes for daily living assistance), most dental care, routine eye exams and eyeglasses, hearing aids, cosmetic surgery, acupuncture (except for chronic lower back pain), routine foot care, and healthcare during international travel (except limited emergency care near U.S. borders). Medicare Advantage plans may offer some of these services as supplemental benefits, but coverage is plan-specific and often limited.

How much does Medicare cost if I’m still working at 65?

If you’re still working at age 65 with creditable employer coverage (typically employers with 20+ employees), you may delay Medicare Part B enrollment without penalty, saving the $202.90 monthly premium. However, it’s generally recommended to enroll in premium-free Part A when eligible. When your employment or employer coverage ends, you’ll have an 8-month Special Enrollment Period to enroll in Part B without penalties. Carefully coordinate Medicare enrollment with your employer’s HR department to ensure continuous coverage and avoid gaps or penalties.

About PromiseCare Medical Group

PromiseCare Partners operates the Inland Empire’s largest Independent Physician Association network, serving communities throughout Riverside and San Bernardino Counties. Our network includes over 60 primary care physicians and more than 400 specialists dedicated to providing excellent clinical outcomes, patient safety, and exceptional service. PromiseCare accepts all major Medicare plans including Original Medicare, Medicare Advantage, and serves patients with Medigap supplemental insurance.

Our experienced physicians—including Dr. Michael Curley (Family Medicine, Geriatric Medicine, Women’s Health), Dr. Ratan Tiwari (Cardiology), Dr. Edivina Gonzales (Internal Medicine), and Dr. David C. Stanford (Internal Medicine)—provide comprehensive care tailored to Medicare beneficiaries’ unique needs. We focus on preventive care, chronic disease management, and coordinated treatment to help patients maintain optimal health throughout retirement.

To schedule an appointment with a PromiseCare physician or learn more about our Medicare services, call (951) 390-2840 or visit promisecare.com. We’re here to support your health and wellbeing at every stage of life.