Understanding Your Medicare Parts

Part B covers medically necessary services from doctors and healthcare providers — in an office, clinic, or outpatient hospital setting.

• Primary care doctor visits
• Specialist appointments
• Mental health services
• Second surgical opinions

Part B covers many preventive screenings at no cost to you — when provided by a Medicare-accepting doctor.

• Annual Wellness Visit (free)
• Cancer screenings (mammogram, colonoscopy)
• Flu, pneumonia & COVID vaccines
• Diabetes & cardiovascular screening

Outpatient lab tests, X-rays, MRIs, and other diagnostic imaging are covered under Part B when ordered by your doctor.

• Blood tests & urinalysis
• X-rays and MRIs
• CT and PET scans
• EKGs and other diagnostics

If your doctor prescribes equipment for home use, Part B covers 80% of the approved cost for medically necessary items.

• Wheelchairs & walkers
• Hospital beds for home use
• Oxygen equipment
• Blood sugar monitors

Part B has a standard monthly premium plus an annual deductible. After the deductible, Medicare pays 80% and you pay 20% — with no out-of-pocket cap.

• Standard premium: $185/month (2025)
• Annual deductible: $257
• You pay 20% after deductible
• Higher income = IRMAA surcharge

Miss your enrollment window without qualifying coverage and you'll pay 10% extra for every 12 months delayed — permanently added to your premium.

• 10% added per 12-month delay
• Penalty is permanent — lasts your lifetime on Part B
• Exceptions for active employer coverage
• Talk to Betsy before deciding

Medicare Advantage plans must cover everything Original Medicare covers — plus many offer substantial additional benefits.

• Hospital coverage (Part A)
• Medical coverage (Part B)
• Emergency & urgent care
• Often includes Part D drug coverage

Many Advantage plans offer benefits that go beyond Original Medicare — extras that can make a real difference in daily life.

• Dental, vision & hearing coverage
• Fitness memberships (SilverSneakers)
• Transportation to appointments
• Over-the-counter allowances

Every Medicare Advantage plan must have an annual limit on how much you can pay out of pocket. Original Medicare has no such cap.

• 2025 max: $9,350 in-network
• After cap: plan pays 100%
• Protects against catastrophic costs
• Original Medicare has no such limit

Most Advantage plans are HMO or PPO. The difference affects how you access care and flexibility with your doctors.

• HMO: stay in network, referrals often needed
• PPO: more flexibility, higher out-of-network costs
• PFFS: pay-as-you-go structure
• SNP: plans for specific conditions

Many Advantage plans have $0 extra monthly premium on top of your Part B premium. Costs vary by plan, area, and benefits.

• Many plans: $0 additional premium
• You still pay Part B premium ($185/mo)
• Copays vary by service type
• Annual out-of-pocket maximum applies

You can join, switch, or drop a Medicare Advantage plan during specific enrollment windows each year.

• Annual Enrollment: Oct 15 – Dec 7
• Open Enrollment: Jan 1 – Mar 31
• Initial Coverage Election Period
• Special Enrollment Periods available

Each Part D plan covers a specific list of drugs called a formulary. Drugs are grouped into cost tiers — lower tiers cost you less.

• Tier 1: Preferred generics (lowest cost)
• Tier 2–3: Non-preferred & brand-name drugs
• Tier 4–5: Specialty drugs (highest cost)
• Formularies vary by plan — compare carefully

Part D covers prescription drugs available at retail, mail-order, and specialty pharmacies.

• Generic and brand-name medications
• Insulin & diabetes supplies
• Many recommended vaccines
• Specialty & biologic medications

Starting in 2025, there is a new $2,000 annual cap on drug costs under Part D — a major improvement for people with expensive medications.

• $2,000 out-of-pocket cap (new in 2025)
• After cap: plan pays 100%
• Medicare Prescription Payment Plan available
• Spread costs across the year monthly

Part D plans work with preferred pharmacy networks. Using preferred pharmacies can significantly lower your copays.

• Preferred pharmacies = lower costs
• Mail-order often cheaper per fill
• 90-day supplies typically available
• Networks vary by plan and area

Part D premiums vary by plan, ranging from around $10 to over $100/month. There's also an annual deductible before coverage kicks in.

• Premiums vary: avg. ~$46/month
• Max deductible: $590 (2025)
• Higher income = IRMAA surcharge
• Extra Help available for lower income

Go 63+ days without creditable drug coverage after becoming eligible and you'll pay a late penalty added permanently to your premium.

• 1% of national base premium per month delayed
• Penalty is permanent
• Creditable employer coverage avoids penalty
• Don't wait — talk to Betsy first