Have questions about Medicare? You're not alone. Whether you're approaching 65 or re-evaluating your current coverage, the information below is designed to give you clear, straightforward answers. If you don't find what you're looking for, our team at Peterka Insurance is always happy to help!
Give us a call at (714) 289-1099 or request a free consultation.
Give us a call at (714) 289-1099 or request a free consultation.
Medicare Basics
What is Medicare?
Medicare is the federal health insurance program administered by the Centers for Medicare & Medicaid Services (CMS). It primarily covers Americans age 65 and older, as well as certain younger individuals with qualifying disabilities, End-Stage Renal Disease (ESRD), or Amyotrophic Lateral Sclerosis (ALS).
What are the different parts of Medicare?
Medicare is divided into four parts, each covering different services:
What does Medicare NOT cover?
Original Medicare does not cover most dental, vision, or hearing care, routine foot care, long-term custodial care, or care received outside the United States. Many beneficiaries add supplemental coverage such as a Medicare Supplement (Medigap) plan or a Medicare Advantage plan to help cover these gaps.
Is Medicare the same as Medicaid?
No. Medicare is a federal program based on age or disability, regardless of income. Medicaid is a joint federal and state program based on financial need. Some low-income individuals qualify for both — a status known as being "dual eligible."
Are there any pre-existing conditions with Medicare?
Yes, in most circumstances when applying for a Supplement (Medigap) plan, insurance companies can "decline to offer coverage" if you are outside of specific election periods.
Medicare is the federal health insurance program administered by the Centers for Medicare & Medicaid Services (CMS). It primarily covers Americans age 65 and older, as well as certain younger individuals with qualifying disabilities, End-Stage Renal Disease (ESRD), or Amyotrophic Lateral Sclerosis (ALS).
What are the different parts of Medicare?
Medicare is divided into four parts, each covering different services:
- Part A (Hospital Insurance) covers inpatient hospital stays, skilled nursing facility care, hospice, and some home health services. Most people do not pay a premium for Part A if they or their spouse paid Medicare taxes for at least 10 years.
- Part B (Medical Insurance) covers outpatient care, doctor visits, preventive services, and durable medical equipment. Part B requires a monthly premium, which in 2026 starts at $202.90 for most beneficiaries but this is income related.
- Part C (Medicare Advantage) is an alternative way to receive your Medicare benefits through a private insurance company approved by Medicare. These plans bundle Part A and Part B coverage and often include Part D (prescription drugs) and extras like dental, vision, and hearing.
- Part D (Prescription Drug Plans) adds prescription drug coverage to Original Medicare (Parts A & B) or certain other Medicare plans. Part D plans are offered by private insurers and vary in cost and formulary.
What does Medicare NOT cover?
Original Medicare does not cover most dental, vision, or hearing care, routine foot care, long-term custodial care, or care received outside the United States. Many beneficiaries add supplemental coverage such as a Medicare Supplement (Medigap) plan or a Medicare Advantage plan to help cover these gaps.
Is Medicare the same as Medicaid?
No. Medicare is a federal program based on age or disability, regardless of income. Medicaid is a joint federal and state program based on financial need. Some low-income individuals qualify for both — a status known as being "dual eligible."
Are there any pre-existing conditions with Medicare?
Yes, in most circumstances when applying for a Supplement (Medigap) plan, insurance companies can "decline to offer coverage" if you are outside of specific election periods.
Medicare Advantage vs Medigap (Medicare Supplement)
What is the difference between Medicare Advantage and Medicare Supplement Insurance?
This is one of the most common questions we receive, and the answer matters a great deal for your coverage and budget. Original Medicare (Parts A & B) covers many healthcare costs but leaves you responsible for deductibles, copays, and coinsurance — with no out-of-pocket maximum.
There are two primary ways to fill those gaps:
Medicare Advantage (Part C) is an alternative to Original Medicare through an insurance company. These plans often have low or $0 premiums and may include dental, vision, hearing, and prescription drug coverage. However, they typically use provider networks (HMO or PPO) and require referrals or prior authorizations for certain services.
Medicare Supplement (Medigap) works alongside Original Medicare, covering some or all of your remaining out-of-pocket costs like copays, coinsurance, and deductibles. Medigap plans are standardized by the federal government, meaning a Plan G from one carrier offers the same basic benefits as a Plan G from another — only the premium differs. Medigap plans generally allow you to see any doctor or specialist in the U.S. who accepts Medicare, without referrals.
The right choice depends on your health needs, preferred doctors, budget, and how often you travel. Our licensed agents can walk you through a side-by-side comparison at no cost to you.
Which Supplement (Medigap) plan is most popular?
Plan G is currently the most popular Supplement plan for new Medicare beneficiaries (those who became eligible after January 1, 2020). It covers nearly all out-of-pocket costs under Original Medicare, with the exception of the Part B deductible. Plan N is another common option that offers slightly lower premiums in exchange for small copays on some office and emergency room visits.
Note: Plan F, which covers the Part B deductible, is no longer available to beneficiaries who became eligible for Medicare on or after January 1, 2020.
Can I switch between Medicare Advantage and Medigap?
You can switch from Medicare Advantage back to Original Medicare during certain enrollment periods. However, if you want to add a Supplement plan after your initial enrollment window has passed, insurers in most states can require medical underwriting, meaning they can decline coverage or charge higher premiums based on your health history.
This is one of the most common questions we receive, and the answer matters a great deal for your coverage and budget. Original Medicare (Parts A & B) covers many healthcare costs but leaves you responsible for deductibles, copays, and coinsurance — with no out-of-pocket maximum.
There are two primary ways to fill those gaps:
Medicare Advantage (Part C) is an alternative to Original Medicare through an insurance company. These plans often have low or $0 premiums and may include dental, vision, hearing, and prescription drug coverage. However, they typically use provider networks (HMO or PPO) and require referrals or prior authorizations for certain services.
Medicare Supplement (Medigap) works alongside Original Medicare, covering some or all of your remaining out-of-pocket costs like copays, coinsurance, and deductibles. Medigap plans are standardized by the federal government, meaning a Plan G from one carrier offers the same basic benefits as a Plan G from another — only the premium differs. Medigap plans generally allow you to see any doctor or specialist in the U.S. who accepts Medicare, without referrals.
The right choice depends on your health needs, preferred doctors, budget, and how often you travel. Our licensed agents can walk you through a side-by-side comparison at no cost to you.
Which Supplement (Medigap) plan is most popular?
Plan G is currently the most popular Supplement plan for new Medicare beneficiaries (those who became eligible after January 1, 2020). It covers nearly all out-of-pocket costs under Original Medicare, with the exception of the Part B deductible. Plan N is another common option that offers slightly lower premiums in exchange for small copays on some office and emergency room visits.
Note: Plan F, which covers the Part B deductible, is no longer available to beneficiaries who became eligible for Medicare on or after January 1, 2020.
Can I switch between Medicare Advantage and Medigap?
You can switch from Medicare Advantage back to Original Medicare during certain enrollment periods. However, if you want to add a Supplement plan after your initial enrollment window has passed, insurers in most states can require medical underwriting, meaning they can decline coverage or charge higher premiums based on your health history.
Enrollment Windows & Deadlines
When am I first eligible for Medicare?
You become eligible for Medicare at age 65. Your Initial Enrollment Period (IEP) is a 7-month window that begins 3 months before the month of your 65th birthday, includes your birthday month, and extends 3 months after. Enrolling during the first three months of your IEP ensures your coverage starts on the first day of your birthday month.
What happens if I miss my Initial Enrollment Period?
If you miss your IEP and don't have qualifying coverage elsewhere (such as employer-sponsored insurance), you may face a late enrollment penalty and a gap in coverage. For Part B, the late penalty is 10% added to your premium for each 12-month period you were eligible but didn't enroll — and that penalty stays with you for life. For Part D, the penalty is calculated based on the number of months you went without creditable drug coverage.
What is a Special Enrollment Period (SEP)?
A Special Enrollment Period allows you to enroll in Medicare outside of standard enrollment windows if you experience a qualifying life event, such as losing employer-sponsored health coverage, moving to a new plan's service area, or losing Medicaid eligibility. SEPs vary in length depending on the triggering event.
When can I make changes to my Medicare Advantage plan each year?
There are two key annual windows:
You become eligible for Medicare at age 65. Your Initial Enrollment Period (IEP) is a 7-month window that begins 3 months before the month of your 65th birthday, includes your birthday month, and extends 3 months after. Enrolling during the first three months of your IEP ensures your coverage starts on the first day of your birthday month.
What happens if I miss my Initial Enrollment Period?
If you miss your IEP and don't have qualifying coverage elsewhere (such as employer-sponsored insurance), you may face a late enrollment penalty and a gap in coverage. For Part B, the late penalty is 10% added to your premium for each 12-month period you were eligible but didn't enroll — and that penalty stays with you for life. For Part D, the penalty is calculated based on the number of months you went without creditable drug coverage.
What is a Special Enrollment Period (SEP)?
A Special Enrollment Period allows you to enroll in Medicare outside of standard enrollment windows if you experience a qualifying life event, such as losing employer-sponsored health coverage, moving to a new plan's service area, or losing Medicaid eligibility. SEPs vary in length depending on the triggering event.
When can I make changes to my Medicare Advantage plan each year?
There are two key annual windows:
- Annual Enrollment Period (AEP): October 15 – December 7. During this time, anyone with Medicare can switch Medicare Advantage plans, switch from Medicare Advantage to Original Medicare, or change their Part D prescription drug plan. Changes take effect January 1.
- Medicare Advantage Open Enrollment Period (OEP): January 1 – March 31. If you are already enrolled in a Medicare Advantage plan, you can switch to a different Medicare Advantage plan or return to Original Medicare during this period.
California-Specific Information
Does California have any special Medicare rules?
Yes. California's Birthday Rule allows Medigap policyholders to switch to a plan with equal or lesser benefits from any carrier during a 60-day window around their birthday each year, without any medical questions asked. This gives Californians meaningful flexibility to shop for better rates as they age.
Are there Medicare Advantage plans specific to the Orange County area?
Yes. Medicare Advantage plans are regional, and the plans available to you depend on your zip code. The Orange County area has a robust selection of Medicare Advantage plans from carriers including UnitedHealthcare, Anthem Blue Cross, Blue Shield of California, Humana, SCAN Health Plan, and others. Our agents are based in Irvine and specialize in helping Orange County residents compare the plans available in their specific area.
Yes. California's Birthday Rule allows Medigap policyholders to switch to a plan with equal or lesser benefits from any carrier during a 60-day window around their birthday each year, without any medical questions asked. This gives Californians meaningful flexibility to shop for better rates as they age.
Are there Medicare Advantage plans specific to the Orange County area?
Yes. Medicare Advantage plans are regional, and the plans available to you depend on your zip code. The Orange County area has a robust selection of Medicare Advantage plans from carriers including UnitedHealthcare, Anthem Blue Cross, Blue Shield of California, Humana, SCAN Health Plan, and others. Our agents are based in Irvine and specialize in helping Orange County residents compare the plans available in their specific area.
Costs & Coverage Gaps
What will Medicare cost me each month?
Your Medicare costs depend on which parts and plans you have:
What is IRMAA?
IRMAA stands for Income-Related Monthly Adjustment Amount. If your modified adjusted gross income (MAGI) reported on your federal tax return from two years prior exceeds certain thresholds, you will pay a higher premium for Medicare Part B and Part D. If your income has significantly decreased since the year used for IRMAA calculation, you can request a review using Form SSA-44.
What is the Medicare "coverage gap" or "donut hole"?
The coverage gap, historically known as the "donut hole," was a period during which Part D enrollees had reduced drug coverage after reaching a certain spending threshold. As of 2025, federal law has eliminated the donut hole and capped out-of-pocket prescription drug costs for Medicare beneficiaries under the Inflation Reduction Act. This is a meaningful improvement for beneficiaries who take high-cost medications.
Does Medicare cover long-term care?
Medicare provides limited coverage for skilled nursing facility care following a qualifying hospital stay, but it does not cover custodial long-term care — the kind of assistance with daily activities (bathing, dressing, eating) that many people need as they age. Long-term care insurance is a separate product designed to help cover these costs. We can help you evaluate whether a long-term care policy makes sense for your situation.
Your Medicare costs depend on which parts and plans you have:
- Part A: $0 premium for most people (if you or your spouse paid Medicare taxes for 10+ years). Those who don't qualify for premium-free Part A pay up to $565/month in 2026.
- Part B: $202.90/month standard premium in 2026, though higher-income beneficiaries pay more through IRMAA (Income-Related Monthly Adjustment Amount).
- Part C (Medicare Advantage): Premiums vary widely by plan and location. Some plans have $0 premiums; others charge more in exchange for broader networks or lower copays.
- Part D: Premiums vary by plan, typically ranging from under $10 to over $200/month depending on the formulary and coverage level.
- Medigap (Supplements): Premiums vary by plan type, carrier, age, and location. In Orange County, monthly premiums for a Plan G can range broadly depending on the carrier and your age at enrollment.
What is IRMAA?
IRMAA stands for Income-Related Monthly Adjustment Amount. If your modified adjusted gross income (MAGI) reported on your federal tax return from two years prior exceeds certain thresholds, you will pay a higher premium for Medicare Part B and Part D. If your income has significantly decreased since the year used for IRMAA calculation, you can request a review using Form SSA-44.
What is the Medicare "coverage gap" or "donut hole"?
The coverage gap, historically known as the "donut hole," was a period during which Part D enrollees had reduced drug coverage after reaching a certain spending threshold. As of 2025, federal law has eliminated the donut hole and capped out-of-pocket prescription drug costs for Medicare beneficiaries under the Inflation Reduction Act. This is a meaningful improvement for beneficiaries who take high-cost medications.
Does Medicare cover long-term care?
Medicare provides limited coverage for skilled nursing facility care following a qualifying hospital stay, but it does not cover custodial long-term care — the kind of assistance with daily activities (bathing, dressing, eating) that many people need as they age. Long-term care insurance is a separate product designed to help cover these costs. We can help you evaluate whether a long-term care policy makes sense for your situation.
Still have questions?
Medicare decisions are among the most important financial and healthcare choices you'll make. At Peterka Insurance, we take pride in being educators first. We represent various insurance organizations offering many products in your area, and our licensed agents will help you compare your options objectively with no pressure and no cost to you.
Call us at (714) 289-1099, or request a free Medicare consultation today.
Call us at (714) 289-1099, or request a free Medicare consultation today.