Medicare FAQ

Answers to the questions we hear every day.

Medicare is one of the most consequential financial decisions of your life — and one of the most confusing. Below are answers to the questions we hear most often from clients in New Hampshire, Massachusetts, and beyond. If you don’t see your question here, call us directly. Reviews are always free.

Costs and Premiums

What does Medicare cost in 2026?

Part A (Hospital Insurance):

Part B (Medical Insurance):

Part D (Prescription Drug Coverage):

What is IRMAA?
IRMAA stands for Income-Related Monthly Adjustment Amount. If your income exceeds certain thresholds, you pay a surcharge on top of your standard Part B and Part D premiums. For 2026, IRMAA applies to individuals with income above $106,000 and married couples above $212,000 (based on your tax return from two years prior). The surcharge can range from a moderate monthly addition to several hundred dollars per month at higher income levels.

If your income has recently decreased — due to retirement, divorce, or death of a spouse — you can request that Medicare use a more recent year’s income by filing Form SSA-44. We can walk you through that process.

What are the late enrollment penalties?
Part B late penalty: 10% permanently added to your Part B premium for each 12-month period you were eligible but not enrolled. This penalty lasts for life.

Part D late penalty: 1% of the national base beneficiary premium for each month you went without creditable drug coverage. This is also permanent. At 2026 figures, a two-year gap creates a surcharge of approximately 24%.

The best way to avoid both penalties is to enroll during your Initial Enrollment Period or qualify for a Special Enrollment Period with proper documentation.

Understanding the Plans

What is the difference between Original Medicare and Medicare Advantage?
Original Medicare (Parts A and B) is the federal government program. It covers most hospitals and doctors who accept Medicare anywhere in the country. You can add a Part D plan for drugs and a Medigap plan for cost-sharing. Original Medicare has no annual out-of-pocket maximum on its own — meaning a serious illness could generate unlimited 20% coinsurance charges.

Medicare Advantage (Part C) is provided by private insurance companies approved by Medicare. These plans must cover at least what Original Medicare covers, and most include Part D drug coverage. Medicare Advantage plans typically have annual out-of-pocket maximums and may offer supplemental benefits like dental, vision, hearing, and fitness programs. However, most Medicare Advantage plans use provider networks.

Neither is universally “better” — the right choice depends on your doctors, your medications, your travel patterns, and your financial situation.

What is a Medicare Supplement Plan (Medigap)?
A Medigap plan is private insurance sold to fill the gaps in Original Medicare — the 20% coinsurance, the hospital deductible, and excess charges. Medigap Plan G is currently the most comprehensive option available to new enrollees and covers almost all out-of-pocket costs, leaving only the annual Part B deductible ($283 in 2026) as your responsibility.

Medigap plans are standardized by the federal government in most states — Plan G is the same regardless of which company sells it, and about 93% of doctors who accept Medicare accept Medigap. The differences between companies are price, financial strength, and customer service.

Massachusetts residents: your Medigap plans work differently. Massachusetts is one of only three states (along with Minnesota and Wisconsin) that does not follow the standard federal lettered plan system. Massachusetts has its own standardized Medigap benefit structures — Core, Supplement 1, and Supplement 1A — that predate the federal standardization. If you’re a Massachusetts resident, the plan letter names you see advertised nationally (Plan G, Plan N, etc.) may not directly apply. We can explain the Massachusetts-specific options and how they compare.

What is the difference between Plan G and Plan N?
Plan G and Plan N are the two most popular Medigap options for people who became eligible for Medicare on or after January 1, 2020.

Plan G covers virtually everything Original Medicare doesn’t — hospital coinsurance, Part B coinsurance, the Part A deductible, skilled nursing coinsurance, and excess charges. The only thing you pay out of pocket is the annual Part B deductible ($283 in 2026).

Plan N covers the same categories as Plan G except excess charges, and requires you to pay copays of up to $20 for doctor visits and up to $50 for emergency room visits that don’t result in inpatient admission. Plan N typically costs $30–$60 less per month than Plan G. Whether Plan N saves you money over time depends on how often you see doctors and whether your providers charge Medicare excess charges.

If you rarely see doctors and your providers accept Medicare assignment (meaning they don’t charge excess fees), Plan N can be a smart way to reduce premiums. If you have frequent specialist visits, Plan G often costs less in total.

Is Plan F still available?
Medicare Supplement Plan F was the most comprehensive Medigap plan available — it covered the Part B deductible in addition to everything Plan G covers. However, Plan F is no longer available to people who became newly eligible for Medicare on or after January 1, 2020. If you became eligible before that date, you may still be able to purchase Plan F or switch to Plan F from another plan (subject to underwriting).

For new enrollees, Plan G is the most comprehensive option available.

How are Medigap premiums priced — and do they go up every year?
Medigap insurers use one of three pricing methods:

When comparing Medigap quotes, always ask which pricing method the plan uses. A lower premium at 65 from an attained-age plan may cost more at 75 than an issue-age plan that started higher. We can show you long-term cost projections when comparing options.

Your best window is the six-month Medigap Open Enrollment Period, which starts the month your Part B coverage begins. During this window, you have guaranteed-issue rights — any insurance company must sell you any plan they offer, regardless of your health history. After this window closes, insurers can use medical underwriting, meaning they can decline your application or charge more based on your health.

What is the difference between an HMO and a PPO?

If you travel frequently, split time between states (Massachusetts and Florida is a common pattern), or have specialists you want to keep seeing outside a narrow network, a PPO or Original Medicare with a Medigap plan generally offers greater flexibility.

What is a Part B Give Back benefit?
Some Medicare Advantage plans offer a Part B premium reduction — sometimes called a “Give Back” benefit — that pays part of your monthly Part B premium. In 2026, the standard Part B premium is $202.90 per month. A plan with a $50 Give Back credit would effectively reduce your Part B cost to $152.90 per month.

This benefit sounds appealing but requires careful evaluation. Plans offering significant premium reductions often have narrower networks, higher cost sharing when you need care, or fewer supplemental benefits. A plan that saves you $50 per month on premiums but costs you $200 more in copays over the year is not a net savings. We always run a full cost comparison — premiums plus expected out-of-pocket — when evaluating any plan, including those with Give Back benefits.

A Special Needs Plan is a type of Medicare Advantage plan restricted to people with specific health situations — a qualifying chronic condition, dual enrollment in Medicare and Medicaid, or living in an institution. SNPs are designed around the specific needs of their members, with formularies, supplemental benefits, and care management programs targeted to the qualifying condition.

C-SNPs (Chronic Condition SNPs) are the most relevant for most clients and are available in New Hampshire. They cover conditions including diabetes, cardiovascular disease, chronic kidney disease, COPD, and others. C-SNP enrollment grew 71% in 2025 and now represents 21% of all Medicare Advantage enrollment nationally. New Hampshire does not currently have Dual Eligible SNPs (D-SNPs).

Prescription Drug Coverage

Is there an out-of-pocket cap on Part D?
Yes — starting in 2025, the Inflation Reduction Act created a $2,000 annual out-of-pocket cap on Medicare Part D drug costs. Once you’ve spent $2,000 in covered drug costs in a calendar year, your Part D plan covers 100% of covered drug costs for the rest of the year. This cap replaced the former “coverage gap” (donut hole) and eliminates catastrophic drug spending for people on Medicare. The $2,000 cap is adjusted for inflation in future years.

What is the Welcome to Medicare preventive visit?
When you first enroll in Medicare Part B, you’re entitled to a one-time “Welcome to Medicare” preventive visit during your first 12 months of Part B coverage. This is a free visit (covered 100%, no copay or deductible) that includes a review of your medical and family history, an assessment of your health risks, a vision test, a height, weight, and blood pressure screening, and a referral for other preventive services.

Many new Medicare enrollees don’t know this benefit exists and miss the 12-month window. Schedule it with your primary care physician as soon as your Part B begins. After that first year, Medicare also covers an annual Wellness Visit every 12 months at no cost.

If you don’t have creditable drug coverage from another source (employer plan, VA, TRICARE), you should enroll in a Part D plan when you become eligible — even if you take few or no medications. Waiting creates a permanent penalty and leaves you unprotected if a health event requires expensive prescriptions.

What is a formulary?
A formulary is the list of drugs a Part D plan covers, organized into tiers. Lower tiers typically have lower cost sharing. Generics are usually on tier 1 or 2; branded drugs may be on tier 3 or 4 with significantly higher copays. Before enrolling in any Part D plan, verify that your current medications are on the formulary at an acceptable tier using the Medicare Plan Finder at medicare.gov.

What is Extra Help (Low Income Subsidy)?
Extra Help is a federal program that helps people with limited income and resources pay for Part D premiums, deductibles, and copays. In 2026, individuals with income below approximately $23,000 and assets below approximately $17,000 may qualify. People who receive Medicaid or Supplemental Security Income (SSI) typically qualify automatically. Contact us or call Social Security at 1-800-772-1213 to apply.

Special Situations

I have a Health Savings Account (HSA). How does Medicare affect it?
Once you enroll in any part of Medicare (including Part A), you can no longer contribute to a Health Savings Account. This is a critical planning point for people who want to keep contributing to their HSA.

There’s also a six-month lookback rule: if you apply for Social Security after age 65, Medicare Part A will be backdated up to six months. Any HSA contributions made during those backdated months become excess contributions and trigger a tax penalty. To avoid this, you should stop HSA contributions at least six months before you plan to apply for Social Security or Medicare.

If you’re 65, still working, covered by a high-deductible employer plan, and not yet enrolled in Medicare, you can continue contributing to your HSA. Once you’re ready to enroll in Medicare, plan the timing carefully. We help clients navigate this transition regularly.

I’m a federal employee with FEHB coverage. Do I need Medicare?
Federal employees covered by the Federal Employees Health Benefits (FEHB) program have unique considerations. FEHB plans continue into retirement, and they interact with Medicare differently than private employer plans.

Generally: FEHB is considered creditable coverage, so you can delay Part B without a late penalty while you’re actively employed. Once you retire, you can keep FEHB coverage and let it coordinate with Medicare. Many retired federal employees carry both — Medicare becomes primary and FEHB wraps around it, often eliminating most out-of-pocket costs.

Whether to enroll in Part B at retirement depends on your specific FEHB plan’s costs and benefits versus the Part B premium. This is a calculation worth doing carefully, and we’re glad to help.

I have VA benefits. Do I also need Medicare?
VA benefits and Medicare operate independently — one does not replace the other.

VA benefits cover care received at VA facilities. Medicare covers care at non-VA providers. If you want access to care outside the VA system — including specialists, hospitals, and care closer to home — Medicare gives you that access. Many veterans in New Hampshire carry both, using the VA for certain services and Medicare for others.

You can delay Part B enrollment if you have creditable employer coverage, but VA benefits alone do not qualify you to delay Part B without penalty. If you’ve been relying on VA coverage without enrolling in Part B at 65, contact us to review your options before the General Enrollment Period.

This is one of the most common planning questions we receive. An HMO Medicare Advantage plan generally will not cover you in both states — it uses a local network. A PPO Medicare Advantage plan will provide some out-of-network coverage but typically at higher cost sharing. Original Medicare with a Medigap plan is usually the most flexible option for snowbirds — it’s accepted by any Medicare-participating provider anywhere in the United States.

We have clients in both New Hampshire and Massachusetts who split time with Florida, and we routinely help people think through this decision. Read our detailed guide here.

I’m still covered by my employer’s plan. Do I need Medicare at 65?
It depends on the size of your employer. If your employer has 20 or more employees, your employer plan is primary and Medicare is secondary — you can delay Part B without penalty for as long as you’re actively employed and covered. If your employer has fewer than 20 employees, Medicare becomes primary at 65, and your employer plan pays second (or possibly nothing at all if you haven’t enrolled in Medicare). In that situation, delaying Part B is a serious mistake.

Get the answer in writing from HR — specifically whether your plan qualifies as primary coverage under the Medicare Secondary Payer rules. Read our full guide on this topic here.

Can I delay Part B if I have retiree health coverage?
No. Retiree health coverage does not qualify you to delay Part B enrollment. Retiree plans are designed to wrap around Medicare — meaning they expect Medicare to pay first. If you enroll in retiree coverage at 65 without also enrolling in Part B, your retiree plan may deny claims, and you’ll eventually face the GEP and a permanent late penalty.

What Medicare Doesn’t Cover

Does Medicare cover long-term care?
No. Medicare covers short-term skilled nursing care (up to 100 days per benefit period) following a qualifying hospital stay. It does not cover ongoing custodial care — the daily help with bathing, dressing, eating, and other activities that people with chronic illness, disability, or dementia need over months or years. In Massachusetts, the median annual cost of assisted living in 2026 is $115,200; nursing home private rooms run $189,800 per year.

Long-term care costs fall on private savings, long-term care insurance, or Medicaid (after spending down most of your assets to $2,000 in Massachusetts). Read our long-term care coverage guide here.

Does Medicare cover dental, vision, or hearing?
Original Medicare covers these only in limited, medically necessary situations — not routine dental, exams, glasses, hearing aids, or cleanings. Some Medicare Advantage plans include dental, vision, and hearing benefits as supplemental coverage. Standalone dental and vision plans are also available through private insurers for people on Original Medicare.

Does Medicare cover care outside the United States?
Generally, no. Original Medicare covers emergency care in Canada or Mexico only in very specific geographic situations. Medicare Advantage plans may offer limited international emergency coverage. If you travel internationally, a travel health insurance policy is worth considering.

Making Changes to Your Medicare Coverage

When can I change my Medicare Advantage or Part D plan?

Can I switch from Medicare Advantage back to Original Medicare?
Yes — during the Annual Enrollment Period or the Medicare Advantage Open Enrollment Period. Keep in mind that if you return to Original Medicare outside of your six-month Medigap Open Enrollment window, insurance companies can use medical underwriting to decide whether to sell you a Medigap plan and at what price. In most states (including New Hampshire and Massachusetts), this is a significant consideration — your health history matters once that initial window closes.

Working With an Agent

What is a Scope of Appointment?
A Scope of Appointment (SOA) is a form required by the Centers for Medicare and Medicaid Services (CMS) before any meeting where Medicare Advantage or Part D plans are discussed. It outlines what plan types will be covered in the conversation and must be signed by you in advance — generally at least 48 hours before the meeting, except at a marketing event or when you initiate contact the same day.

What is an Annual Notice of Change?
Each fall, your Medicare Advantage or Part D plan is required to send you an Annual Notice of Change (ANOC) detailing any changes to your plan’s premiums, benefits, formulary, or cost sharing for the coming year. You should review this carefully during AEP — if your plan’s costs or coverage have changed, comparing it against other available plans before December 7 could save you money.

What does it mean that Gilman Agency is an independent agent?
An independent agency is not contractually restricted to any single insurance carrier. We represent Aetna, Humana, UnitedHealthcare, WellSense, and others — which means we can compare plans across multiple companies to find the one that best fits your health needs, your medications, and your budget. A captive agent represents only one company and can only show you that company’s products.

Our reviews are always free. We are compensated by the insurance companies when you enroll, and that compensation does not change based on which plan you select.