Medicare guidance built around your doctors, prescriptions, budget, and priorities
Medicare gives you important choices, but the choices are not always explained in a way that feels simple. Guided Brokerage helps people throughout Texas and Oklahoma understand how Original Medicare, Medicare Advantage, Medicare Supplement insurance, and Part D prescription coverage fit together. We can review your options in English or Spanish and help you focus on the details that are most likely to affect your care and your budget.
There is no single “best” Medicare option for everyone
A plan that works well for a neighbor may not fit your doctors, prescriptions, preferred hospitals, travel habits, or comfort with out-of-pocket costs. The goal is to understand the tradeoffs before you enroll—not after you need care.
What we can review together
- Whether your doctors, specialists, hospitals, and pharmacies participate
- How your prescriptions are covered and what restrictions may apply
- Monthly premiums, deductibles, copays, coinsurance, and annual limits
- Whether you need routine dental, vision, hearing, or other added benefits
- How often you travel or spend time outside your local service area
- Important enrollment dates and possible late-enrollment penalties
Good to know: Medicare plans, provider networks, drug lists, benefits, and costs can change from year to year. Reviewing your coverage annually can help you avoid surprises.
Section 1
Medicare 101
Medicare 101: understand each part before choosing a plan
Medicare is individual coverage, so spouses do not enroll together and may make different choices. Open the sections below for a plain-language explanation of what each part covers, what it can cost, and which gaps deserve attention. Dollar amounts shown are for 2026 and can change each year.
Medicare Part AHospital coverage, 2026 costs, eligibility, and penalties
What Part A covers
Part A helps cover inpatient hospital care, limited skilled nursing facility care after a qualifying inpatient stay, hospice care, inpatient rehabilitation, and certain home health services. It does not cover unlimited long-term or custodial care.
What Part A costs in 2026
- Most people pay no Part A premium because they or a spouse earned at least 40 quarters of Medicare-covered work.
- If you must buy Part A, the 2026 premium is $311 per month with 30–39 quarters of coverage or $565 per month with fewer than 30 quarters.
- The inpatient hospital deductible is $1,736 per benefit period, not once per calendar year.
- Hospital coinsurance is $0 for days 1–60, $434 per day for days 61–90, and $868 per lifetime reserve day in 2026.
- For a covered skilled nursing facility stay, the 2026 coinsurance is $0 for days 1–20 and $217 per day for days 21–100.
No. Original Medicare has no yearly maximum out-of-pocket limit. Because a new hospital benefit period can begin after you have been out of inpatient hospital or skilled nursing care for 60 days in a row, the Part A deductible can occur more than once in a year.
Enrollment and possible penalty
People who qualify for premium-free Part A can generally enroll without a late penalty. If you must buy Part A and delay enrollment without qualifying coverage, the monthly premium may increase by 10%, generally for twice the number of years you delayed.
Medicare Part BMedical coverage, 2026 costs, no MOOP, and late-enrollment rules
What Part B covers
Part B helps cover doctor and specialist visits, outpatient hospital care, preventive services, lab work, durable medical equipment, ambulance services, mental health care, and other medically necessary services. Coverage depends on Medicare rules and whether the service, item, and provider meet Medicare requirements.
What Part B costs in 2026
- The standard Part B premium is $202.90 per month. Higher-income beneficiaries may pay an Income-Related Monthly Adjustment Amount.
- The annual Part B deductible is $283.
- After the deductible, you usually pay 20% of the Medicare-approved amount for covered Part B services when the provider accepts assignment. Some preventive services have no cost sharing.
No. Original Medicare has no annual medical maximum out-of-pocket limit. A Medicare Supplement policy or a Medicare Advantage plan can address this exposure in different ways.
Enrollment requirements and penalty
You generally need Part B before joining Medicare Advantage or buying Medigap. If you delay Part B without qualifying active-employer coverage, the premium can increase 10% for each full 12-month period you could have had Part B. The penalty usually lasts as long as you have Part B. COBRA and retiree coverage do not always protect you from the penalty, so verify the rules before delaying enrollment.
Medicare Part DPrescription coverage, 2026 costs, drug-cost cap, and penalties
What Part D covers
Part D helps cover outpatient prescription drugs through a private Medicare-approved plan. It may be included in Medicare Advantage or purchased as a separate plan with Original Medicare. Each plan has its own formulary, drug tiers, pharmacy network, and rules such as prior authorization, step therapy, or quantity limits.
What Part D costs in 2026
- Premiums and copays vary by plan, prescriptions, and pharmacy. Higher-income beneficiaries may also pay a Part D income-related adjustment.
- A plan may charge a deductible, but the 2026 deductible cannot exceed $615.
- After reaching the deductible, a member generally pays plan-specific copays or coinsurance. Under the standard benefit, coinsurance is 25% until covered-drug out-of-pocket spending reaches the annual cap.
- The 2026 out-of-pocket cap for covered Part D drugs is $2,100. Premiums and drugs not covered by the plan do not count toward that cap.
Part D has a yearly out-of-pocket cap for covered drugs rather than a medical MOOP. Once qualifying spending reaches $2,100 in 2026, you pay $0 for covered Part D drugs for the rest of the calendar year.
Enrollment and possible penalty
If you go 63 days or more without Part D or other creditable prescription coverage after becoming eligible, you may owe a late-enrollment penalty. For 2026, Medicare calculates it as 1% of the $38.99 national base beneficiary premium for every full uncovered month, rounded to the nearest ten cents. It is generally added to your premium for as long as you have Medicare drug coverage.
Review current Part D costs and penalty rules at Medicare.gov.
Medicare Supplement (Medigap)Standardized plans, Plan G, predictable costs, and what is not included
How Medicare Supplement works
Medigap is private insurance that works alongside Original Medicare. Original Medicare pays first; the supplement may then help with eligible deductibles, copayments, and coinsurance according to the standardized plan letter. You can generally use any U.S. doctor or hospital that accepts Medicare. Medigap does not work with Medicare Advantage.
Quick comparison of standardized plans
| Plan | Coverage profile |
|---|---|
| A | Basic benefits, including Part A hospital coinsurance and Part B coinsurance; does not cover the Part A or Part B deductible. |
| B | Plan A benefits plus the Part A deductible. |
| C | Broad coverage including the Part B deductible; generally unavailable to people newly eligible for Medicare on or after January 1, 2020. |
| D | Broad coverage but not the Part B deductible or Part B excess charges. |
| F | Broad coverage including the Part B deductible and excess charges; generally unavailable to people newly eligible on or after January 1, 2020. |
| G | Broad coverage, including Part B excess charges, but not the Part B deductible. A high-deductible version may also be available. |
| K | Generally pays 50% of several cost-sharing benefits and has an $8,000 out-of-pocket limit in 2026 after required deductibles and cost sharing. |
| L | Generally pays 75% of several cost-sharing benefits and has a $4,000 out-of-pocket limit in 2026 after required deductibles and cost sharing. |
| M | Broad benefits but pays 50% of the Part A deductible and does not cover the Part B deductible or excess charges. |
| N | Similar to Plan G for many benefits, with certain office and emergency-room copays; does not cover the Part B deductible or excess charges. |
Benefits are standardized in most states, but premiums are not. Massachusetts, Minnesota, and Wisconsin standardize Medigap differently.
What does Plan G cost?
There is no single official average Plan G premium that is accurate for every consumer. Premiums can differ significantly by ZIP code, age, sex, tobacco use, household discounts, carrier, and the company’s pricing method—even though the standardized medical benefits are the same. The most useful number is a current, personalized comparison of Plan G rates available in your area.
Dental, vision, hearing, and prescriptions
Standard Medigap Plan G does not include routine dental care, routine vision care, hearing aids, or outpatient prescription coverage. These may require separate dental, vision, hearing, and Part D coverage, creating additional premiums and out-of-pocket costs.
Medicare Advantage (Part C)Costs, networks, MOOP, plan types, and extra benefits
How Medicare Advantage works
Medicare Advantage is another way to receive Part A and Part B benefits through a private plan that contracts with Medicare. You must remain enrolled in Part A and Part B and normally continue paying the Part B premium. Most plans include Part D prescription coverage.
Why people consider it
- Many plans combine hospital, medical, and prescription benefits in one plan.
- Some have a $0 additional monthly plan premium, although other costs still apply.
- Plans must include an annual maximum out-of-pocket limit for covered Part A and Part B services.
- Some plans use predictable copays for many services and may have a $0 medical deductible.
- Depending on the plan and eligibility, extra benefits may include dental, vision, hearing, fitness, transportation, over-the-counter allowances, or healthy-food benefits.
- Some plans offer a Part B premium reduction, often called a giveback.
No. Givebacks, transportation, grocery or healthy-food allowances, dental benefits, $0 medical deductibles, and other extras are plan-specific. Some benefits have dollar limits, provider restrictions, prior authorization, or eligibility requirements. Grocery benefits are often limited to qualifying members with certain chronic conditions. Always review the Evidence of Coverage.
Common plan types
- HMO: Usually requires in-network care except emergencies and may require a referral for specialists.
- PPO: Usually offers in-network and out-of-network coverage, with lower costs in network.
- PFFS: Sets plan payment terms that a provider must accept; provider acceptance should be confirmed before each visit.
- SNP: Special Needs Plans are designed for people who meet specific health, institutional, or Medicaid-related eligibility rules.
Costs and tradeoffs
Costs vary by plan. A plan may use deductibles, copays, coinsurance, or a combination, so it would be inaccurate to say every plan has only fixed copays or no medical deductible. Provider networks, referrals, prior authorization, drug formularies, and the annual medical out-of-pocket maximum should all be compared. A low premium can save money in a light-use year, but the likely costs for specialists, hospital care, outpatient procedures, and prescriptions matter too.
Compare Original Medicare and Medicare Advantage at Medicare.gov.
Important: You cannot use a Medicare Supplement policy to pay Medicare Advantage copays or deductibles. The practical decision is usually Medicare Advantage versus Original Medicare with the separate Part D and Medigap options that fit your needs.
Five questions that narrow the choices
- Which doctors, specialists, and hospitals do you want to keep?
- Which prescriptions do you take, including dosage and frequency?
- Do you prefer lower monthly premiums or more predictable costs when you receive care?
- Do you travel frequently or live in another state for part of the year?
- Which extra benefits matter, and what rules or limits apply to them?
Section 2
Enrollment Periods
Medicare enrollment periods
Enrollment timing matters. Missing the right window can delay coverage or lead to penalties, while certain life events may create a Special Enrollment Period. The correct window depends on whether you are new to Medicare, already enrolled, still working, losing employer coverage, moving, or experiencing another qualifying change.
Initial Enrollment Period
For most people who become eligible at 65, the Initial Enrollment Period lasts seven months: the three months before the month you turn 65, your birthday month, and the three months after. When coverage begins depends on when you enroll. People receiving certain Social Security or Railroad Retirement benefits may be enrolled automatically.
General Enrollment Period
If you missed your first opportunity and do not qualify for a Special Enrollment Period, the General Enrollment Period for Part A and Part B runs from January 1 through March 31. Coverage generally begins the month after enrollment, and late-enrollment penalties may apply.
Annual Medicare Open Enrollment
From October 15 through December 7, people with Medicare can generally join, drop, or switch Medicare Advantage or Part D plans for coverage beginning January 1. This is an important time to recheck prescriptions, pharmacies, provider networks, and plan costs for the coming year.
Medicare Advantage Open Enrollment
From January 1 through March 31, a person already enrolled in Medicare Advantage can generally switch to another Medicare Advantage plan or return to Original Medicare and join a separate Part D plan. This period does not provide every option available during fall Open Enrollment.
Special Enrollment Periods
Moving, losing certain coverage, leaving employer coverage, qualifying for Extra Help, or other changes may allow enrollment outside the regular windows. Each Special Enrollment Period has its own rules and deadline, so it is wise to ask before assuming you must wait.
Medigap timing is different
Your federal Medigap Open Enrollment Period is a one-time six-month period that begins when you are 65 or older and enrolled in Part B. During that window, you generally have the strongest federal protections for purchasing a Medigap policy. Outside that period, medical underwriting may apply unless you have a guaranteed-issue right or additional protection under state law.
Still working at 65? Employer size, active employment, COBRA, retiree coverage, and whether your drug coverage is creditable can change the answer. Review the rules before delaying Part B or Part D.
Official resources: Medicare sign-up periods and plan enrollment periods.
Section 3
Medicare Advantage
Medicare Advantage plans
Medicare Advantage, also known as Part C, is an alternative to receiving benefits through Original Medicare. These plans are offered by private insurance companies that contract with Medicare. You must have Part A and Part B to join, you remain in Medicare, and you generally continue paying your Part B premium.
Why someone might consider Medicare Advantage
- Many plans combine medical and prescription drug coverage in one plan
- Plans may offer dental, vision, hearing, fitness, transportation, or other additional benefits
- Some plans have low or $0 additional monthly premiums, although other costs still apply
- Every Medicare Advantage plan has an annual maximum for covered Part A and Part B out-of-pocket expenses
Important tradeoffs to review
Most plans use provider networks and service areas. Some require referrals or prior authorization for certain services. Copays and coinsurance can vary by service, and out-of-network coverage may be limited except for emergencies or urgently needed care. Added benefits also have rules, limits, and participating providers.
A practical comparison checklist
- Doctors and hospitals: Confirm every important provider directly with the plan and provider.
- Prescriptions: Check the formulary, tier, pharmacy network, and utilization rules.
- Total cost: Compare the premium, medical deductible, drug deductible, copays, coinsurance, and maximum out-of-pocket amount.
- Travel: Understand routine coverage outside the service area.
- Plan rules: Review referrals, prior authorization, and how to obtain specialized care.
A low premium does not automatically mean a low total cost. Consider the care you are likely to use and the maximum you could owe during a more difficult health year.
Official resource: Compare Original Medicare and Medicare Advantage.
Section 4
Medicare Supplement
Medicare Supplement insurance (Medigap)
Medigap is private insurance designed to work with Original Medicare. It may help pay some of the deductibles, copayments, and coinsurance left after Medicare pays its share for covered services. It is not the same as Medicare Advantage, and a person cannot use Medigap to supplement a Medicare Advantage plan.
How standardized plans work
In most states, Medigap policies are identified by letters. Policies with the same letter generally provide the same standardized medical benefits regardless of the insurance company, but premiums, household discounts, rate histories, customer service, and underwriting practices can differ. Not every carrier offers every plan.
Why someone might consider Medigap
- Freedom to use any doctor or hospital nationwide that accepts Medicare
- More predictable cost sharing for Medicare-covered services
- No plan network for Original Medicare services
- Some plans provide limited foreign travel emergency coverage
What Medigap generally does not cover
Medigap policies generally do not include outpatient prescription drug coverage, routine dental or vision care, hearing aids, long-term custodial care, or private-duty nursing. A separate Part D plan is normally needed for prescription coverage.
Timing can affect acceptance and price
The strongest federal opportunity is the six-month Medigap Open Enrollment Period that starts when you are 65 or older and enrolled in Part B. After that period, an insurer may use medical underwriting unless a guaranteed-issue right or state protection applies. Before changing or dropping existing coverage, confirm in writing that the replacement coverage has been approved.
Official resources: How Medigap works and what Medigap covers.
Section 5
Part D Prescription
Medicare Part D prescription coverage
Part D helps cover outpatient prescription drugs. Coverage is provided by private companies approved by Medicare. You may receive Part D through a stand-alone prescription drug plan used with Original Medicare or through a Medicare Advantage plan that includes drug coverage.
Why your medication list matters
Each plan has a formulary, or covered-drug list. Drugs are usually organized into tiers that affect what you pay. A plan may also require prior authorization, step therapy, or quantity limits. Because formularies and costs can change, the plan with the lowest premium is not necessarily the lowest-cost plan for your prescriptions.
What to compare
- Your exact prescriptions, dosages, quantities, and refill frequency
- The plan’s premium and prescription deductible
- Drug tiers, copays, and coinsurance
- Preferred, standard, mail-order, and out-of-network pharmacy rules
- Prior authorization, step therapy, and quantity limits
- Coverage rules for specialty or high-cost medication
Avoiding a possible late-enrollment penalty
If you go 63 days or more without Part D or other creditable prescription coverage after you are eligible, you may owe a late-enrollment penalty if you enroll later. Keep notices showing whether employer or retiree drug coverage is creditable.
Review Part D every year
Your prescriptions may change, and the plan can change its premium, deductible, pharmacy arrangements, formulary, and cost sharing for the next year. An annual review using an updated medication list can reveal meaningful differences.
Official resources: Medicare drug coverage and pharmacy networks.
Section 6
Medicare FAQs
Medicare frequently asked questions
Is Medicare automatic when I turn 65?
Some people are enrolled automatically because they already receive qualifying Social Security or Railroad Retirement benefits. Others must actively enroll. Do not assume—confirm your status before your enrollment window closes.
Can I keep working and delay Medicare?
Possibly. The answer depends on active employer coverage, employer size, whether the coverage is based on current employment, and whether prescription coverage is creditable. COBRA and retiree coverage do not always protect you from Medicare penalties in the same way as active-employment coverage.
What is the difference between Medicare Advantage and Medigap?
Medicare Advantage is another way to receive Medicare benefits through a private plan. Medigap works alongside Original Medicare to help with certain out-of-pocket costs. They do not work together.
Do Medicare Advantage plans really have $0 premiums?
Some have a $0 additional plan premium, but you generally continue paying the Part B premium and may owe deductibles, copays, and coinsurance when you receive care.
Will my doctor accept my plan?
Provider participation depends on the coverage. With Medicare Advantage, verify the plan network. With Original Medicare, ask whether the provider accepts Medicare and assignment. Provider directories can change, so confirm important providers directly.
Does Medicare cover long-term custodial care?
Medicare generally does not pay for ongoing custodial care when that is the only care needed. Limited skilled nursing coverage has specific eligibility requirements.
Can my plan change each year?
Yes. Premiums, benefits, copays, formularies, pharmacies, and provider networks may change. Read the Annual Notice of Change and review coverage before the next plan year.
Does it cost anything to ask Guided Brokerage questions?
Your consultation is free and there is no obligation to enroll. We can explain choices in English or Spanish and help you identify what should be verified before making a decision.