Medicare Basics: the whole picture, without the jargon

What is Original Medicare?

Original Medicare is the federal health insurance program itself: the coverage you earn through years of working and paying Medicare taxes. It comes in two parts, and the easiest way to remember them is A for "Admitted" and B for "Basically everything else medical."

The most important thing to understand about Original Medicare

After you meet the Part B deductible, Original Medicare generally pays 80% of the Medicare-approved amount for covered services. You pay the other 20%. Here's the part that surprises people: there is no yearly limit on that 20%. If you had a $100,000 medical year, your share could be $20,000.

Original Medicare also does not include prescription drug coverage, and it doesn't cover routine dental, vision, or hearing care.

What is a Medicare Advantage (MAPD) plan?

A Medicare Advantage plan, officially "Part C," is offered by a private insurance company that Medicare has approved. Think of it as an all-in-one bundle: the plan takes over delivering your Part A and Part B benefits, and most plans also build in Part D prescription drug coverage. When drug coverage is included, you'll see it called an MAPD plan (Medicare Advantage Prescription Drug).

What people like about Medicare Advantage

• Low monthly cost. Many plans in our area have low or even $0 monthly premiums (you keep paying your Part B premium either way).
• One card, one plan. Hospital, medical, and usually drug coverage together.
• Extra benefits. Many plans include routine dental, vision, hearing aids, gym memberships, or over-the-counter allowances. These are things Original Medicare doesn't cover.
• A safety net. Unlike Original Medicare alone, every Advantage plan has a yearly maximum out-of-pocket limit. In 2026, that limit can be no higher than $9,250 for in-network care, and many plans set it much lower. Once you hit it, the plan pays 100% of covered services for the rest of the year.

The trade-offs to understand

• Networks. Most plans are HMOs or PPOs, which means they work best (or only) with the plan's network of doctors and hospitals. Checking that your doctors are in network is step one, and it's something I verify for every client.
• Pay as you go. Instead of one premium covering most costs, you pay copays or coinsurance when you use care: a copay for a specialist visit, a daily copay for hospital stays, and so on.
• Plans are local and change yearly. The plans available in Roseville aren't necessarily the ones available in Grass Valley or Marysville, and benefits can change every January. An annual review keeps your plan honest.

What is a Medicare Supplement (Medigap) plan?

A Medicare Supplement plan takes the opposite approach. Instead of replacing how you receive your Medicare benefits, it works alongside Original Medicare and helps pay the bills Medicare leaves behind: the hospital deductible, the Part B deductible (on some older plans), and especially that uncapped 20% coinsurance. People call these plans "Medigap" because they fill the gaps.

What people like about Supplements

• Predictability. With the most popular plans, your out-of-pocket costs for Medicare-covered services are minimal and predictable. You budget for the premium, and surprises are rare.
• Freedom of choice. There are no networks. You can see any doctor or hospital in the United States that accepts Medicare, with no referrals needed. That's valuable if you travel, split time between homes, or see specialists at UC Davis, Sutter, UCSF, or anywhere else.
• Standardized benefits. Medigap plans are standardized by letter (Plan G and Plan N are the most popular for people new to Medicare today). A Plan G from one company has the exact same benefits as a Plan G from another, so companies compete mostly on price and service.

The trade-offs to understand

• A real monthly premium. You'll pay a meaningful premium every month in addition to your Part B premium, whether you use care or not.
• No drug coverage or extras. Medigap covers medical gaps only. You'll add a separate Part D drug plan, and dental/vision are purchased separately if you want them.
• Timing matters a lot. When you first enroll in Part B at 65, you get a one-time, 6-month Medigap Open Enrollment Period when companies must accept you regardless of health history. (California also has a unique "Birthday Rule" that lets existing Medigap policyholders switch to a plan of equal or lesser benefit around their birthday each year without health questions.) Outside those windows, you can be declined for health reasons, so this decision deserves care up front.

What is Medicare Part D (prescription drug coverage)?

Original Medicare doesn't cover most prescriptions you pick up at the pharmacy. Part D fixes that. It's drug coverage offered through private plans, and it reaches you one of two ways:

• Built into a Medicare Advantage plan (the "D" in MAPD), or
• As a stand-alone drug plan (PDP) that you pair with Original Medicare, typically alongside a Medicare Supplement.

How it works in plain terms

Each plan has a list of covered drugs (a formulary) organized into tiers: generics on low tiers with small copays, brand-name and specialty drugs on higher tiers costing more. Plans may have a deductible (no more than $615 in 2026), and each plan has preferred pharmacies where your costs are lowest.

Recent law changed Part D in a big way: your out-of-pocket spending on covered drugs is now capped at $2,100 for 2026. Once you reach the cap, covered medications cost you $0 for the rest of the year. You can also choose to spread your drug costs into even monthly payments through the Medicare Prescription Payment Plan.

A note on my services: I focus on Medicare Advantage and Medicare Supplement plans and do not sell stand-alone Part D plans, but I'll gladly help you understand how drug coverage works and show you how to compare stand-alone plans on Medicare.gov, or connect you with HICAP for free counseling.

When can you enroll or make changes?

Common questions I hear in Placer, Sacramento & Nevada counties