Making Sense of Medicare
Turning 65 or becoming eligible for Medicare is a milestone that comes with an overwhelming amount of paperwork, acronyms, and decisions. With multiple parts, plan options, enrollment periods, and coverage gaps, it is no wonder that many new Medicare beneficiaries feel confused about their choices.
At Zimmer Medical Group, we accept Medicare and work with patients navigating this transition every day. While we cannot provide insurance advice, we can help you understand the basics so you can make informed decisions about your healthcare coverage.
The Four Parts of Medicare
Part A: Hospital Insurance
Medicare Part A covers inpatient hospital care, skilled nursing facility care, hospice care, and some home health services. Most people do not pay a monthly premium for Part A if they or their spouse paid Medicare taxes for at least 10 years while working.
Part A covers:
- Hospital stays (semi-private room, meals, nursing services, medications during your stay)
- Skilled nursing facility care (up to 100 days per benefit period after a qualifying hospital stay)
- Home health services (intermittent skilled nursing, physical therapy, occupational therapy)
- Hospice care for terminal illness
Part A has a deductible ($1,736 in 2026) that applies per benefit period, not per calendar year. A benefit period begins when you are admitted to the hospital and ends when you have been out of the hospital or skilled nursing facility for 60 consecutive days. Past the deductible, days 61 through 90 of a hospital stay carry a daily coinsurance ($434 in 2026), and days 21 through 100 in a skilled nursing facility carry their own daily coinsurance ($217 in 2026). The Centers for Medicare & Medicaid Services publishes these amounts each fall for the year ahead, so confirm the current figures before planning around them.
Part B: Medical Insurance
Medicare Part B covers outpatient medical services, including doctor visits, preventive services, laboratory tests, imaging, durable medical equipment, and ambulance services. Part B requires a monthly premium ($202.90 per month in 2026 for most people, with higher premiums for higher earners).
Part B covers:
- Doctor visits and specialist consultations
- Preventive services including annual wellness visits, screenings, and vaccinations
- Laboratory tests and diagnostic imaging
- Outpatient surgery
- Mental health services
- Durable medical equipment (wheelchairs, walkers, hospital beds)
After meeting your annual Part B deductible ($283 in 2026), Medicare typically pays 80 percent of approved charges, and you are responsible for the remaining 20 percent coinsurance. This 20 percent can add up quickly, especially for hospitalizations or expensive treatments, which is why many beneficiaries purchase supplemental coverage.
Part C: Medicare Advantage
Medicare Advantage plans are offered by private insurance companies approved by Medicare. They provide all Part A and Part B coverage, often with additional benefits such as dental, vision, hearing, fitness programs, and prescription drug coverage.
Key features of Medicare Advantage:
- Monthly premiums vary by plan (some have $0 premiums beyond your Part B premium)
- Plans typically have lower out-of-pocket costs for routine care
- Most require you to use a network of providers
- Many include prescription drug coverage (Part D)
- Out-of-pocket maximums protect you from catastrophic costs
The trade-off is that Medicare Advantage plans often require referrals for specialists and may have limited provider networks. If your preferred doctors and hospitals are in the plan's network, Medicare Advantage can be an excellent and cost-effective choice.
Part D: Prescription Drug Coverage
Medicare Part D provides prescription drug coverage through private insurance plans. Part D plans have their own monthly premiums, deductibles, and formularies (lists of covered medications).
The four-stage structure many beneficiaries remember no longer applies. The coverage gap known as the donut hole was eliminated in 2025 under the Inflation Reduction Act, and Part D now runs in three stages:
- Deductible stage: You pay the full negotiated price until you meet your plan's deductible. No Part D plan may set that deductible above $615 in 2026.
- Initial coverage stage: You pay 25 percent coinsurance for covered generic and brand-name drugs.
- Catastrophic coverage: Once your own out-of-pocket spending on covered Part D drugs reaches $2,100 in 2026, you pay nothing further for those drugs for the rest of the calendar year.
That annual cap is the change most worth knowing about, because the spending it limits previously had no ceiling at all. Medicare.gov's page on drug coverage costs carries the current figures.
Every Part D plan must also offer the Medicare Prescription Payment Plan, a voluntary option that spreads your out-of-pocket drug costs across monthly bills from your plan instead of charging them at the pharmacy counter. It does not lower what you owe, only when you pay it, which helps most when expensive prescriptions land early in the year.
Choosing the right Part D plan requires reviewing which medications you take, comparing formularies, and calculating your estimated annual out-of-pocket costs across different plans.
Medicare Supplement Plans (Medigap)
If you choose Original Medicare (Parts A and B), you may want a Medigap policy to cover the costs that Medicare does not pay, including deductibles, copayments, and the 20 percent Part B coinsurance. Medigap plans are standardized and labeled with letters (Plan F, Plan G, Plan N, etc.), with each letter offering a specific set of benefits.
According to Medicare.gov, the most popular Medigap plans are Plan G (which covers nearly all out-of-pocket costs except the Part B deductible) and Plan N (which has lower premiums but includes small copayments for some services).
Important: You cannot have both a Medigap policy and a Medicare Advantage plan. You must choose one approach or the other.
Key Enrollment Periods
Initial Enrollment Period (IEP)
A seven-month window surrounding your 65th birthday (three months before, your birthday month, and three months after). This is the best time to enroll, as you have guaranteed-issue rights for Medigap policies during this period.
Annual Enrollment Period (AEP)
October 15 through December 7 each year. During this period, you can switch Medicare Advantage plans, switch between Original Medicare and Medicare Advantage, or change your Part D plan. Changes take effect January 1.
Special Enrollment Periods
Available if you experience qualifying life events such as moving, losing other health coverage, or qualifying for both Medicare and Medicaid.
What Medicare Actually Pays For at a Primary Care Visit
The parts and plan letters matter less day to day than a simpler question: when you sit down in an exam room, what does Medicare pay for? Knowing the answer in advance prevents most of the surprise bills we get asked about.
Preventive Services Billed Without Coinsurance
Medicare treats a defined list of preventive services differently from ordinary office care. When the physician accepts assignment, services on that list are billed without the usual coinsurance, and that list is longer than most people realize: the Welcome to Medicare visit, the yearly wellness visit, cardiovascular and diabetes screening, bone density testing, colorectal and lung cancer screening, and most routine vaccines. Medicare.gov's page on the yearly wellness visit spells out what that visit includes and how often you qualify. Our explainer on the Medicare annual wellness visit versus an annual physical covers the distinction that trips people up most.
Chronic Disease Care Is Ordinary Part B Care
Managing diabetes, hypertension, or chronic kidney disease is not preventive care in Medicare's vocabulary, even though the point of it is prevention. Those visits, the labs that go with them, and the medication adjustments they produce bill as regular Part B services with your normal deductible and coinsurance. The same is true of bone-density follow-up once osteoporosis has been diagnosed rather than screened for.
Why the Visit Type Changes the Bill
Medicare pays physicians from a published national fee schedule, maintained by the Centers for Medicare & Medicaid Services, and the code the office submits determines both what Medicare pays and what you owe. A wellness visit that turns into a discussion of a new symptom becomes two services on one day: the preventive one and a problem-focused one. That is correct billing, not an error, but it is the single most common reason a patient who expected nothing receives a statement. Say up front which you came for, and ask the front desk to explain the coding if you are unsure. Our primary care team is glad to walk through it before the visit rather than after.
Tips for Making the Most of Your Medicare
- Use your free preventive services. Medicare covers an annual wellness visit, many cancer screenings, cardiovascular screenings, diabetes screenings, and vaccinations at no cost. Take advantage of them.
- Review your plan annually. Drug formularies, premiums, and provider networks change each year. Use the Annual Enrollment Period to compare options.
- Understand your costs before procedures. Ask your doctor's office to verify that a service is covered before you receive it.
- Keep records. Maintain copies of Medicare statements, Explanation of Benefits (EOB) documents, and correspondence.
- Seek help if needed. Your State Health Insurance Assistance Program (SHIP) offers free, unbiased Medicare counseling.
Have questions about how Medicare works with your care at our practice? Contact Zimmer Medical Group to speak with our team. We are here to help you navigate your coverage and get the most out of your benefits.
