The ABCD’s of Medicare – Basics of Medicare

by Jill Clifford

The ABCD’s of Medicare – Medicare Supplements
by Jill Clifford

One Medicare coverage choice is keeping original Medicare Parts A and B, plus Part D (or

other credible prescription drug coverage), and adding a Medigap policy, also called a

Medicare Supplement plan. Today, we will cover functions of Medigap plans. In Part 3 of the

ABC’s of Medicare, we will cover pros, cons, and factors to consider when selecting a

Medigap plan.

To enroll in a Medigap plan, an individual must have Medicare Part A and B. The individual

must pay the monthly premium for Part B, $202.90 in 2026, as well as a Medigap premium. It

is illegal for anyone to enroll an individual into both a Medicare Advantage plan AND a

Medigap plan.

Medigap plans are policies sold by private companies to help pay for "gaps" left by Original

Medicare, such as remaining health care copayments, coinsurance, and deductibles. The

Omnibus Reconciliation Act of 1980 brought Medigap insurance under federal oversight,

creating a minimum standard of coverage for the different supplement plans which all private

companies must meet. Any Plan G, for example, must cover the same basic benefits as any

other Plan G. Variations in plans result from company strength, customer support, premium

costs, rate increases, including any rate “freezes,” and added benefits.

The Supplement plan chart illustrates plans available today (Plan A through Plan N). Plans

C and F, the only ones that paid the Part B deductible ($283 in 2026), are no longer available

to new applicants. However, anyone currently enrolled in Plan C or F may remain, and

individuals who were first Medicare eligible before January 2020 may still enroll in those

plans.

Medigap policies may be issued either guaranteed or underwritten. Individuals turning 65 or

first eligible are guaranteed issue into any plan available. Those losing credible coverage,

through retirement for example, may also be eligible for guarantee issue, but plan selection

may be limited.

Others applying for Medigap plans will be underwritten, meaning applicants are required to

answer health history and medication questions. Companies use this information to determine

whether to offer or deny coverage, and whether a standard or increased rate will apply if

coverage is offered. Rates will increase (usually annually) after enrollment in a Medigap plan.

However, an individual’s plan cannot be canceled or incur rate increases as a result of health

problems and expenses, as long as they continue to pay both the supplement and Part B

premiums.

1. All plans include the hospital coinsurance coverage.

2. Plan K pays 50% of covered expenses until a maximum out of pocket is reached of

$8,000, and once the out-of- pocket yearly limit is met, Plan K pays 100% of covered services for the

rest of the calendar year once you meet.

3. Plan L pays 75% of the rest of expenses until a maximum out of pocket is reached of

$4,000, and once the out-of- pocket yearly limit is met, Plan K pays 100% of covered services for the

rest of the calendar year once you meet.

4. Except Plan A, all plans cover some or all of $1,736 Part A deductible (2026), for one to 60

days in the hospital.

5. Excess charges, which occur if a provider does not accept the Medicare approved

payment as payment in full, rarely happen, but only Plans F and G covers such charges.

6. Plan N, except for excess charges, offers nearly equal benefits as Plan G, but requires

copayments of $20 for any doctor visit, and $50 for any ER visit that does not result in an

inpatient admission.

7. Supplement plans D, G, M, and N offer foreign travel emergency coverage up to plan

limits, which original Medicare does not cover. For example, with an annual deductible of

$250, the plan will pay 80% of emergency medical costs up to $50,000 when traveling out of

the country.

8. Plans F and G also have a high deductible option which require first paying a plan

deductible of $2950 in 2026 before the plan begins to pay. Once the plan deductible is met,

the plan pays 100% of covered services for the rest of the calendar year. High deductible plan

G does not cover the Medicare Part B deductible. However, high deductible plans F and G

count your payment of the Medicare Part B deductible toward meeting the plan deductible.

Both the standard and High Deductible Plans F and G are only available to those who were

enrolled in Medicare by January 1, 2020.

The ABCD’s of Medicare – Medicare Supplement Pros and Cons

by Jill Clifford

The ABCD’s of Medicare – Medicare Advantage Plans

by Jill Clifford

As of 2006, all Medicare recipients are required to have Medicare Parts A, B, and D, or

credible coverage as good as the standard Medicare plan.

Our Medicare coverage choices include:

1) Medicare Parts A, B with a Part D prescription drug plan;

2) Medicare Parts A, B, D, and add a Medicare Supplement plan;

3) a Medicare Advantage plan, with prescription drug coverage (MAPD), or without (MA)

if we have other credible prescription drug coverage, like Veterans Affairs insurance, Tricare,

or certain retirement plans.

Today we will discuss the third option: Medicare Advantage plans. To enroll in a MAPD

plan, the individual must be enrolled in Medicare Parts A and B, continue paying Part B

premiums ($202.90 monthly in 2026), unless Medicaid or someone else pays them, and live

in the service area of the plan.

All MAPD plans have a maximum out-of-pocket limit (MOOP). When a MAPD individual

has copayments (flat dollar amounts) or coinsurance (percentage of dollar amounts) that

reach that out-of-pocket limit, the plan will pick up all of the Medicare approved expense for

the rest of the year. The MOOP does not include the cost of prescription drugs, only medical

expenses.

Although, there are many types of MAPD plans, we are limited to HMO (Health

Management Organization) and PPO (Preferred Provider Organization) plans, and PACE

plans (although there are none available for 2026) in our area. PACE (Programs of All-

inclusive Care for the Elderly) is a Medicare/Medicaid program for individuals who would

otherwise need a nursing home level of care, to remain in the community. We also have

DSNP (Dual Special Needs Plan) plans for individuals with both Medicare and Medicaid,

which we will discuss in another article. Lastly, several companies are offering CSNP (Chronic

Special Needs Plan) plans for individuals with diabetes, chronic heart failure, and a few other

critical diseases. We do not have Private Fee for Service (PFFS), Point of Sale (POS),

Medical Savings Account (MSA) or Cost Plans in our area.

Many of the available plans have a zero dollar premium; many have monthly premiums.

Some plans have a medical deductible which must be paid before the plan’s payment share

begins; most do not. Most MAPD plans have a prescription drug deductible.

There are a few plans that do not include prescription drug coverage. These are designed

particularly for veterans, so often nick-named “vet plans.” Since we are required to maintain

prescription drug coverage, these are for individuals who have prescription coverage through

the VA (Veterans Administration), TRICARE for Life, CHAMPVA, or from a retirement plan

prescription drug coverage. No one can have both a vet plan and a stand-alone prescription

drug plan.

With HMO plans, individuals must use doctors and facilities in the HMO network, or pay

total costs for out-of-network. If necessary, the primary care physician may apply for an exception to network from an HMO. With most HMO plans, a referral from the primary care

provider is required to see a specialist. However, some HMO plans have waived that

requirement.

With PPO plans, individuals may use services in or out of the PPO network, but usually pay

more for out-of-network providers. PPO plans generally have two maximum out-of-pocket

limits, one for in network, and one combined in and out of network. PPO plans do not require

referrals to see specialists. However, many specialists require referrals from primary care

physicians, even if the plan does not.

What are the advantages for selecting an Medicare Advantage plan?

First, premiums are much less than most Medicare Supplements and a Part D plan.

Second, with MOOP, MAPDs have a yearly limit to the total cost an individual would pay

should some medical catastrophe occur. Conversely, basic Medicare Part B has no limit to the

20% co-insurance an individual could be charged. However, some of the greatest

advantages are with the variety of added benefits that these plans may include -- for dental,

vision, hearing, transportation, health club memberships, over-the-counter supplements and

medical supplies, and more.

Most MAPD plans participate in an insulin savings program, which limits the cost of certain

insulins to $35 a month.

If we choose to enroll in a MAPD, we should examine the range of Medicare Advantage

plans available, and select the one that best fits our individual needs.

The ABCD’s of Medicare – Extra Help and Medicaid

by Jill Clifford

Today we’ll cover the Extra Help program for prescription drugs and Medicare

Savings Program, also known as Medicaid. You or someone you know may be eligible.

Extra Help, administered through Social Security, could save thousands of dollars in

prescription drug costs. Many eligible people may be unaware of these benefits or how

to get them. To be eligible for the Extra Help, an individual or couple must be under the

maximums for both assets and gross income. Assets include cash, bank and stock

accounts, IRA’s, and real estate other than one’s primary home. Assets do not include

the primary home, car, furniture, other personal belongings, or life insurance. Further,

even if some Americans exceed income limits, they may still qualify if they are

supporting other family members.

2026 Limitations: 

Maximums change each year, and may be otherwise adjusted. Maximums may be

higher under special circumstances, as when a single person or couple is caring for

dependent children or elderly person(s).

The ABCD’s of Medicare – Medicare Enrollment Periods

By Jill Clifford

Standard enrollment periods for Medicare and Medicare plans are Initial Enrollment Period

(IEP), Annual Enrollment Period (AEP), Open Enrollment Period (OEP) for Medicare

Advantage only, and the General Enrollment Period for Medicare Part B. There are also

special enrollment periods (SEPs), allowing individuals to enroll into Medicare and Medicare

plans, which we will cover in other articles.

For individuals turning 65 years old, Medicare normally sends their Medicare card and

letter of eligibility around four months before the month they turn 65. Individuals are required

to enroll in Medicare Part B, unless they have credible coverage as good as Medicare, like an

employer’s plan. NOTE: Insurance under employers’ COBRA (Consolidated Omnibus Budget

Reconciliation Act) is NOT considered credible coverage for Medicare. There is a 10%

penalty assessed for every year that a person does not enroll in Part B when eligible, unless

they have other credible coverage. A penalty is also assessed for not enrolling in Part D,

whether a stand-alone prescription drug plan (PDP) or within a Medicare Advantage plan.

NOTE: Veterans Administration (VA) medical benefits ARE NOT considered credible

coverage for Medicare; Part B enrollment is not optional. However, VA prescription drug

coverage IS considered credible for Medicare Part D.

The Initial Enrollment Period (IEP) is a seven month window to enroll in a Medicare plan,

whether a stand-alone PDP, with or without a Medicare Supplement plan, or a Medicare

Advantage plan. IEP is three months before the 65 th birthday, the month of the 65 th birthday,

and three months following the 65 th birthday. Medicare is effective on the first day of the

birthday month. Exception: if the 65th birthday falls on the first of the month, Medicare

effective date is the first of the prior month. For example, if the 65 th birthday is October 1 st ,

Medicare is effective on September 1 st .

If covered under employer’s insurance, individuals may opt to decline Medicare Part B

(medical benefits) before Part B is effective, and only keep Medicare Part A (hospitalization).

There is no premium for Part A if an individual or spouse qualifies for Medicare. Premium for

Medicare Part B is $202.90 per month in 2026, unless annual income exceeds $109,000 for

an individual, or $218,000 for joint married. Above that, Medicare also charges IRMAA

(Income-Related Monthly Adjusted Amount) for both Medicare Part B and Part D. Remember,

however, enrollment in both Medicare Part B and D is required, unless there is other credible

coverage. Individuals may apply for Part B premium payment by the state, if their monthly

income is less than $1995, or $2705 for a couple.

If not enrolled in a Medicare plan during their IEP (Initial Enrollment Period), individuals

must wait until Annual Enrollment Period (AEP), October 15 through December 7 each

year. AEP is also when individuals already on Medicare may change their Medicare plans.

AEP enrollments are effective January 1, the following year.

Individuals on Medicare Advantage (MA) plans may change MA plans during Open

Enrollment Period (OEP), January 1 through March 31. They may also choose to drop their

plan, go back to original Medicare Parts A and B, and enroll into a prescription drug plan

(PDP). OEP is not a period when individuals may change PDP plans, or initially enroll in

either a PDP or MA.

If not enrolled in Medicare Part B when eligible, there is a General Enrollment Period from

January 1 to March 31. There may be a late enrollment penalty, depending on whether or not

the individual qualifies for a SEP, like losing employer coverage. Part B coverage will be

effective the first day of the month after enrollment.

The ABCD’s of Medicare – Stop the Irritating Calls!

By Jill Clifford

Under the Electronic Code of Federal Regulations (e-CFR), Title 42, there is a section

specifically addressing unsolicited calls to Medicare beneficiaries: “42 CFR § 423.2264 -

Beneficiary contact.” They describe a beneficiary as a Medicare recipient or their caregiver(s).

Contact is any outreach activities to these people by sponsors (companies) marketing

Medicare plans, and their brokers and agents. Unsolicited contact is only allowed by

conventional mail and other print media (for example, advertisements and direct mail) or

email (provided every email contains an opt-out option).

The law specifically prohibits the “use telephone solicitation (that is, cold calling), robocalls,

text messages, or voicemail messages, including, but not limited to, the following:

(A) Calls based on referrals.

(B) Calls to former enrollees who have disenrolled or those in the process of

disenrolling.

(C) Calls to beneficiaries who attended a sales event, unless the beneficiary gave

express permission to be contacted.

(D) Calls to prospective enrollees to confirm receipt of mailed information.

So how do we stop the people who are violating these rules?

First, protect yourself by not engaging with unsolicited callers who want to talk with you about

Medicare. DO NOT provide unsolicited callers with your name, your Medicare identification

number or your Social Security number. Scammers could use this information to make

changes to your plan or enroll you in another plan without your knowledge or consent.

Second, if you do get an unsolicited call about Medicare, ask the caller for their name, license

number, and phone number. Tell the caller, you will call them right back if they will give you

their number, then hang up. If that is refused, simply hang up.

Call 1-800-Medicare (1-800-633-2273) or Washington State Health Insurance Program

(SHIP) at 1-800-562-6900 to report that you received an unsolicited call, giving them

whatever information you have on the caller.

Agents who make unsolicited calls to Medicare beneficiaries can be fined per call, can be

forced to do retraining, can lose their insurance company contracts, or lose their state

insurance license.

If we do not take action against these rogue agents and brokers, we will continue to get

unsolicited calls. So help yourself and everyone else who is receiving these irritating calls by

taking action!

Medicare and Medicaid Resources

Listed below are Federal and Washington Resources, with Phone number and Website:

Social Security: 1-800-772-1213

TDD: 1-800-325-0778

Website: socialsecurity.gov

Kent Social Security Office: 1-866-931-7671

Address: 321 Ramsay Way, WA 98032

Extra Help (Prescription Drug) 1-800-772-1213

Website: ssa.gov/medicare/prescriptionhelp/

Medicare: 1-800-633-4227

Website: Medicare.gov

Medicaid: 1-877-267-2323

Website: Medicaid.gov

Auburn Community Services Office | DSHS: (877) 501-2233

TTY: (800) 833-6384

Website: WashingtonConnection.org

Address: 810 28th St NE Auburn, WA 98002

(For help with Medicaid, food stamps, cash assistance, transportation, etc.)

State Health Insurance Assistance Program (SHIP): 1-800-562-6900

TTY 1-360-586-0241

Website: shiphelp.org/about-medicare

Long Term Care System (ALTSA) : 1-855-567-0252

TTY/TDD 1-800-833-6384

Website: dshs.wa.gov/altsa/long-term-care-service

WA Association of Area Agency on Aging:

Seattle office: 206-684-0660

Address: 700 5 th Ave, #51, Seattle, WA 98104

Tacoma office: 253-780-4600

Address: 4301 S Pine St, Suite 446, Tacoma, WA 98409

Website: agingwashington.org

(For information help with long term care, elder abuse, Medicare, etc.)