Understanding Medicare. Making Confident Coverage Decisions.

Medicare provides essential health insurance coverage for millions of Americans, but understanding how its different parts work together can be challenging.

Whether you’re approaching age 65, preparing to retire, continuing to work beyond 65, or reviewing your existing coverage, the decisions you make can affect your healthcare costs, access to providers, and financial security.

At Right Balance Life & Health, we help you understand your Medicare options, evaluate the trade-offs, and select coverage that fits your healthcare needs, budget, and personal circumstances.

Our approach begins with education and a careful assessment of your situation—not a predetermined insurance recommendation.

Explore Medicare Topics

1. Understanding the Four Parts of Medicare
2. Choosing Your Medicare Coverage Approach
3. Medicare Advantage vs. Medigap: At a Glance
4. Medicare Enrollment: Timing Matters
5. Understanding Medicare Costs and IRMAA
6. What Medicare Does Not Cover: Understanding the Gaps
7. How We Help You Navigate Medicare
8. Frequently Asked Questions
9. Request a Medicare Consultation

Understanding the Four Parts of Medicare

Medicare Part A — Hospital Insurance

Medicare Part A primarily helps cover inpatient hospital care, skilled nursing facility care under qualifying conditions, hospice care, and certain home health services.

Most people qualify for premium-free Part A based on their own or a spouse’s Medicare-covered employment history.

However, premium-free does not mean cost-free. Part A includes deductibles and potentially significant out-of-pocket expenses, depending on the services received and the length of care.

Part A generally does not cover long-term custodial care, such as ongoing assistance with bathing, dressing, or other daily activities.

Medicare Part B — Medical Insurance

Medicare Part B helps cover medically necessary services and supplies, including physician visits, outpatient care, preventive services, diagnostic testing, durable medical equipment, and certain home health services.

Unlike Part A, Part B generally requires a monthly premium. Higher-income beneficiaries may pay an additional amount known as the Income-Related Monthly Adjustment Amount (IRMAA).

Under Original Medicare, beneficiaries generally pay an annual Part B deductible and then 20% of the Medicare-approved amount for most covered services, after meeting the deductible.

An important consideration: Original Medicare does not have an annual out-of-pocket spending limit. Without supplemental coverage, beneficiaries may face substantial expenses if they require extensive medical treatment.

Enrollment timing also matters. Individuals who delay Part B enrollment without qualifying for a Special Enrollment Period may face lifelong late-enrollment penalties.

Medicare Part C — Medicare Advantage

Medicare Advantage (Part C) is an alternative way to receive Medicare benefits through private insurance companies approved by Medicare.

Medicare Advantage plans provide all medically necessary services covered by Original Medicare Parts A and B, except hospice care, which generally remains covered by Original Medicare. Most Medicare Advantage plans also include Part D prescription drug coverage.

Many plans offer additional benefits that Original Medicare does not cover, such as certain dental, vision, hearing, and fitness services. These benefits vary by plan and may have limitations.

Important considerations when evaluating Medicare Advantage plans include:

• Provider networks: Many plans use HMO or PPO networks that can affect which doctors, specialists, and hospitals you can use.
• Out-of-pocket costs: Plans generally have copayments, coinsurance, and an annual maximum out-of-pocket limit for covered Part A and Part B services.
• Prescription coverage: Drug formularies, pharmacy networks, and medication costs vary among plans.
• Prior authorization: Certain medical services may require approval from the insurance company before receiving treatment.
• Additional benefits: Dental, vision, hearing, and other supplemental benefits should be evaluated based on their actual coverage and limitations.

Some Medicare Advantage plans have a $0 additional monthly plan premium, although beneficiaries generally must continue paying their Medicare Part B premium.

Medicare Advantage is not Medicare Supplement (Medigap) insurance. These are fundamentally different approaches to managing healthcare coverage and expenses.

The most appropriate choice depends on your healthcare needs, preferred providers, prescription medications, financial circumstances, and tolerance for potential out-of-pocket expenses.

Medicare Part D — Prescription Drug Coverage

Medicare Part D helps cover the cost of prescription medications. Coverage is provided through private insurance companies approved by Medicare.

You can obtain Part D coverage through a standalone Prescription Drug Plan (PDP), typically paired with Original Medicare, or through a Medicare Advantage plan that includes prescription drug coverage (MAPD).

Important considerations when evaluating Part D coverage include:

• Drug formularies: Each plan maintains a list of covered medications. Coverage and cost-sharing can vary significantly between plans.
• Pharmacy networks: Your prescription costs may depend on whether you use a preferred, standard, or out-of-network pharmacy.
• Monthly premiums: Premiums vary by plan, and higher-income beneficiaries may pay an additional IRMAA amount.
• Deductibles and cost-sharing: Plans may have deductibles, copayments, or coinsurance that affect your prescription expenses.
• Annual out-of-pocket protection: Beginning in 2025, Medicare introduced an annual cap on out-of-pocket spending for covered Part D drugs. The limit is adjusted annually.

An important consideration: Even if you currently take few or no prescription medications, delaying Part D enrollment without other creditable prescription drug coverage may result in a permanent late-enrollment penalty.

Because formularies, pharmacy arrangements, and costs can change annually, reviewing prescription drug coverage during Medicare’s Annual Enrollment Period can be particularly valuable.

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Choosing Your Medicare Coverage Approach

Once you understand the four parts of Medicare, the next major decision is how you want to receive your healthcare coverage.

For most Medicare beneficiaries, there are two principal approaches:

Option 1: Original Medicare (Parts A and B), typically combined with a Medicare Supplement (Medigap) policy and a standalone Part D prescription drug plan.

Option 2: Medicare Advantage (Part C), which provides Medicare-covered services through a private insurance plan and often includes prescription drug coverage.

Both approaches can provide substantial healthcare protection, but they differ in important ways, including provider access, monthly premiums, out-of-pocket expenses, coverage restrictions, and financial predictability.

Neither approach is universally better. The appropriate choice depends on your medical needs, financial circumstances, preferences, and willingness to accept certain risks and limitations.

Option 1: Original Medicare with Medicare Supplement Insurance (Medigap)

Original Medicare consists of Part A (Hospital Insurance) and Part B (Medical Insurance). Many beneficiaries purchase a Medicare Supplement policy, commonly called Medigap, to help pay deductibles, coinsurance, and other expenses that Original Medicare does not fully cover.

A standalone Part D prescription drug plan is generally added to provide prescription coverage.

Potential Advantages

• Broad provider access: You can generally visit any doctor or hospital in the United States that accepts Medicare, without being restricted to a particular insurance company’s provider network.
• Predictable medical expenses: Depending on the Medigap plan selected, much of the cost-sharing associated with Original Medicare may be covered.
• No routine network referrals: Original Medicare generally does not require referrals to see specialists.
• Travel flexibility: Coverage is available throughout the United States wherever Medicare is accepted. Certain Medigap plans also provide limited emergency medical coverage during foreign travel.

Important Considerations

• Higher monthly premiums: Beneficiaries typically pay separate premiums for Part B, Medigap, and Part D.
• Limited supplemental benefits: Medigap generally does not cover routine dental, vision, or hearing services, and these may require separate coverage.
• Premium increases: Medigap premiums may increase over time, potentially affecting affordability during retirement.
• Prescription coverage: A separate Part D plan is generally needed.

An Important Enrollment Consideration

In most states, including Texas, your initial six-month Medigap Open Enrollment Period begins when you are age 65 or older and enrolled in Medicare Part B.

During this period, insurance companies generally cannot deny Medigap coverage or charge higher premiums because of your health history.

Outside this enrollment period and certain other guaranteed-issue situations, insurers may use medical underwriting. This means that switching from Medicare Advantage to Original Medicare with Medigap later may be difficult or expensive—or you may be unable to obtain the Medigap policy you want.

For this reason, your initial Medicare coverage decision deserves careful consideration, including how your healthcare needs might change in the future.

Option 2: Medicare Advantage (Part C)

Medicare Advantage offers an alternative to receiving healthcare benefits directly through Original Medicare. These plans are offered by private insurance companies approved by Medicare and must provide coverage for all medically necessary services covered under Parts A and B, subject to Medicare rules.

Most Medicare Advantage plans also include Part D prescription drug coverage.

Potential Advantages

• Lower monthly premiums: Many Medicare Advantage plans have a $0 additional monthly premium, although beneficiaries generally must continue paying their Medicare Part B premium.
• Annual out-of-pocket protection: Plans establish an annual maximum on what beneficiaries pay for covered Part A and Part B services.
• Additional benefits: Many plans offer dental, vision, hearing, fitness, and other supplemental benefits not typically covered by Original Medicare.
• Integrated coverage: Medical and prescription drug benefits are often combined into a single plan.
• Coordinated care: Some plans emphasize coordination among physicians, specialists, and healthcare facilities.

Important Considerations

• Provider networks: HMO and PPO plans may restrict access to certain physicians, specialists, or hospitals. Out-of-network care may be more expensive or unavailable except in specified circumstances.
• Cost-sharing: Copayments and coinsurance can accumulate throughout the year, particularly when extensive medical treatment is required.
• Prior authorization: Certain procedures, treatments, and services may require approval from the insurance company.
• Annual plan changes: Premiums, provider networks, drug formularies, and supplemental benefits may change from year to year.
• Geographic limitations: Routine healthcare coverage may be less convenient when traveling extensively or residing in multiple states.

Understanding the Financial Trade-Off

Medicare Advantage plans often appeal to beneficiaries who prefer lower monthly premiums and are comfortable paying copayments or coinsurance when they receive medical services.

Original Medicare combined with comprehensive Medigap coverage generally requires higher monthly premiums but can provide greater predictability of medical expenses and broader provider access.

Neither approach eliminates every healthcare expense or financial risk.

An Important Long-Term Consideration

Beneficiaries who initially select Medicare Advantage may later decide that Original Medicare with Medigap would better meet their needs.

However, outside certain guaranteed-issue protections, obtaining Medigap coverage may require medical underwriting. A change in health could make switching difficult.

Consequently, evaluating Medicare coverage involves more than comparing this year’s premiums and benefits. It also requires considering future healthcare needs, financial flexibility, and the ability to change coverage.

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Medicare Advantage vs. Original Medicare with Medigap: At a Glance

Both approaches provide Medicare coverage, but they differ in how healthcare is delivered, how expenses are shared, and how much flexibility beneficiaries have when selecting providers. The following comparison highlights important differences.

Comparison	Original Medicare + Medigap	Medicare Advantage
Monthly Premiums	Part B, Medigap, and usually Part D premiums	Part B premium plus any additional plan premium; many plans offer $0 additional premiums
Provider access	Any provider nationwide who accepts Medicare	Generally subject to plan networks and coverage rules
Deductibles and cost-sharing	Medigap helps cover many Original Medicare expenses, depending on the policy	Copayments, coinsurance, and deductibles vary by plan
Annual out-of-pocket limits	Original Medicare has no limit; Medigap can substantially reduce exposure	Annual limit for covered Part A and B services; amount varies by plan
Prescription coverage	Usually requires a separate Part D plan	Most plans include Part D coverage
Prior authorization	Generally not required for Original Medicare services	May be required for certain services and treatments
Additional benefits	Routine dental, vision, and hearing generally require separate coverage	Many plans include additional benefits, subject to limitations
Changing coverage later	Medigap changes may require medical underwriting outside protected enrollment periods	Plans can generally be changed during applicable enrollment periods; obtaining Medigap later may be difficult

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Medicare Enrollment: Timing Matters

Understanding when to enroll in Medicare is just as important as choosing the right coverage.

Enrollment decisions can affect when your benefits begin, whether you experience a gap in healthcare coverage, and whether you incur late-enrollment penalties that may continue for years—or even for life.

The rules are especially important for individuals who continue working beyond age 65 or receive health insurance through a spouse’s employer.

Medicare provides several enrollment periods, each serving a different purpose. Understanding which rules apply to your circumstances can help you avoid unnecessary expenses and preserve your coverage options.

Initial Enrollment Period (IEP): Your First Opportunity to Enroll

For most people, Medicare eligibility begins at age 65.

Your Initial Enrollment Period is a seven-month window consisting of:

• The three months before the month you turn 65.
• The month you turn 65.
• The three months following your 65th birthday month.

For example, someone turning 65 in July generally has an Initial Enrollment Period beginning April 1 and ending October 31.

Why Enrollment Timing Matters

Enrolling before your birthday month generally allows Medicare coverage to begin on the first day of the month you turn 65. If you enroll during or after your birthday month, coverage may begin later.

Special rules apply to individuals born on the first day of a month.

Automatic Enrollment

Some individuals receiving Social Security or Railroad Retirement Board benefits before age 65 are automatically enrolled in Medicare Parts A and B.

Others must actively enroll through Social Security.

What If You’re Still Working at 65?

You may be able to delay Part B enrollment without penalty if you have qualifying employer-sponsored group health coverage based on your own or your spouse’s current employment.

However, the rules depend on factors such as employer size and the type of coverage.

COBRA and retiree health insurance generally do not provide the same protection against Part B late-enrollment penalties as coverage based on current employment.

Important: Before delaying Medicare enrollment, confirm how your existing coverage coordinates with Medicare and whether you qualify for a future Special Enrollment Period.

Special Enrollment Period (SEP): Enrolling After Age 65

Many Americans continue working beyond age 65 and maintain health insurance through their employer or their spouse’s employer.

Under certain circumstances, Medicare allows these individuals to delay enrolling in Part B without incurring a late-enrollment penalty.

Qualifying for a Special Enrollment Period

Generally, you may qualify for a Part B Special Enrollment Period if you have group health plan coverage based on your own or your spouse’s current employment.

You can typically enroll in Part B:

• At any time while you remain covered by a qualifying employer group health plan based on current employment.
• During the eight-month period beginning the month after employment ends or qualifying employer group health coverage ends, whichever occurs first.

Important: Not All Health Coverage Qualifies

COBRA, retiree health insurance, and individual health insurance generally do not qualify as coverage based on current employment for purposes of delaying Part B enrollment without penalty.

Additionally, employer size can affect whether Medicare or the employer plan pays first. For employees age 65 and older, Medicare generally pays first when the employer has fewer than 20 employees.

Prescription Drug Coverage Requires Separate Consideration

Part D has different enrollment rules. To avoid a Part D late-enrollment penalty, you generally must maintain creditable prescription drug coverage and avoid a continuous period of 63 days or more without such coverage after your Initial Enrollment Period.

A Special Consideration for Health Savings Accounts (HSAs)

Individuals who continue contributing to an HSA should carefully coordinate their Medicare enrollment dates.

Once enrolled in Medicare, you are no longer eligible to contribute to an HSA. In addition, premium-free Medicare Part A coverage may be retroactive for up to six months, potentially creating excess HSA contributions.

Our Recommendation

Before leaving employer coverage or delaying Medicare enrollment, review your circumstances carefully. A relatively simple enrollment decision can have significant financial consequences.

Annual Enrollment Period (AEP): October 15 – December 7

Medicare’s Annual Enrollment Period runs from October 15 through December 7 each year, with coverage changes generally taking effect on January 1 of the following year.

During this period, eligible Medicare beneficiaries can:

• Switch from Original Medicare to a Medicare Advantage plan.
• Switch from Medicare Advantage back to Original Medicare.
• Change from one Medicare Advantage plan to another.
• Join, switch, or drop a standalone Medicare Part D prescription drug plan, subject to applicable enrollment rules.

Why an Annual Review Matters

Medicare Advantage and Part D plans can change from year to year. Changes may include:

• Monthly premiums, deductibles, and copayments.
• Prescription drug formularies and pharmacy networks.
• Participating doctors, specialists, and hospitals.
• Dental, vision, hearing, and other supplemental benefits.
• Prior authorization requirements and other coverage provisions.

A plan that works well this year may not be the best fit next year.

An Important Medigap Consideration

Although the Annual Enrollment Period allows beneficiaries to leave Medicare Advantage and return to Original Medicare, it does not automatically guarantee the ability to purchase a Medicare Supplement (Medigap) policy.

Outside certain guaranteed-issue situations, Medigap insurers may require medical underwriting and may decline an application.

For this reason, beneficiaries considering a change from Medicare Advantage to Original Medicare with Medigap should investigate their Medigap eligibility before making the change.

Our Approach

We encourage Medicare beneficiaries to review their coverage annually, particularly when their healthcare needs, prescriptions, providers, or financial circumstances have changed.

Medicare Advantage Open Enrollment Period: January 1 – March 31

The Medicare Advantage Open Enrollment Period runs from January 1 through March 31 each year.

Unlike the Annual Enrollment Period, this enrollment window is available only to individuals who are already enrolled in a Medicare Advantage plan.

During this period, eligible beneficiaries may:

• Switch from their current Medicare Advantage plan to another Medicare Advantage plan, with or without prescription drug coverage.
• Leave Medicare Advantage and return to Original Medicare.
• Join a standalone Part D prescription drug plan if they return to Original Medicare.

Important Limitations

• Only one change is permitted during this enrollment period.
• Individuals enrolled exclusively in Original Medicare cannot use this period to join a Medicare Advantage plan.
• Individuals with Original Medicare generally cannot use this period to switch standalone Part D plans.
• Coverage changes generally take effect on the first day of the month following the plan’s receipt of the enrollment request.

What About Medicare Supplement Insurance?

Returning to Original Medicare does not automatically guarantee eligibility for a Medigap policy.

Depending on your circumstances, medical underwriting may be required, and an insurer may decline coverage.

Certain guaranteed-issue rights and trial rights provide exceptions, so it is important to evaluate your eligibility before making a change.

Why This Enrollment Period Matters

This period provides an opportunity for Medicare Advantage members to reconsider their coverage after the new plan year begins.

For example, you might discover that a preferred physician is no longer in your plan’s network or that your out-of-pocket expenses are higher than anticipated.

Reviewing your options early can help you determine whether a change would better meet your needs.

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Understanding Medicare Costs: Premiums, Deductibles, and IRMAA

Medicare provides substantial healthcare protection, but it is not free. Understanding the full cost of coverage is an important part of retirement planning.

Your total Medicare expenses may include monthly premiums, deductibles, copayments, coinsurance, prescription medications, and services that Medicare does not cover.

These expenses depend on the coverage approach you select, your healthcare needs, and, in some cases, your income.

For higher-income beneficiaries, Medicare premiums can be significantly greater than the standard amounts. This is because Medicare uses an income-based adjustment known as IRMAA.

Understanding these costs—and how they may change during retirement—can help you make better-informed decisions about both healthcare coverage and retirement finances.

Medicare Premiums and IRMAA: How Your Income Affects Your Costs

Most Medicare beneficiaries pay a monthly premium for Part B (Medical Insurance). Those who enroll in Part D prescription drug coverage generally pay an additional premium.

However, higher-income beneficiaries may pay more for both Part B and Part D because of an adjustment called the Income-Related Monthly Adjustment Amount (IRMAA).

How IRMAA Works

Medicare generally determines IRMAA using your modified adjusted gross income (MAGI) from your federal income tax return filed two years earlier.

For example, your 2026 Medicare premiums are generally based on your 2024 tax return.

For IRMAA purposes, MAGI generally consists of your adjusted gross income plus tax-exempt interest income.

IRMAA thresholds depend on your tax filing status, and the income brackets are adjusted annually.

Why Retirement Planning Matters

Certain financial events can increase your Medicare premiums, including:

• Roth IRA conversions.
• Large capital gains from selling investments.
• Taxable distributions from traditional retirement accounts.
• Increased pension or other taxable retirement income.

Because Medicare generally uses a two-year income lookback, a financial decision made today may affect your Medicare premiums two years later.

Can IRMAA Be Reduced After Retirement?

Yes, under certain circumstances.

If you experience a qualifying life-changing event, such as retirement or a reduction in work hours, you may request that Social Security reconsider your IRMAA determination using more recent income information.

Other qualifying events may include marriage, divorce, or the death of a spouse.

However, a voluntary Roth conversion or investment gain generally does not, by itself, qualify as a life-changing event for purposes of reducing IRMAA.

Looking Beyond the Monthly Premium

When comparing Medicare coverage options, it is important to evaluate the total potential cost of healthcare—not simply the advertised plan premium.

A comprehensive review considers premiums, deductibles, expected medical expenses, prescription costs, and the financial consequences of unexpected healthcare needs.

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What Medicare Does Not Cover: Understanding the Gaps

Medicare provides extensive medical coverage, but certain healthcare services and expenses are either excluded or covered only under specific circumstances.

Understanding these limitations is essential when evaluating your overall healthcare and retirement financial plan.

Dental, Vision, and Hearing

Original Medicare generally does not cover routine dental examinations, cleanings, dentures, eyeglasses, or hearing aids.

There are exceptions for certain medically necessary services, including some dental procedures directly related to covered medical treatment.

Many Medicare Advantage plans offer supplemental dental, vision, and hearing benefits. However, coverage limits, provider networks, and out-of-pocket costs vary considerably.

Standalone insurance policies may provide additional protection, but their premiums and benefit limitations should be carefully evaluated.

Long-Term Care and Custodial Care

One of Medicare’s most significant limitations involves long-term care.

Medicare generally does not pay for ongoing custodial care, such as assistance with bathing, dressing, eating, or other activities of daily living, when that is the only care needed.

Medicare may cover qualifying short-term skilled nursing facility care, certain home health services, and hospice care, but these benefits have specific eligibility requirements and limitations.

Medicare is not a substitute for long-term care insurance.

Extended care needs may require personal savings, family support, long-term care insurance, or Medicaid for individuals who meet applicable eligibility requirements.

Healthcare Expenses While Traveling

Original Medicare generally provides coverage throughout the United States wherever providers accept Medicare.

However, Medicare typically does not cover healthcare services received outside the United States, except in limited circumstances.

Some Medicare Supplement policies provide limited foreign travel emergency benefits.

Medicare Advantage plans generally cover emergency and urgently needed services throughout the United States, but routine care may be subject to network and geographic restrictions. Some plans also offer limited international emergency coverage.

Other Potential Coverage Gaps

Depending on your coverage, additional expenses may include:

• Routine foot care and certain other noncovered services.
• Cosmetic procedures that are not medically necessary.
• Prescription medications excluded from your plan’s formulary.
• Medical services that do not meet Medicare’s coverage requirements.
• Deductibles, copayments, and coinsurance associated with covered care.

Planning for the Unexpected

A sound Medicare strategy considers more than routine medical expenses.

It also evaluates the financial consequences of serious illness, extended care needs, changes in health, and unexpected out-of-pocket expenses.

Our objective is to help clients identify these risks, understand available coverage options, and make informed decisions about how best to manage them.

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How We Help You Navigate Medicare

Choosing Medicare coverage involves more than comparing premiums and benefits. The right decision begins with understanding your healthcare needs, financial circumstances, and personal priorities.

At Right Balance Life & Health, our approach is built around education, careful analysis, and personalized guidance.

1. Understanding Your Situation

We begin by listening.

Are you approaching age 65? Planning to retire? Continuing to work? Concerned about rising healthcare costs? Or simply wondering whether your current Medicare coverage remains appropriate?

We discuss your healthcare needs, preferred doctors and hospitals, prescription medications, existing insurance, budget, and long-term concerns.

2. Explaining Your Coverage Options

We help you understand the differences between Original Medicare, Medicare Supplement insurance, Medicare Advantage, and prescription drug plans.

Our goal is to explain the advantages, limitations, and financial trade-offs of each approach so you can make an informed decision.

3. Evaluating Plans and Potential Costs

We review available insurance options based on your individual circumstances.

This may include comparing:

• Monthly premiums and potential out-of-pocket expenses.
• Provider networks and access to preferred physicians.
• Prescription drug coverage and estimated medication costs.
• Deductibles, copayments, and coinsurance.
• Supplemental benefits and coverage limitations.
• Potential changes in healthcare needs over time.

4. Assisting With Enrollment

Once you’ve selected an appropriate coverage option, we can help you understand enrollment requirements, important deadlines, and the application process.

We also help identify circumstances that may require special attention, such as transitioning from employer coverage or coordinating Medicare with other insurance.

5. Providing Ongoing Support

Your healthcare needs and Medicare coverage options may change over time.

We encourage periodic coverage reviews, particularly during Medicare’s Annual Enrollment Period, to help ensure your coverage continues to meet your needs.

Medicare Decisions in the Context of Retirement Planning

Healthcare coverage is an important component of retirement financial security.

Medicare premiums, income-related adjustments, potential long-term care expenses, and unexpected medical costs can affect retirement income and savings.

Our broader financial services experience allows us to recognize these connections and help clients identify issues that may deserve additional planning.

Our commitment is straightforward: Help you understand your choices, evaluate the trade-offs, and make Medicare decisions with greater confidence.

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Frequently Asked Questions About Medicare

Do I need to enroll in Medicare when I turn 65 if I’m still working?

Not necessarily. If you or your spouse are still working and you have qualifying employer-sponsored group health insurance, you may be able to delay Medicare Part B enrollment without incurring a late-enrollment penalty.

However, several factors should be considered:

• Employer size: If your employer has 20 or more employees, the employer’s group health plan generally pays before Medicare. For smaller employers, Medicare generally pays first.
• Type of coverage: COBRA and retiree health insurance generally do not qualify as coverage based on current employment for purposes of delaying Part B without penalty.
• Prescription drug coverage: You should verify whether your employer’s prescription coverage is considered creditable under Medicare Part D rules.
• Health Savings Accounts: Medicare enrollment affects your eligibility to contribute to an HSA. Retroactive Part A enrollment can create additional complications.

If you delay Part B because you have qualifying employer coverage, you may be eligible for a Special Enrollment Period when that coverage or employment ends.

Before deciding to delay Medicare enrollment, confirm how your employer coverage coordinates with Medicare and whether you qualify for an enrollment exception.

What’s the difference between Medicare Advantage and Medicare Supplement (Medigap) insurance?

Medicare Advantage and Medicare Supplement (Medigap) insurance are two different approaches to managing Medicare coverage and healthcare expenses.

Medicare Advantage (Part C) is an alternative way to receive your Medicare benefits through a private insurance company. These plans typically use provider networks, may require prior authorization for certain services, and generally include an annual out-of-pocket limit for covered Part A and Part B services.

Many Medicare Advantage plans also include prescription drug coverage and additional benefits, such as dental, vision, and hearing services.

Medicare Supplement (Medigap) works alongside Original Medicare (Parts A and B). It helps pay certain deductibles, copayments, and coinsurance that Original Medicare would otherwise leave to the beneficiary.

With Original Medicare and Medigap, you can generally use any healthcare provider nationwide who accepts Medicare. A separate Part D plan is usually needed for prescription coverage.

An important distinction: Medicare Advantage plans may offer lower monthly premiums, while Original Medicare combined with comprehensive Medigap coverage generally offers greater predictability of medical expenses and broader provider access.

You cannot use a Medigap policy to pay Medicare Advantage plan cost-sharing.

Neither approach is universally better. The appropriate choice depends on your healthcare needs, budget, preferred providers, and long-term priorities.

Can I switch from Medicare Advantage to Medicare Supplement (Medigap) insurance later?

Yes, but there is an important distinction between your ability to leave Medicare Advantage and your ability to obtain Medicare Supplement (Medigap) insurance.

You can generally leave Medicare Advantage and return to Original Medicare during certain enrollment periods, including:

• Annual Enrollment Period: October 15 through December 7.
• Medicare Advantage Open Enrollment Period: January 1 through March 31, if you are already enrolled in Medicare Advantage.
• Certain Special Enrollment Periods: Available when qualifying circumstances occur.

However, returning to Original Medicare does not automatically guarantee that you can purchase a Medigap policy.

Why Medical Underwriting Matters

In Texas, outside your initial Medigap Open Enrollment Period and certain guaranteed-issue situations, insurance companies may evaluate your medical history before issuing a policy.

Depending on your health, an insurer may charge a higher premium or decline your application.

Important Exceptions

Federal law provides certain guaranteed-issue protections, including specific trial rights.

For example, if you joined Medicare Advantage when you first became eligible for Medicare at age 65, you generally have a one-year trial right to return to Original Medicare and purchase certain Medigap policies without medical underwriting.

Other protections may apply depending on your circumstances.

Our Recommendation

Before leaving Medicare Advantage, investigate your eligibility for Medigap coverage and understand the applicable enrollment rules.

Your ability to obtain supplemental coverage in the future is an important consideration when making your initial Medicare decision.

Does Medicare cover nursing homes, assisted living, or long-term care?

Medicare provides limited coverage for certain skilled nursing and home health services, but it generally does not pay for long-term custodial care.

Understanding this distinction is important.

What Medicare May Cover

• Skilled nursing facility care: Medicare Part A may cover up to 100 days per benefit period when specific eligibility requirements are satisfied. Under Original Medicare, days 1–20 generally have no daily coinsurance, while days 21–100 require daily coinsurance.
• Home health services: Medicare may cover qualifying intermittent skilled nursing care, therapy, and certain home health aide services when eligibility requirements are met.
• Hospice care: Medicare covers qualifying hospice services for individuals who meet the applicable eligibility requirements.

What Medicare Generally Does Not Cover

Medicare generally does not pay for ongoing assistance with everyday activities, such as:

• Bathing and dressing.
• Eating and using the bathroom.
• Moving safely around the home.
• Supervision and assistance associated with certain cognitive impairments.

This type of assistance is commonly called custodial care.

Medicare also generally does not cover assisted living expenses or long-term nursing home residence when skilled medical care is not required.

How Can These Expenses Be Managed?

Potential funding sources include personal savings, long-term care insurance, certain life insurance or annuity products with long-term care benefits, and Medicaid for individuals who meet its eligibility requirements.

Because extended care can create substantial financial pressure, long-term care planning deserves consideration as part of a comprehensive retirement strategy.

The key distinction: Medicare primarily covers qualifying medical and skilled care—not the ongoing personal assistance that often accounts for much of the cost of long-term care.

Can I change my Medicare coverage if my healthcare needs or financial circumstances change?

Yes. Medicare provides opportunities to change coverage, although the options available depend on your current coverage, the time of year, and your individual circumstances.

During the Annual Enrollment Period (October 15–December 7), eligible beneficiaries can generally change Medicare Advantage plans, change Part D prescription drug plans, or switch between Medicare Advantage and Original Medicare.

During the Medicare Advantage Open Enrollment Period (January 1–March 31), individuals already enrolled in Medicare Advantage can make one qualifying coverage change, including switching to another Medicare Advantage plan or returning to Original Medicare.

Special Enrollment Periods may also be available following certain events, such as moving outside a plan’s service area, losing qualifying coverage, or becoming eligible for certain assistance programs.

What If My Health Changes?

A significant change in health does not automatically create a Special Enrollment Period.

Additionally, while you may be able to return to Original Medicare during an applicable enrollment period, obtaining a Medicare Supplement (Medigap) policy may require medical underwriting unless you qualify for guaranteed-issue protections.

What If My Financial Circumstances Change?

Changes in income may affect Medicare premiums, particularly if you are subject to IRMAA.

Certain qualifying life-changing events, such as retirement or a reduction in work hours, may allow you to request a reconsideration of your IRMAA determination.

Beneficiaries with limited income and resources may also qualify for programs that help pay Medicare premiums, prescription drug costs, or other healthcare expenses.

Our Recommendation

Review your Medicare coverage whenever your healthcare needs, prescriptions, preferred providers, or financial circumstances change.

Even when an immediate coverage change is not permitted, understanding your options can help you prepare for the next available enrollment opportunity.

Does it cost anything to work with a Medicare insurance agent?

There is generally no additional cost to work with Right Balance Life & Health when evaluating and enrolling in Medicare insurance plans that we represent.

How Are Medicare Insurance Agents Compensated?

Insurance agents are typically compensated by insurance companies when clients enroll in eligible plans through their assistance.

For Medicare Advantage and Part D plans, agent compensation is subject to Medicare regulations.

Will I Pay More for My Insurance?

No. For the same Medicare insurance plan, your premium and covered benefits are generally the same whether you enroll through an agent or directly with the insurance company.

What Services Can an Agent Provide?

We can help you:

• Understand Medicare enrollment requirements and deadlines.
• Compare Medicare Advantage, Medicare Supplement, and prescription drug coverage options.
• Evaluate provider networks, prescription coverage, and potential out-of-pocket expenses.
• Understand important differences between available plans.
• Complete enrollment applications and address coverage questions.
• Review your coverage as your circumstances change.

Our Approach

Our objective is to provide clear explanations, identify important trade-offs, and help you make informed decisions.

We believe Medicare guidance should begin with understanding your needs—not promoting a particular insurance product.

Please Note: We do not necessarily represent every insurance company or Medicare plan available in your area. We will explain the scope of the plans we represent and direct you to Medicare’s official resources for information about all available options.

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Let’s Discuss Your Medicare Options

Whether you’re approaching age 65, preparing to retire, reviewing your current coverage, or helping a family member navigate Medicare, we’re here to help.

At Right Balance Life & Health, we believe informed decisions begin with understanding your individual circumstances.

We’ll take the time to answer your questions, explain available coverage options, and help you evaluate the advantages and limitations of each approach.

Have questions about Medicare? Let’s talk.

Contact us to schedule a conversation about your Medicare coverage needs.

We do not offer every plan available in your area. Currently we represent eight organizations which offer 74 products in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

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