HowMedicareWorks By Robert N. Heck
An interactive guide to Medicare Basics tailored for residents of Kent County. Learn about Parts A, B, C and D, eligibility and enrollment, and how Medicare pays when you have other coverage.
The ABCD's of Medicare
Click each card to understand the four primary components of Medicare.
What it Covers:
- Inpatient care in a hospital
- Care at a skilled nursing facility (SNF) after a hospital stay
- Some home health care and hospice care services
Eligibility & Cost:
Usually premium-free at age 65 if you or your spouse worked and paid Medicare taxes for 10+ years.
Spousal Rules: You may be eligible based on a spouse's work history if you are married (1+ year), divorced (married 10+ years and single), or widowed (married 9+ months and single).
What it Covers:
- Doctors' office visits and services
- Lab tests and most outpatient care
- Preventative services and medical equipment
Cost & Penalties:
Most people pay a monthly premium that is typically deducted straight from Social Security. For 2026, the standard monthly premium is $202.90, and the annual deductible is $283.00. (Note: Premiums may be higher based on your income).
Warning: If you decline Part B when first eligible without having coverage through an active employer, your premium goes up 10% for each 12-month period you delay enrolling.
How it Works:
Offered by private companies, these plans roll your Part A, B, and usually D coverage into one bundle with limits on your out-of-pocket costs.
Networks & Extras:
- Often includes extra coverage like vision, hearing, and dental.
- Usually requires you to use specific provider networks (HMOs or PPOs) except in emergencies.
Costs:
You must keep paying your Part B premium. You may also pay a flat Advantage premium, plus copays when you receive care. You cannot pair this with a Medigap plan.
What it Covers:
Original Medicare doesn't cover medications. Part D plans (offered by private companies) help cover those costs.
The 4 Coverage Phases:
- Annual Deductible
- Initial Coverage (Copays apply)
- Coverage Gap (The "Donut Hole")
- After the Gap (Catastrophic coverage)
Costs:
Includes a monthly premium. Like Part B, failing to enroll when first eligible without other creditable coverage can result in a late enrollment penalty.
Your Medicare Decision Path
There are two main ways to get your Medicare coverage. Follow the steps below to see how they differ.
Step 1: Choose your primary coverage foundation.
Original Medicare (A & B)
You have your core medical and hospital coverage. Now, you have two optional additions to complete your coverage:
Step 2: Add Prescriptions (Part D)
Original Medicare does not cover most prescriptions. You can enroll in a stand-alone Part D plan.
Step 3: Add Supplement (Medigap)
Original Medicare leaves you with deductibles and 20% coinsurance. A Medigap plan helps cover these remaining costs.
Medicare Advantage (Part C)
You have selected the "All-in-One" bundle. Medicare Advantage plans are offered by private companies.
What happens next?
- Step 2: Prescription Drugs (Part D) are usually already included in the plan.
- Step 3: You cannot add a Medigap policy. It is illegal for anyone to sell you one if you have Part C.
- You must use the plan's network of doctors (HMO/PPO).
Original + Medigap vs Advantage
Understanding the core differences between your two primary path choices.
| Feature | Medicare Supplement (Medigap) | Medicare Advantage (Part C) |
|---|---|---|
| Part B Premium | Must be paid; is separate from the Medicare Supplement premium. | Must be paid; is separate from the Medicare Advantage Plan premium. |
| Monthly Premium | Must be paid; is separate from the Part B premium. | Must be paid; is separate from the Part B premium (though some plans have a $0 premium). |
| Plan Structure | Standardized plans set by Medicare (identified by letters A-N). | Determined by private insurance carriers. |
| Benefits | Helps pay remaining health care costs after Medicare, such as copayments, coinsurance and deductibles. | Medicare Part A and Part B combined, plus extra services added by the plan (often dental, vision, hearing). |
| Providers & Hospitals | Members can use any provider or hospital in the U.S. that accepts Medicare. | Members may be required to use providers and hospitals from within the plan's network. |
| Prescription Drugs | Does not include prescription drug coverage. Enrollment in a separate Part D plan is recommended. | Prescription drug coverage may be built into the plan. |
Standardized Medigap Plan Coverage
If you choose Original Medicare, Medigap policies help cover the "gaps". The basic benefits are identical across insurance companies. Compare how popular plans (G, K, L, N) cover common Medicare gaps.
*Note: Plan N has $20/$50 copays for office/ER visits.
The 4 Phases of Part D (Prescription Drugs)
Click each phase to see how your prescription costs change throughout the year.
Enrollment Periods & Special Scenarios
When to sign up, how to switch, and what happens if you keep working.
Initial Enrollment Period (IEP)
This 7-month period is your first chance to sign up for Medicare. It applies to Parts A, B, C, and D.
📅 Calculate Your 7-Month Window
Your Enrollment Window:
Recurring Enrollment Periods
Annual Enrollment (AEP)
Oct 15 - Dec 7For changing Part C (Advantage) or Part D (Prescription) plans. Coverage begins January 1st.
Advantage Open Enrollment
Jan 1 - Mar 31If you have an Advantage Plan, you can switch to a different one or go back to Original Medicare once during this window.
General Enrollment Period
Jan 1 - Mar 31If you missed your IEP and don't qualify for a Special Enrollment, you can sign up for Part A/B here. Coverage starts July 1st. Late penalties may apply.
Working Past 65, Retiree & COBRA Rules
If you have employer coverage, you might be able to delay Medicare Part B without a penalty via a Special Enrollment Period (SEP).
-
Actively Working (20+ Employees)
You can delay Part B. You have an 8-month SEP starting the month after employment or group coverage ends (whichever is first). No late penalties apply.
-
COBRA Coverage
COBRA is not considered active employment coverage. You are not eligible for an SEP. Enroll in Medicare during your IEP to avoid lifetime penalties.
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Retiree Health Insurance
Like COBRA, retiree insurance is not active employment. Enroll in Part B when first eligible. Speak to your plan admin to see how retiree insurance coordinates with Medicare.
Coordination of Benefits: Who Pays First?
When you have Medicare and other insurance, rules decide the "primary payer" (pays first) and "secondary payer" (pays remainder up to limits). Use the tool below to find out your status.
Interactive Payer Tool
*Note: This is a general guide based on Medicare rules. Always verify coordination of benefits with your plan administrator.
Kent County Spotlight
Important local factors for Dover & surrounding areas.
🏥 Hospital Networks
If you choose a Medicare Advantage (Part C) plan, ensure your preferred local hospitals are in-network. Major providers in our area include Bayhealth Hospital (Kent Campus) in Dover and its surrounding network facilities.
💰 Local Pricing
If you opt for Original Medicare + Medigap, be aware that Medigap premiums are often rated by your specific zip code (e.g., 19901). It pays to shop around with different insurance carriers licensed in Delaware.
🤝 Trusted Local Guidance
Medicare can be complicated, but you don't have to navigate it alone. Reach out to a trusted local broker like Robert N. Heck for personalized, one-on-one help finding the right coverage for your specific needs here in Kent County.