Medicare isn't one program — it's four distinct pieces of coverage, each with its own rules. Get comfortable with these before anything else, because every later module is built on this vocabulary.
HOSPITAL INSURANCE
Part A
Inpatient hospital stays, limited skilled nursing facility care, hospice, and some home health.
Premium
$0 for most people (40+ work quarters). Those with fewer quarters can pay up to $565/mo in 2026.
Deductible
$1,736 per benefit period (2026) — not annual, it resets each time a new benefit period starts.
Coinsurance
$434/day for hospital days 61–90; $868/day for lifetime reserve days; $217/day for SNF days 21–100.
MEDICAL INSURANCE
Part B
Doctor visits, outpatient care, preventive services, and durable medical equipment.
Premium
$202.90/mo standard (2026). Higher-income beneficiaries pay more via IRMAA — up to $689.90/mo above $109,000 individual / $218,000 joint income.
Deductible
$283 annual (2026).
Coinsurance
Typically 20% of the Medicare-approved amount after the deductible, with no annual out-of-pocket cap on its own.
MEDICARE ADVANTAGE
Part C
Not a separate benefit — a private-plan alternative that bundles Part A and B (almost always Part D too) into one plan with its own network, costs, and extra benefits.
Premium
Set by the plan — many are $0/mo, some carry a premium on top of the standard Part B premium.
Cost structure
Plan-specific copays and coinsurance, capped by an annual out-of-pocket maximum (MOOP) the plan must set.
Why it matters
This is where Modules 05–08 live — it's a bundle and a trade-off, not a fifth kind of coverage, and inside it there are real sub-decisions: plan type, SNP eligibility, and MAPD vs. MA-only.
PRESCRIPTION DRUGS
Part D
Covers prescription drugs through a plan-specific formulary — a tiered list of what's covered and at what cost.
Premium
Averages around $34.50/mo in 2026, but varies widely by plan.
Deductible
Up to $615 max (2026) — some plans set it lower or waive it.
Out-of-pocket cap
Hard cap of $2,100/year (2026) on covered drugs. After that, the plan pays 100% for the rest of the year. Insulin is separately capped at $35/month.
Standalone vs. bundled
A standalone PDP if staying on Original Medicare, or bundled into an MA plan (MAPD). Generally not both at once — see Module 07 for when that split actually matters.
Worth knowing
The old Part D "donut hole" is gone. Since 2025, the benefit runs in three phases — deductible, initial coverage, then catastrophic (the client pays $0 once they hit the cap). If a client mentions the donut hole, that's a good moment to tell them what's actually changed.
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