Your Medicare & Medicaid
Questions, Answered

Medicare is a federal health insurance program primarily for Americans 65 and older. It also covers younger people with certain qualifying disabilities, End-Stage Renal Disease (ESRD), or ALS (Lou Gehrig's Disease). You typically become eligible at 65 if you or your spouse worked and paid Medicare taxes for at least 10 years (40 quarters). SSDI recipients become eligible after receiving disability benefits for 24 months.

Medicare has four main parts: Part A (hospital insurance — inpatient care, SNF, hospice), Part B (medical insurance — outpatient care, doctor visits, preventive services, DME), Part C (Medicare Advantage — private plan that bundles A+B and usually D), and Part D (prescription drug coverage). Medigap (Medicare Supplement) is a separate private policy that fills cost gaps left by Original Medicare.

Original Medicare does not cover routine dental care, routine eye exams or glasses, hearing aids, most long-term custodial care (nursing home), cosmetic procedures, or care outside the U.S. Many Medicare Advantage plans do cover dental, vision, and hearing. Long-term care is covered by Medicaid for those who financially qualify.

No — they are two different ways to get Medicare coverage. Original Medicare (Parts A and B) is run by the federal government and lets you see any provider nationwide who accepts Medicare. Medicare Advantage (Part C) is run by private insurers approved by Medicare, typically uses a network, and often includes extra benefits. Neither is universally better — the right choice depends entirely on your individual situation.

Original Medicare does not cover routine dental, vision, or hearing care. However, many Medicare Advantage (Part C) plans include these benefits — often with $0 copays for preventive dental visits, annual eye exams, allowances for glasses or contacts, and hearing aid benefits. We specifically look for plans that include these extras when comparing options for our clients.

Your Initial Enrollment Period (IEP) is 7 months long: it begins 3 months before your 65th birthday month and ends 3 months after. Ideally, enroll during the 3 months before your birthday so coverage starts on time. If you're still covered by a large employer plan when you turn 65, different rules may apply — and getting it wrong can lead to gaps in coverage or permanent penalties. Call us before making this decision.

Missing your Part B enrollment window triggers a permanent 10% per-year premium penalty that lasts for as long as you have Medicare. You would also have to wait until the General Enrollment Period (January 1–March 31) with coverage starting July 1. Part D has a similar 1% per-month penalty. Our agents proactively track enrollment deadlines to ensure no client ever faces these penalties.

A Special Enrollment Period allows you to enroll in or change Medicare coverage outside standard windows when a qualifying life event occurs. Common triggers include: losing employer or union coverage, moving out of your plan's service area, gaining or losing Medicaid eligibility, or qualifying for Extra Help. You typically have 60 days from the event to act. Contact us immediately if you experience a qualifying event.

Annual Open Enrollment (AEP) runs October 15 – December 7 each year. During AEP you can: switch between Original Medicare and Medicare Advantage, change Medicare Advantage plans, join or switch a Part D drug plan, or drop Part D coverage. Changes take effect January 1. There is also a Medicare Advantage Open Enrollment Period (OEP) January 1–March 31, during which Advantage enrollees can make one plan change.

Yes — if you're covered by a group health plan from an employer with 20 or more employees (based on your own current work or your spouse's), you may delay Part B enrollment without penalty. However, COBRA, retiree coverage, marketplace plans, and coverage from employers with fewer than 20 employees do NOT count as qualifying coverage for this purpose. The rules are complex and mistakes are costly — we recommend calling us before making this decision.

Medicare Advantage (Part C) is offered by private insurers and bundles Parts A, B, and usually D into one plan. Many have $0 premiums, include extra benefits (dental, vision, fitness), and set an annual out-of-pocket maximum. However, they use provider networks and may require referrals to specialists. Original Medicare lets you see any provider nationwide but has no out-of-pocket cap and doesn't cover extras. We compare both paths for every client.

Medigap and Medicare Supplement are the same thing — just different names for the same product. These are private policies that fill the "gaps" in Original Medicare, such as the Part A deductible, Part B coinsurance, and skilled nursing coinsurance. Plans are standardized A through N, meaning Plan G offers the same benefits regardless of which insurance company sells it. We shop purely on price to find the lowest rate available for your age and zip code.

Keeping your preferred physicians is always our first priority. For Medicare Advantage plans, we verify in-network status for every doctor you care about before recommending a plan. For Original Medicare with Medigap, you can see any doctor in the country who accepts Medicare — no network restrictions at all. We never recommend a plan that would force you to give up a doctor you rely on.

A Dual Special Needs Plan (D-SNP) is a Medicare Advantage plan for people who qualify for both Medicare and Medicaid — called "dual eligibles." These plans coordinate benefits from both programs, often providing comprehensive coverage with $0 premiums, $0 copays, and extra benefits like dental, vision, OTC allowances, and transportation. This is one of the most valuable and underutilized benefits available. If you think you might qualify, call us — we check eligibility for free.

Most Medicare Advantage plans do not cover care received outside the U.S., with the exception of emergency care within 100 miles of the U.S. border. Some Medigap plans (C, D, F, G, M, N) include a foreign travel emergency benefit covering 80% of emergency care costs abroad after a $250 deductible, up to a $50,000 lifetime limit. If you travel internationally frequently, we factor this into our plan recommendations.

Medicare is a federal program based on age or disability — you earn it through work history. Medicaid is a joint federal-state program based on financial need — income and assets are the primary factors. Medicaid covers things Medicare doesn't, including long-term custodial nursing home care. Eligibility and benefits vary significantly by state. Some people qualify for both programs — called "dual eligibles" — and can receive outstanding combined coverage through D-SNP plans.

Medicaid eligibility is primarily based on income and, in some cases, assets. In states that expanded Medicaid under the ACA, adults with income at or below 138% of the Federal Poverty Level (roughly $20,783/year for an individual in 2024) generally qualify. Special rules apply for seniors, people with disabilities, pregnant women, and children. The fastest way to find out is to call us — we run a free eligibility check in minutes.

Extra Help (also called the Low Income Subsidy or LIS) is a federal program that helps people with limited income and resources pay Part D costs — including premiums, deductibles, and copays. Those who qualify for Full Extra Help may pay $0 for their Part D plan premium and as little as a few dollars per prescription. Medicaid recipients are typically automatically eligible. We check every client for Extra Help eligibility during our free consultation.

Yes — Medicaid is the primary payer for long-term custodial care in nursing homes. Medicare only covers skilled nursing facility care for up to 100 days following a qualifying hospital stay, and only when skilled care (not just custodial care) is needed. For ongoing nursing home stays, Medicaid provides coverage for those who meet income and asset requirements. Planning ahead for long-term care Medicaid eligibility is complex — call us to discuss your options.

Part A is $0 for most people who worked 40+ quarters. The standard Part B premium for 2026 is $185.00/month (higher for higher incomes due to IRMAA). Medicare Advantage plans typically add $0 on top of Part B. Medigap plans range from $80–$300+/month depending on plan type, age, and location. Part D drug plans start around $10–$15/month. Premiums are updated annually by CMS and may vary. We calculate your total expected annual cost across all options before you make any decision.

IRMAA (Income-Related Monthly Adjustment Amount) is an additional premium surcharge for Part B and Part D applied to higher-income beneficiaries. In 2026, it kicks in for individuals with income above $103,000 ($206,000 for joint filers). IRMAA is based on your income from two years prior. If your income has decreased since then due to retirement or other life events, you may qualify for an IRMAA appeal. We help clients navigate this process.

Don't pay a confusing Medicare bill without understanding it first — billing errors are far more common than most people realize. If you're a client of ours, contact your dedicated agent immediately and we'll review the bill, identify any errors, and help you dispute anything incorrect with the insurer or provider. If you're not yet our client, call us anyway — we're happy to help review it at no charge.

Yes, truly. We are paid by insurance carriers when we successfully enroll a client — this is standard practice for licensed Medicare brokers and is regulated by CMS. Federal law requires that your monthly premium be exactly the same whether you use a broker or enroll directly. There are no consultation fees, no hidden charges, and no obligation to enroll in any plan we show you. Our incentive is your satisfaction — that's what keeps clients referring their families to us.

Absolutely not — enrollment is the beginning, not the end, of our relationship. Your dedicated agent remains your year-round contact for billing questions, coverage disputes, medication changes, finding in-network specialists, and anything else that comes up. Every fall we proactively reach out to review your plan and check whether a switch would save you money or improve your coverage for the coming year.

Getting started takes about 2 minutes. You can call or text us at (571) 992-9195, email info@capitalcoveragegroup.com, or fill out the contact form on our website. We'll schedule a brief, no-pressure conversation at your convenience. It helps to have a list of your current medications, your preferred doctors, and an estimate of your income — but we can work with whatever you have, including nothing at all.

We are licensed in multiple states including Virginia, Maryland, Washington D.C., Pennsylvania, Delaware, and North Carolina. If your family member lives in one of our licensed states, we can absolutely help them. If they're in a state we're not yet licensed in, we can refer them to a trusted independent broker in their area. Call us and we'll figure out the best path forward.