Medicare Benefits Quick Reference
A personalized reference for understanding your Medicare coverage, key deadlines, and common coordination scenarios
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1 Your Medicare information
Fill in your details so this reference is personalized when you print or save it.
Medicare Advantage details
Medigap supplement details
2 What Original Medicare covers
Important disclaimer
This reference provides general information about Medicare. It is not legal, financial, or clinical advice. Coverage rules change annually. Always verify current details with Medicare (1-800-MEDICARE) or your plan.
| Coverage area | What's included |
|---|---|
| Part A — Hospital Insurance |
Inpatient hospital stays, skilled nursing facility care (limited), hospice care, some home health care.
Key detail: Covers up to 60 days at full coverage (after deductible). Days 61–90 require daily coinsurance (~$434/day in 2026). Lifetime reserve days 91–150 at ~$868/day. After 150 days, you pay all costs.
|
| Part B — Medical Insurance |
Doctor visits, outpatient care, preventive services, durable medical equipment, mental health services, ambulance services.
Key detail: 80/20 split after annual deductible ($283/year in 2026). Medicare pays 80%, you pay 20%. Outpatient surgery, lab tests, and diagnostic tests covered at 80%.
|
Generally NOT covered by Original Medicare:
- Long-term care (custodial / nursing home care)
- Most dental care (cleanings, fillings, dentures)
- Most vision care (eyeglasses, routine eye exams)
- Hearing aids and exams for fitting them
- Care outside the United States (with limited exceptions)
These are general guidelines. Coverage details vary by situation and can change each year. Always verify with Medicare (1-800-MEDICARE / 1-800-633-4227) or your plan before making decisions.
3 Common coordination scenarios
For each situation: what's typically covered, what isn't, and the common gotcha. Add your own notes for your specific situation.
Hospital discharge → home (SNF vs. home health eligibility)
Typically covered
Home health services if you're homebound and need skilled care. SNF care if you had a qualifying 3-day inpatient hospital stay.
Typically NOT covered
Custodial care (help with daily activities only). SNF care without a qualifying inpatient stay. "Observation status" days don't count toward the 3-day requirement.
Common gotcha
Many patients are placed on "observation status" without being formally admitted. This can disqualify you from SNF coverage. Always ask: "Am I admitted as an inpatient?"
Your notes
Doctor retirement / provider transition
Typically covered
Visits with a new Medicare-accepting provider. Records transfer (providers are required to make records available). Transitional care management visits.
Typically NOT covered
Fees some practices charge for copying/transferring records (varies by state). Concierge or direct primary care membership fees.
Common gotcha
Records don't always transfer automatically. Request them in writing before the old practice closes. Confirm the new provider accepts Original Medicare or your specific Advantage plan.
Your notes
Adding or changing specialists
Typically covered
Specialist visits with a Medicare-accepting provider. Original Medicare does not require referrals for most specialists.
Typically NOT covered
Out-of-network specialists under most Medicare Advantage plans. Specialists who have opted out of Medicare entirely.
Common gotcha
Medicare Advantage plans often require referrals and prior authorization for specialists. Check your plan's provider directory first. Going out-of-network may mean paying the full cost.
Your notes
Prescription changes after hospitalization
Typically covered
Medications on your Part D plan formulary. Many plans offer a transition supply (usually 30 days) for new prescriptions after a hospital stay.
Typically NOT covered
Medications not on your plan's formulary. Brand-name drugs when a generic equivalent exists (higher cost-sharing at minimum).
Common gotcha
Hospital doctors may prescribe medications that aren't on your Part D formulary. Check your plan's formulary immediately after discharge. You may need an exception request or a substitute medication.
Your notes
Durable medical equipment (DME)
Typically covered
DME prescribed by a doctor and deemed medically necessary: wheelchairs, walkers, hospital beds, oxygen equipment, CPAP machines. Part B covers 80% after deductible.
Typically NOT covered
Equipment from non-Medicare-enrolled suppliers. Items considered convenience rather than medically necessary. Duplicate equipment.
Common gotcha
You must use a Medicare-enrolled supplier. Many items require prior authorization under Advantage plans. Some equipment is rented, not purchased — after 13 months of rental, you may own it.
Your notes
Annual wellness visit vs. regular checkup
Typically covered
Annual Wellness Visit (AWV) at $0 cost-sharing once per year (after the first 12 months on Part B). Includes health risk assessment, screening schedule review, advance care planning discussion.
Typically NOT covered
A "regular checkup" or "physical exam" is NOT the same as an AWV and is not covered by Original Medicare. If additional tests or services are performed during the AWV, those may trigger separate charges.
Common gotcha
If your doctor addresses a medical complaint during your AWV (not just preventive review), the visit can be "split-billed" — part preventive ($0) and part diagnostic (subject to deductible/coinsurance). Always clarify with the office beforehand.
Your notes
4 Key deadlines & enrollment periods
Missing an enrollment window can mean gaps in coverage or late-enrollment penalties. Keep these dates handy.
| Period | Details |
|---|---|
| Initial Enrollment Period (IEP) |
3 months before → birth month → 3 months after turning 65
7-month window to sign up for Part A and Part B without penalty. Coverage start date depends on which month you enroll.
If you miss this window, you may face late-enrollment penalties and delayed coverage.
|
| General Enrollment Period (GEP) |
Jan 1 – Mar 31 each year
For people who missed their IEP and don't qualify for a Special Enrollment Period. Coverage starts July 1.
Late-enrollment penalty may apply (10% higher Part B premium for each 12-month period you could have had Part B but didn't).
|
| Open Enrollment Period (OEP) |
Oct 15 – Dec 7 each year
Change your Medicare coverage for the following year. Switch between Original Medicare and Advantage plans, change Part D plans, or add/drop coverage.
Changes take effect January 1.
|
| Medicare Advantage Open Enrollment |
Jan 1 – Mar 31 each year
If you're already in a Medicare Advantage plan, you can switch to a different MA plan or return to Original Medicare (and join a Part D plan).
One change allowed during this period. Change takes effect the first of the month after the plan receives your request.
|
| Special Enrollment Periods (SEP) |
Triggered by qualifying life events
Moving to a new area, losing employer coverage, qualifying for Medicaid, or other life changes. Each SEP has its own rules and timeframes.
Contact Medicare (1-800-MEDICARE) or your State Health Insurance Assistance Program (SHIP) to confirm your eligibility.
|
| Medigap Open Enrollment |
6-month guaranteed issue period
Starts the month you turn 65 and are enrolled in Part B. During this window, insurance companies cannot deny you a Medigap policy or charge more because of health conditions.
After this window closes, insurers can use medical underwriting — and may deny coverage or charge higher premiums based on health status.
|
5 When to ask for help
Check any that apply to your current situation.
If you checked any of these, you may benefit from administrative coordination support. Averyn Care navigators help families organize insurance-related paperwork, track pending items, and follow up on coverage questions — so you're not managing the bureaucracy alone.
6 Glossary
Key Medicare terms you'll encounter in plan documents, billing statements, and conversations with providers.
- Beneficiary — A person who has Medicare coverage. Also called a "Medicare beneficiary" or "enrollee."
- Coinsurance — Your share of costs after you've met your deductible, expressed as a percentage. Under Part B, this is typically 20%.
- Copay (Copayment) — A fixed dollar amount you pay for a covered service, often used by Medicare Advantage and Part D plans (e.g., $20 per doctor visit).
- Creditable Coverage — Health coverage (often from an employer) that is at least as good as Medicare's standard benefit. Having creditable coverage lets you delay Medicare enrollment without a late-enrollment penalty.
- Deductible — The amount you pay out of pocket before Medicare starts paying its share. Part A and Part B have separate deductibles.
- Donut Hole / Coverage Gap — A phase of Part D prescription drug coverage where you temporarily pay a higher share of drug costs, after you and your plan have spent a certain amount. The Inflation Reduction Act capped out-of-pocket Part D costs, adjusted annually after 2025 ($2,100 in 2026).
- EOB (Explanation of Benefits) — A statement from your Medicare Advantage or Part D plan explaining what was billed, what the plan paid, and what you owe. (Similar to an MSN for Original Medicare.)
- Formulary — A list of prescription drugs covered by your Part D or Medicare Advantage plan. Drugs are organized into tiers, with different cost-sharing at each level.
- Medigap — Private supplemental insurance that helps pay costs Original Medicare doesn't cover — like coinsurance, copayments, and deductibles. Also called "Medicare Supplement Insurance." Standardized plans are labeled A through N.
- MSN (Medicare Summary Notice) — A statement Medicare sends every 3 months to people with Original Medicare. Lists services and supplies billed, what Medicare paid, and what you may owe.
- Prior Authorization — Approval your plan requires before it will cover certain services, procedures, or medications. Common in Medicare Advantage plans. Failure to get prior auth can result in denial of coverage.
- SNF (Skilled Nursing Facility) — A facility that provides short-term skilled nursing care and rehabilitation after a qualifying hospital stay. Medicare Part A covers up to 100 days per benefit period (with cost-sharing after day 20).
Need help navigating Medicare coordination?
Scan to read our full guide on Medicare benefits — and learn how Averyn Care can help organize your insurance paperwork and follow up on coverage questions.
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