Medicare FAQ

Medicare is a federal health insurance program primarily for people 65 or older. You may also qualify before 65 if you have certain disabilities or End-Stage Renal Disease (ESRD). To get Medicare, you (or your spouse) generally must have worked and paid Medicare taxes for at least 10 years.

Original Medicare (Parts A and B) covers hospital stays (Part A) and outpatient care, doctor visits, and preventive services (Part B). It does not cover prescription drugs, dental, vision, or hearing. You'll need additional coverage, Part D for drugs, and either Medigap or Medicare Advantage for broader coverage.

Part A is free for most people. Part B costs about $202.90/month in 2026 (standard premium). Additional costs depend on your coverage type: Medicare Advantage plans vary widely; Medigap plans add a monthly premium; Part D plans add a drug premium. Your income can also affect your Part B premium (IRMAA surcharges apply above certain income thresholds).

Yes. Medicare is a federal program primarily for people 65+ and is based on your work history. Medicaid is a joint federal-state program for people with limited income and resources, available at any age. Some people qualify for both, they're called dual-eligible beneficiaries.

You have a 7-month Initial Enrollment Period (IEP) around your 65th birthday: 3 months before, your birthday month, and 3 months after. Enrolling before your birthday month means your coverage starts on the first of your birthday month. It's best to enroll 3 months early to avoid any gaps.

Yes, if you have active employer coverage through your own current employment (or a working spouse's employer). In that case, you can delay Part B without penalty and use a Special Enrollment Period when that coverage ends. COBRA, retiree coverage, and marketplace coverage do NOT qualify for this exception.

Missing your Initial Enrollment Period for Part B can result in a permanent late enrollment penalty, 10% added to your Part B premium for each 12-month period you were without coverage. Part D also has a permanent penalty of 1% per month. Penalties add up quickly.

You can enroll online at ssa.gov, by calling Social Security at 1-800-772-1213, or by visiting your local Social Security office. If you're already receiving Social Security benefits, you're usually enrolled automatically. After getting Parts A and B, you work with a licensed agent (like us) to choose your additional coverage.

It depends on your situation. Medicare Advantage typically has lower monthly premiums but network restrictions and costs-sharing when you use care. Medigap has higher premiums but more predictable costs and nationwide coverage. The right choice depends on your health, budget, doctors, and how much you travel. We'll walk you through both options side by side.

No. Medigap works with Original Medicare, not Medicare Advantage. If you're enrolled in a Medicare Advantage plan, you can't use a Medigap policy.

Original Medicare does not include prescription drug coverage. You'll need either a standalone Part D plan (if you have Original Medicare + Medigap) or a Medicare Advantage plan that includes Part D. Some Medicare Advantage plans include drug coverage; others don't, check the plan's Summary of Benefits.

Each plan has an online provider directory. We always check your specific doctors against available plans before making a recommendation, that's part of our free comparison service.

With Original Medicare, you can see any doctor who accepts Medicare, nationwide. With Medicare Advantage, you must stay within the plan's network (or pay more for out-of-network care). We always verify your doctors are in-network before recommending a plan.

You must be enrolled in both Medicare and Medicaid (full or partial). If you receive help from a QMB, SLMB, or QI program, you're partially dual-eligible and may qualify. Contact us or call Idaho Medicaid to confirm your status.

Extra Help (also called the Low Income Subsidy or LIS) is a federal program that helps people with limited income and resources pay for Part D prescription drug costs. It can reduce your drug premiums, deductibles, and copays significantly. Fully dual-eligible individuals qualify automatically.

SHIP stands for State Health Insurance Assistance Program. It's a free counseling service available in every state for people with Medicare. In Idaho, call 1-800-247-4422. SHIP counselors provide unbiased, non-commercial guidance, they don't sell insurance.

In everyday use, no. People say Medicare agent, Medicare broker, and Medicare advisor to mean the same thing: someone licensed by the state to help you compare and enroll in coverage. What actually matters is whether that person is captive or independent. A captive agent works for one insurance company and can only sell you that company's plans. An independent agent or broker is contracted with several companies, so they can compare across them. Payton is independent and contracted with 6 organizations in Idaho. Whichever word you searched to find us, that's the distinction worth asking any agent about.

Nothing. Our consultations are completely free to you. Insurance carriers pay agents a commission when a client enrolls in a plan, so there's no cost to you for our help and no difference in what you pay for the plan.

We represent multiple insurance carriers. We do not offer every plan available in every area, We do not offer every plan available in your area. Currently we represent 6 organizations which offer 27 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.

It helps to have: your Medicare card (Parts A and B), a list of your current medications (with dosages), the names of your doctors and preferred pharmacies, and a rough sense of your monthly budget for insurance costs. Don't worry if you don't have everything, we can work with what you have.

After enrollment, you receive a welcome kit from the insurance carrier with your plan ID card and Summary of Benefits. We're still your point of contact for any questions, billing issues, or plan changes. We also do a review every fall during open enrollment to make sure your plan is still the best fit.