State Health Insurance Program (SHIP)

If you are turning 65 and not covered by an employer plan:

Enroll in Medicare Parts A and B

Decide if you would like to get Medicare through Original Medicare or an Advantage plan (see FAQ titled “What are Original Medicare and Medicare Advantage Plans?”)

Enroll in a Drug plan or an Advantage plan

Enroll in a Medigap policy if you would like supplemental coverage instead of an Advantage plan

If you are turning 65 and covered by a small employer plan:

Enroll in Medicare Parts A and B

Decide if you would like your employer insurance to act as your supplement and prescription drug plan or if you prefer to purchase them on your own.

If you choose to purchase them on your own, decide if you would like to get Medicare through Original Medicare or an Advantage plan (see FAQ titled “What are Original Medicare and Medicare Advantage Plans?”)

Enroll in a Drug plan or an Advantage plan

Enroll in a Medigap policy if you would like supplemental coverage instead of an Advantage plan

If you are turning 65 and covered by a large employer plan:

See the relevant questions under the FAQ “When and how do I enroll in Medicare?”.

Medicare is a federal health insurance program for people age 65 or older, for certain younger people with disabilities, and for people with end-stage renal disease.

What does Medicare Part A cover?

• Inpatient hospital care

• Skilled nursing facility care (short term). Only if you were first admitted to the hospital as an inpatient for 3 days

• Medically necessary home health care. Only if you were first admitted to the hospital as an inpatient for 3 days

Hospice care

What does Medicare Part B cover?

Part B covers outpatient health care:

• Medically necessary services, such as doctors’ visits, lab tests, x-rays, ambulance transport, durable medical equipment, diabetic supplies, mental health services

• Preventive services

To find out if a test, item or service is covered go to: https://www.medicare.gov/cover...

Medicare Part B does not cover every possible medical expense. Here’s a partial list of what Part B doesn’t generally cover:

• Routine dental care

• Routine vision care

• Most prescription drugs you take at home. (These are covered under Part D). Medicare Part B may cover certain medications administered to you in an outpatient setting.

• Hearing aids

• 24-hour home health care

• Long-term care, such as you might get in a nursing home. If the only care you need is custodial, meaning help with tasks such as bathing and dressing, Medicare doesn’t generally cover it.

What is Medicare Part C?

Part C is also known as an Advantage Plan

What does Medicare Part D cover?

Part D covers prescription drugs

Original Medicare is the name for Medicare managed by the federal government.

What is an Advantage Plan?

Advantage plans (also known as Part C) are an alternative way to get Medicare. They are sold by private health insurance companies who administer Medicare for the federal government.

Advantage plans must cover the same services as Original Medicare (Medicare administered by the federal government) BUT they do not have to cover the services at the same rates. (For example, they can cover Part B services at 70% or with a flat rate co-pay, etc.)

You will still need to have Medicare Part A and pay a monthly premium for Part B.

In Vermont, Advantage plans include a prescription drug plan.

What is the difference between Original Medicare and Medicare Advantage Plans?

Original Medicare is the traditional program offered directly through the federal government, while Medicare Advantage are private plans that contract with the federal government to provide Medicare benefits.

Original Medicare includes Part A and Part B. Most doctors in the United States take Original Medicare.

Medicare Advantage Plans are commonly either HMO (Health Maintenance organization) or PPO (preferred provider organization) or PFFS (Private Fee-for-Service). Plans must cover the same benefits offered by Original Medicare, but they may apply different rules, costs, and restrictions. They also may offer certain benefits that Original Medicare does not. You will still need to have

Medicare Parts A and Parts B.

With Original Medicare you can see any provider and use any facility that accepts Medicare; with Medicare Advantage plans you may need to use doctors and hospitals in the plan’s network.

Original Medicare does not require referrals for specialists; Medicare Advantage Plans may require a referral to see a specialist.

Medicare Advantage Plans may cover additional services, such as vision, hearing and/or dental; Original Medicare does not cover these services.

If I enroll in an Advantage Plan, can I change to Original Medicare at a later date?

Yes, but there are limitations

12 month Trial period

Only available to those who enroll in an Advantage plan when they are first eligible for Medicare or if they drop a Medigap policy to enroll in an Advantage plan for the first time.

Fall Open Enrollment

October 15 – December 7 you can drop an Advantage Plan and return to Original Medicare with a Jan 1 change date

Medicare Advantage Open Enrollment

January 1 – March 31 with the change taking effect the 1st of the following month

However, if you don’t qualify for the 12 month Trial Period, you may not find a Medigap plan that will take you as you will be outside of “guaranteed issue” for Medigap plans.

Do I have to choose between buying and Advantage plan and Original Medicare with a Medigap plan/supplement?

You are not required to buy either a Medigap plan or an Advantage plan. If you have neither, you will be responsible to pay the portion that Medicare does not cover out-of-pocket unless you qualify for financial assistance.

Most people do not pay a monthly premium for Part A.

If you or your spouse worked and paid Medicare taxes for 10 years, you won’t have to pay a premium for Part A

If you didn’t pay Medicare taxes for long enough, you may have to pay a premium for Part A.

Part A has a hospital stay deductible. In 2026 the deductible is $1736 per benefit period. This covers the beneficiaries’ share of costs for the first 60 days of Medicare-covered inpatient hospital care. A benefit period starts the day you are admitted to the hospital and ends 60 days after discharge.

How much does Medicare Part B cost?

Most people pay a monthly premium for Medicare Part B. In 2026 the standard premium is $202.90/month. You could pay more than that (IRMAA) if your income is higher than a certain amount, (in 2026: $109,000 for an individual and $218,000 for a couple filing jointly) and less if you qualify for state-based help if your income is lower than a certain amount.

A Part B deductible applies to some covered services. In 2026 the annual Part B deductible is $283.

After you pay your deductible, Medicare Part B generally pays 80% of approved costs of covered services, and you pay the other 20%. Some services, like flu shots, may cost you nothing.

It varies. In 2026 premiums range from $8.40 month - $238.60/month.

IRMAA stands for Income-Related Monthly Adjustment Amount

Individuals with income over $109,000/year and couples with income greater than $218,000/year in 2026 pay an additional amount above the cost of their Part B and Part D premiums. This extra amount is paid directly to Medicare, not the prescription plan.

How do I know if I will have to pay an IRMAA?

Social Security will contact you, based on your income. Medicare uses the modified adjusted gross income reported on your IRS tax return from 2 years ago.

What if my income goes down, i.e. I retire? Will I still have to pay the IRMAA?

You will need to fill out form SSA-44 to request a reduction in your IRMAA

Medicare Part D is prescription drug coverage through private insurers

How do I know which prescription drug plan is the best for me?

Choose a plan based on the prescriptions you take.

Go to the medicare.gov website for plan comparison and enrollment.

Watch our video to learn how to choose the Part D prescription drug plan that works best for you

What if I don’t take any prescriptions and want to enroll at a later date?

If you take no prescriptions and do not enroll in a prescription drug plan when first eligible, and you choose to enroll at a later date, you will have a lifetime late enrollment penalty added to your monthly premium. The cost is calculated by multiplying 1% of the national average premium times the number of uncovered months you didn’t have Part D or creditable coverage.

When should I enroll?

If you are turning 65, you have a 7 month time period starting 3 months before the month you turn 65, your birthday month, and continuing 3 months after the month you turn 65.

You may also qualify for a Special Enrollment Period, for example if you are losing coverage from your or your spouse’s employer.

How do I enroll in a prescription drug plan?

Go to www.medicare.gov for plan comparison and enrollment.

The Southwestern Vermont on Aging can assist with Part D plan comparison and enrollment: Call our Helpline 1-800-642-5119

Can I change plans?

Every year during Open Enrollment, Oct 15 – Dec 7, you have the opportunity to change prescription drug plans.

How much do prescription drug plans cost?

It varies. In 2026 premiums range from $8.40/month - $238.60/month.

What is the Late Enrollment Penalty?

If you do not enroll in a Part D plan when first eligible, a penalty of 1% per month for each month of non-enrollment will apply for the rest of your life.

When enrolling in Medicare Part A:

You usually have a 7 month Initial Enrollment Period beginning 3 months before the month you turn 65, the month you turn 65, and ending 3 months after the month you turn 65.

Most people enroll in Medicare Part A when they turn 65, even if they have health insurance from an employer. This is because most people paid Medicare taxes while they worked and therefore do not pay a monthly premium for Part A.

However, if you or your employer contribute to an HSA you may want to delay enrolling in Medicare Part A. Once you have Medicare neither you nor your employer are allowed to contribute to an HSA. However, you may continue to withdraw money from your HSA.

When enrolling in Medicare Part B:

Most people enroll in Part B when they turn 65 unless they have insurance from their or their spouse’s current large employer. (20 employees or more)

If you are insured through an employer with fewer than 20 employees, you should enroll in Medicare when you turn 65. In this case Medicare will be your primary insurance and your employer insurance will pay second.

How do I enroll in Parts A and B?

If you are already collecting Social Security at least 4 months before you turn 65, you will be automatically enrolled and do not need to do anything. You will get a “Welcome to Medicare” package and your Medicare card in the mail about 3 months before your 65th birthday. If you do not receive your Medicare card, contact Social Security.

If you are not getting Social Security benefits you will need to submit an application for Medicare to Social Security. You have 2 options:

Apply online: www.ssa.gov

Call Social Security: 1-866-690-1944 Rutland Office

Can I enroll in Part A but delay Part B until I retire?

Yes, if you are insured by a large employer.

I already have Part A. How do I enroll in Part B?

Apply online: ssa.gov

Call Social Security: 1-866-690-1944 Rutland Office

Do I need to enroll in Part A and/or Part B if I am covered by my or my spouse’s insurance from work?

If you are covered under an employer’s or union-based health insurance plan through your or your spouse’s employment, and the employer has 20 employees or more, you DO NOT have to enroll in Medicare Part A or Part B. You will not pay a penalty when you enroll in Part B as long as you enroll within 8 months of losing your coverage. You will want to plan ahead and enroll in Part B a month before you stop working or your employer coverage ends, so you don’t have a gap in coverage.

If you are covered under an employer’s or union-based health insurance plan through your or your spouse’s employment, and the employer has fewer than 20 employees, you DO have to enroll in both Medicare Part A and Part B when you turn 65. In this case

Medicare will be your primary insurance and your employer insurance will be secondary.

These rules are only for coverage by insurance when you or your spouse are actively working, not for retiree insurance coverage.

I have an HSA (Health Savings Account). Does that make a difference?

YES! Once you enroll in Part A neither you nor your employer will be able to contribute to your HSA. If you would like to continue making contributions to your HSA, you can delay both Parts A and B until you (or your spouse) stop working or lose that employer coverage. You will NOT pay a penalty for delaying Medicare as long as you enroll within 8 months of losing your coverage or stopping work (whichever happens first.)

Note: Once you enroll in Part A, it will start up to 6 months retroactively. You should stop making contributions to your HSA 6 months before you enroll in Part A.

I have an HRA (Health Reimbursement Account). Does that make a difference?

No

How do I enroll in an Advantage plan?

You can enroll on the medicare.gov website, or through an insurance agent.

When can I enroll in an Advantage plan?

You usually have a 7 month Initial Enrollment Period beginning 3 months before the month you turn 65, the month you turn 65, and ending 3 months after the month you turn 65.

You may also qualify for a Special Enrollment Period, for example if you are losing coverage from your or your spouse’s employer.

Every year during Open Enrollment, Oct 15 – Dec 7, you have the opportunity to join or change Advantage plans, or change from

Original Medicare to an Advantage plan or vice versa.

When should I enroll in Part D?

If you are turning 65, you have a 7 month time period starting 3 months before the month you turn 65, your birthday month, and continuing 3 months after the month you turn 65.

You may also qualify for a Special Enrollment Period, for example if you are losing coverage from your or your spouse’s employer.

How do I enroll in Part D?

Go to www.medicare.gov for plan comparison and enrollment.

Southwestern Vermont Council on Aging can assist with Part D plan comparison and enrollment: Call our Helpline 1-800-642-5119

If you are under 65 and disabled, you are eligible for Medicare when you have received Social Security Disability Insurance checks for at least 24 months.

How do I enroll in Medicare?

You will be automatically enrolled in Medicare Parts A and B at the beginning of the 25th month that you receive an SSDI check.

Will I need to enroll in anything else?

Yes, you will need to enroll either in a prescription drug plan or an Advantage plan. You may also choose to purchase a supplement. You will not be automatically enrolled in any of these.

What else will I need to know?

You may be eligible for financial assistance with your Part B premium and/or your prescription drug plan premium, including Medicaid for the Working Disabled. See the Financial Assistance section.

Whether or not you purchase a Medigap plan/Supplement (see Medigap Plans/Supplements section) now, you will be eligible to purchase one or change plans once you turn 65.

Medigap plans, also known as Medicare supplement plans, help cover some of the costs Medicare Parts A and B do not cover and you must pay.

How do I choose a Medigap plan?

Medigap plans are standardized policies identified by letters, A-N. The plans are standardized, meaning Plan A offers the same coverage no matter which state you live in when you purchase it, or which insurance company you purchase it from.

Each letter plan offers different coverage and has different out of pocket costs.  See and Compare Medigap Policies 

How much do Medigap plans cost?

Current prices are listed on the VT Department of Financial Regulation website: Medicare Supplemental Rates

Who should buy a Medigap plan?

If you are enrolled in Part B and you want help paying some of the health care costs that Medicare doesn’t cover.

Am I required to buy a Medigap plan?

You are not required to buy a Medigap plan or an Advantage plan. You will be responsible to pay the portion that Medicare does not cover out-of-pocket unless you qualify for financial assistance.

What if I cannot afford to buy a Medigap plan?

Medicaid can cover some of Medicare’s out of pocket costs. Medicaid has income and resource limits. Green Mountain Care

The Medicare Savings Programs have income eligibility limits and can help pay some of Medicare’s costs, including the Part B premium. Medicare Savings Programs

You may qualify for patient financial assistance through your local hospital to help cover the portion of your bill that Medicare does not cover.

Do I need a Medigap plan if I have other coverage?

You may not need a Medigap plan if you have other health insurance, such as from an employer, military retiree, employer retiree coverage, or if you also have Medicaid.

Can I buy a Medigap plan at any time?

The best time to buy a plan is when you first enroll in Part B or up to 6 months after. If you enroll in a plan during this period, the insurer cannot refuse to sell you a plan.

After 6 months have passed, the insurer can refuse to sell you a Medigap plan.

Can the insurance company drop me?

Once you buy a Medigap plan, the insurance plan must continue to renew it as long as you pay your premiums on time.

Can I change plans?

Yes, you can change plans. However, your options may be limited depending on whether it has been more than 6 months since you enrolled in Part B. After 6 months no insurer has to sell you a plan.

How do I enroll in a Medigap plan?

You need to contact the insurance company directly.

Medicare health and drug plans can make changes each year, including costs, coverage, and what providers and pharmacies are in their networks. Medicare Open Enrollment is an annual period of time (October 15 – December 7) when current Medicare users can choose to re-evaluate their Medicare coverage and make changes for the following year.

When is Open Enrollment?

Every year from October 15 – December 7

What can I change during Open Enrollment?

You can change from your current prescription drug plan to a different one.

You can change from your current Advantage plan to a different one.

You can change from your current Advantage plan to Original Medicare with a prescription drug plan or vice versa.

When do the changes take effect?

Jan 1 of the following year.

How do I know if I need to change plans?

People in a Medicare health or prescription drug plan should always review the materials their plans send them, like the “Evidence of Coverage” (EOC) and “Annual Notice of Change” (ANOC). If their plans are changing, they should make sure their plans will still meet their needs for the following year. If they’re satisfied that their current plans will meet their needs for next year and it’s still being offered, they don’t need to do anything.

How do I compare plans?

The www.medicare.gov website

Call the Southwestern Vermont Council on Aging Helpline: 1-800-642-5119

Medicaid can cover some of Medicare’s out of pocket costs, including the Part B premium, Medicare co-pays and deductibles. Medicaid has income and resource limits. Green Mountain Care

You can find the application here: https://dvha.vermont.gov/sites...

You can find the application here: https://www.greenmountaincare....

Yes!

Social Security offers Extra Help with Medicare Prescription drug plan costs: Apply for Medicare Part D Extra Help program

Vermont Pharmacy Program helps pay for prescription drug plan costs: Vermont Medicaid Programs

You can find the application here: Vermont Medicaid Application (Note: this application will also determine whether you qualify for a Medicare Savings Program)

Is there any financial assistance available to pay for my Medigap or supplement premium?

No, however if you qualify for Medicaid it will act as a supplement and you will not need to purchase a Medigap plan.

Take one of our “New to Medicare” classes: call our Helpline 1-800-642-5119 OR 802-786-5990 OR 802-442-5436