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Medicare, Medicaid, and Other Government Healthcare ProgramsBe informed guide
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Medicare Overview

Medicare is a government-funded and run health insurance program for eligible individuals.*


To be eligible you must be:

  • 65+ years old and eligible for Social Security retirement benefits
  • OR have collected Social Security Disability Insurance (SSDI)† more than 24 months
  • OR have been diagnosed with end stage renal disease (ESRD) or ALS
*You must  also meet immigration requirements
†The Social Security Disability Insurance (SSDI) program provides financial assistance to people with disabilities. SSDI pays benefits to you and certain members of your family if you are “insured,” meaning that you worked long enough and paid Social Security taxes.The Parts of Medicare

What it Is

What it Covers

Part A

Hospital Insurance

Hospital care, skilled nursing facilities, hospice, and home health services

Part B

Medical Insurance

Services from doctors, preventative care, out-patient care, lab tests, mental health care, ambulance services, and durable medical equipment

Part C

Medicare Advantage

Part C is an alternative to Part A & B and it includes the benefits and services covered under Parts A & B, and usually Part D.

Part D

Prescription Drug Coverage

All plans must cover a wide range of prescription drugs that people with Medicare take, including most drugs in certain protected classes, like drugs to treat cancer or HIV/AIDS.

Part A + Part B are referred to as Original Medicare
*You must  also meet immigration requirements
†The Social Security Disability Insurance (SSDI) program provides financial assistance to people with disabilities. SSDI pays benefits to you and certain members of your family if you are “insured,” meaning that you worked long enough and paid Social Security taxes.
Medicare Part A: Hospital Insurance
Covered Services In-patient Hospital Care

Part A typically covers in-patient hospital care if you are admitted to a hospital as an in-patient after an official doctor’s order and the hospital accepts Medicare.

 Skilled Nursing Facility (SNF) Care

Part A typically covers SNF care for a limited time if you have days left in your benefit period to use, and you have a qualifying
in-patient hospital stay (typically 3 days).

 Home Health Services

Part A and/or Part B cover eligible home health services including, but not limited to, physical therapy, occupational therapy, speech-language pathology services, and medical social services.

 Hospice Care

Part A typically covers hospice care if your hospice provider and regular doctor certify that you’re terminally ill, with a life expectancy of 6 months or less, you accept comfort care (palliative care), and sign a statement choosing hospice care instead of other treatments for your illness.

Part A Costs
Premium
  • You usually don’t pay a monthly premium for Medicare Part A coverage if you or your spouse paid Medicare taxes for a certain amount of time while working. This is sometimes called “premium-free Part A”
  • If you haven’t paid into the system, the Part A monthly premium can be up to $565*.
Deductible
  • The deductible per benefit period† is $1,736*.
Out-of-Pocket Costs
  • You may also be responsible for paying a cost-share depending on the number of days spent in a hospital, skilled nursing facility, or hospice care.
Penalties
  • If you didn’t get Part A when you were first eligible, there may be a penalty added to your Part A premium.
*Please Note: These values are based on 2026 Medicare costs
†A benefit period begins the day you're admitted as an in-patient in a hospital or skilled nursing facility (SNF). The benefit period ends when you haven't gotten any in-patient hospital care (or skilled care in an SNF) for 60 days in a row. If you go into a hospital or an SNF after one benefit period has ended, a new benefit period begins. You must pay the in-patient hospital deductible for each benefit period. There's no limit to the number of benefit periods.
Medicare Part B: Medical Insurance
Covered ServicesMedically Necessary Services

Services or supplies that are needed to diagnose or treat your medical condition.

Preventative Services

Health care to prevent illness or detect it at an early stage

Part B Covers Things Like: Ambulance Services Mental Health (In-patient and Out-patient) Durable Medical Equipment X-rays, Blood Tests, and other types of scans Doctor and Other Health Care Provider Services
Part B Costs
PremiumGenerally, $202.90* (there are some exceptions for higher incomes)Deductible$283*Out-of-Pocket CostsThe co-insurance for Part B coverage is 80/20, which means that once you have paid your deductible, Medicare will cover 80% of your health care costs and you will be
responsible for 20%. With Part B coverage, there is NO out-of-pocket maximum.PenaltiesIf you didn’t get Part B when you were first eligible, there may be a penalty added to your Part B premium.
*Please Note: These values are based on 2026 Medicare costs
Medicare Part D: Prescription Drug Coverage
Covered Services

Medicare Part D coverage helps pay for prescription drugs.

  • Part D plans are offered by private insurance companies. 
  • Part D plans add drug coverage to Original Medicare. You must have Medicare Part A and/or Part B to join a separate Medicare drug plan.
Part D Costs
PremiumThe premiums vary by plan (average estimated cost = $34.50/month*). Premiums are higher for people with higher incomes.Deductible$615*Out-of-Pocket CostsAfter paying your deductible (maximum $615 out-of-pocket) Part D covers 75% of your drug costs, and you pay 25%. Once your total out of pocket drug costs reach the $2,100 out-of-pocket maximum, Part D pays any remaining drug costs for the year.PenaltiesIf you do not sign up for a Part D plan when first eligible, you pay a late enrollment penalty for life. The cost of the late enrollment penalty depends on how long you went without Part D or creditable prescription drug coverage.
*Please Note: These values are based on 2026 Medicare costs

To learn more about Medicare changes in 2026 that may lower your prescription drug costs visit: https://www.myhealthcarefinances.com/health-insurance/important-changes-to-medicare-in-2026

Medicare Part C: Medicare Advantage
Covered Services

Part C is an alternative to Parts A and B and includes benefits and services covered under Parts A and B, and usually Part D.

  • Plans are offered by Medicare-approved private insurance companies that must follow rules set by Medicare.
  • If you join a Medicare Advantage Plan, you’ll still have Medicare, but you’ll get your Part A and Part B coverage from your Medicare Advantage Plan, not Original Medicare.
  • Medicare Advantage Plans are usually HMOs* or PPOs †.
Includes:
Part A

Hospital Insurance
Part B

Medical Insurance

May also include:
Part D

Prescription Drug Coverage
Part B

Vision, Hearing and/or Dental

*Your health care services start with your primary care physician, and you usually need a referral for your care to be covered with specialty health care providers, except in an emergency. For example, if you get a skin rash, you first go to your primary care physician. The primary care physician may refer you to a dermatologist in your network. Generally, HMOs have smaller networks of health care providers, and health care providers outside of your network will not be covered. While you may have less choice in providers, HMOs are often less expensive.
†Generally, you do not need to start with your primary care physician. While most PPOs have some out-of-network coverage, staying inside the network means lower out-of-pocket costs. Typically, PPOs cost more than HMOs, but you have more choice and control. 

Part C Costs
PremiumThe premiums for this plan are the same as Part B ($202.90*) or more, but vary based on the plan you choseDeductible,
Out-of-pocket CostsThe deductibles, cost-share, and out-of-pocket maximums will also depend on your specific plan. In 2026, the highest allowed out-of-pocket maximum for Medicare Advantage plans is $9,250*, but plans may set lower limits.
Please Note: These values are based on 2026 Medicare costs
Medicare Supplemental Insurance (Medigap)
  • A Medigap plan is a supplemental insurance plan, sold by private insurance companies for those who choose Original Medicare (Parts A and B) that will help pay for “out-of-pocket” costs for care under Parts A and B (not D) such as deductibles, co-payments, and co-insurance amounts.
  • You will pay an additional monthly premium for a Medigap plan.
  • Medigap plans are standardized, meaning every health insurance company offers plans lettered A-N, with the same basic benefits, but the premiums and deductibles vary by plan. Some states have different options.
  • If you buy a Part C plan, you are not eligible to buy a Medigap plan.
Summary of Medigap Plans, where the percentage shown is the amount the plan covers
ABCDFGKLMN
Medicare Part A Co-insurance & Hospital Costs (Up to an additional 365 days after Medicare benefits are used)100%100%100%100%100%100%100%100%100%100%
Medicare Part B Co-insurance or Co-payments100%100%100%100%100%100%50%75%100%100%
Blood First 3 Pints100%100%100%100%100%100%50%75%100%100%
Part A Hospice Co-insurance or Co-payments100%100%100%100%100%100%50%75%100%100%
Skilled Nursing Facility Co-insurance100%100%100%100%50%75%100%100%
Medicare Part A Deductible100%100%100%100%100%50%75%50%100%
Medicare Part B Deductible100%100%100%100%
Medicare Part B Excess Charges100%100%100%100%
Foreign Travel Emergency (up to plan limits)80%80%80%80%80%80%
Out-of-Pocket Maximum$8,000*$4,000*
*Please Note: These values are based on 2026 Medicare costs
Medicare Coverage Options
There are 2 “Lanes” You Can Take for Medicare Coverage
Original Medicare
Part A

Hospital Insurance

Part B

Medical Insurance

Do You Want to Add Prescription Drug Coverage?

Part D

Prescription Drug Coverage

Do You Want to Add Supplemental Coverage?

Medicare
Supplemental Insurance

(Medigap plan)

Medicare Advantage Plan
Part C

Combines Part A, Part B, and usually Part D

Please note

  • Most Medicare Advantage plans cover prescription drugs. If you are enrolling in a Medicare Advantage plan and want prescription drug coverage, make sure the plan includes prescription drug coverage or purchase a Medicare Part D plan.

 

  • If you join a Medicare Advantage plan you can’t buy a Medicare Supplemental Insurance (Medigap) policy
Main Enrollment Periods

Initial Enrollment Period (IEP)

Dates

  • Three months before you turn 65, your seven-month period to choose a Medicare plan begins. You can pick a plan anytime during this period; but, if you would like your coverage to begin when you turn 65, sign up during the 3 months before the month you turn 65.
  • Signing up for coverage after the IEP may result in penalty fees.
Eligible for an Initial Enrollment Period:When Benefits Begin:
65+ and eligible for SSA benefits1st day of month you turn 65*
Under 65 with a disabilityAfter receiving SSDI for 24 months
ALSFirst month disability begins

General Enrollment Period

Dates

  • Three months before you turn 65, your seven-month period to choose a Medicare plan begins. You can pick a plan anytime during this period; but, if you would like your coverage to begin when you turn 65, sign up during the 3 months before the month you turn 65.
  • Signing up for coverage after the IEP may result in penalty fees.
Which Plans:General Enrollment Period:When Benefits Begin:
Part A & BJanuary 1st – March 31stJuly 1st

Special Enrollment Period

Dates

You can make changes to your Medicare coverage when certain events happen in your life, like if you move or you loseother insurance coverage. There are 2 primary ways to qualify for a special enrollment period:
     1)Qualifying life events (e.g. you move out of your current plan’s service area)
     2)Working past 65 with creditable insurance coverage, usually from your employer

  • If you have Medicare and experience a Qualifying Event: Enrollment period lasts 2 months
  • If you delayed enrollment past 65 because you had creditable coverage: Enrollment period lasts 8 months after you stop working or lose health insurance through your employer
  • For Medigap plans there may be other cases which qualify as special enrollment periods

Open Enrollment Period

Dates

During the Open Enrolment Period you can check to make sure that your current Medicare coverage still works for you and compare your options. You should consider your prescription drug costs, monthly premiums, network, and formulary when comparing plans.

October 15th – December 7th every year. Changes made to your coverage during the Open Enrollment Period will take effect January 1 of the new year.

Medicaid Overview

What is It?

Medicaid is a joint federal and state funded program that provides free or low-cost health insurance coverage. While the federal government creates some rules for all states to follow, states have flexibility in their Medicaid design.

Who is Eligible?

  • To receive Medicaid, federal law requires states to cover certain groups of individuals, for example:
    • Low-income families
    • Qualified pregnant women and children
    • Individuals receiving Supplemental Security Income (SSI)
  • States may choose to cover other groups.
  • Children whose household income is at or below 138% of the federal poverty level are covered in all states, some states have also chosen to cover adults at this income level (known as expanded Medicaid). 
Please Note:Medicaid is VERY state specific. This content will provide an overview of Medicaid. For state-specific details, please visit your state’s Medicaid website.
Children's Health Insurance Program
  • The Children’s Health Insurance Program (CHIP) is a joint federal and state program that provides health coverage to uninsured children in families with incomes too high to qualify for Medicaid, but too low to afford private coverage.
     
  • States have flexibility to design their own program within federal guidelines, so benefits vary by state and by the type of CHIP program. States may choose between a Medicaid expansion program, a separate CHIP, or a combination of both types of programs.
As of December 2025 40 states (and DC) have adopted and implemented Medicaid Expansion
Medicaid Cost-Sharing
  • States have the option to charge premiums and establish out-of-pocket costs (for example, co-payments, co-insurance, deductibles) for Medicaid enrollees.
  • Maximum out-of-pocket costs are limited, but states can impose higher charges for targeted groups of somewhat higher income people. 
  • Certain vulnerable groups, such as children and pregnant women, are exempt from most out-of-pocket costs.
Premiums
  • States can charge limited premiums and enrollment fees to certain groups of Medicaid enrollees.
  • States have the option to impose higher, alternative premiums to groups of enrollees whose family income exceeds 150% of the federal poverty level.
Prescription Drugs
  • Medicaid rules give states the ability to use out-of-pocket costs to promote the most cost-effective use of prescription drugs.
  • States may establish different co-payments for generic versus brand-name drugs or for drugs included on a preferred drug list.
  • Out-of-pocket costs for drugs may also differ based on the enrollee's income level.
To know more about the specifics of Medicaid Cost-Sharing and how it applies to different groups of Medicaid enrollees, please visit:  https://www.medicaid.gov/medicaid/cost-sharing/index.html
Medicaid Enrollment

When?

Medicaid applications are accepted at any time of the year. As soon as someone thinks they are eligible for Medicaid they can apply right away.

How?

There are 2 main ways to enroll in Medicaid:

  1. Marketplace Portal: You can apply through your state's Health Insurance marketplace. You can always start at www.HealthCare.gov, which will bring you to the appropriate website for your state.
  2. State Medicaid Agency: You can also apply directly with your state's Medicaid agency. For help finding your state's website – visit www.TriageCancer.org/StateResources

When Does Coverage Start and End?

  • Coverage is effective either on the date of application or 1st day of the month of application
  • You may get up to 3 months of retroactive coverage, if you would have been eligible during that period had you applied. Please note: retroactive coverage depends on how you qualify for Medicaid and your state.
  • If you are no longer eligible for Medicaid, coverage generally stops at the end of the month that you lose eligibility.
Military Insurance
TRICAREVeteran Affairs (VA)
What is it?
  • Tricare is the U.S. military's health care program and functions as government-managed health insurance.
  • Coverage may include health plans, special programs, prescriptions, and dental plans.
  • TRICARE is divided into several different types of coverage programs including TRICARE Prime, TRICARE Select, TRICARE for Life, TRICARE Reserve Select, TRICARE Young Adult, and TRICARE Dental Plan.
  • For more general information on Tricare visit: https://www.tricare.mil/
  • For information on TRICARE Retirement Benefits, please visit: https://tricare.mil/LifeEvents/InjuredonAD/TransitionVA/Retiring.aspx
  • Department of Veterans Affairs comprehensive Medical Benefits Package which includes preventative, primary and specialty care, as well as diagnostic, in-patient and out-patient care services.
  • For more general information on the VA, visit: https://www.va.gov/ For more information on VA Benefits for Veterans, visit: https://www.va.gov/opa/publications/benefits_book.asp
Who is eligible?
  • Uniformed Service members and their families National Guard/Reserve members and their families
  • Survivors of deceased Uniform Service members
  • Former spouses
  • Medal of Honor recipients and their families

You may be eligible for VA health care benefits if you served in the active military, naval, or air service and didn't receive a dishonorable discharge.

Dual Eligibility

When leaving active duty, service members may be entitled to, or eligible for, benefits offered by TRICARE AND Department of Veterans Affairs (VA), depending on whether the service member retires or separates.

Indian Health Service (IHS)

The Indian Health Service is the health care system for federally recognized American Indian and Alaska Natives in the United States

  • Comprehensive primary health care and disease prevention services are provided through a network of hospitals, clinics, and health stations on or near Indian reservations.
  • These facilities, which are managed by the IHS, Tribes, and Tribal organizations, are predominately located in rural and primary care settings.
  • In addition, the IHS contracts with urban Indian organizations (UIOs) for health care services provided in some urban centers.
  • For more information visit: https://www.ihs.gov/
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Disclaimer: The information on this site is intended for U.S. residents only and is provided purely for educational purposes. Health, legal, regulatory, insurance, or financial related-information provided here is not comprehensive and is not intended to provide individual guidance or replace discussions with a healthcare provider, attorney, or other experts. All decisions must be made with your advisers considering your unique situation. © Triage Cancer & Pfizer Inc. 2026

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All rights reserved.
Copyright © 2026 Pfizer Inc. All rights reserved. PP-UNP-USA-8120