Medicare questions, answered

Medicare has four parts. Part A covers hospital stays, skilled nursing, hospice, and some home health. Part B covers doctor visits, outpatient care, and preventive services. Part C (Medicare Advantage) bundles A and B through a private plan, often with drug coverage. Part D covers prescription drugs. Most people pair Original Medicare (A and B) with a drug plan and a supplement, or choose one Advantage plan instead.

Most people become eligible at age 65. Your Initial Enrollment Period is a 7-month window: the three months before your 65th birthday month, the month itself, and the three months after. You can also qualify before 65 after 24 months of Social Security disability benefits, or right away with ALS or End-Stage Renal Disease. We help Sioux Falls-area folks time this right so coverage starts clean.

Part A is premium-free for most people because you (or a spouse) paid Medicare taxes for at least 10 years (40 quarters) of work. If you didn't, you can still buy in, but you'll pay a monthly premium. Even premium-free Part A has a deductible for each hospital benefit period (verify current figures on Medicare.gov). Part B always has a monthly premium.

Part B has a standard monthly premium set by Medicare each year, plus an annual deductible before most coverage kicks in (verify current figures on Medicare.gov). Higher earners pay more through an income adjustment called IRMAA. After the deductible, you generally pay 20% of the Medicare-approved amount for covered services, which is why many people add a supplement or choose an Advantage plan to cap that exposure.

Original Medicare (Parts A and B) is the federal program; you can see any provider that accepts Medicare nationwide, and you typically add a drug plan and a Medigap supplement. Medicare Advantage (Part C) is a private plan that replaces how you get A and B, usually with a network, often bundling drugs and extras like dental or vision. Each path has trade-offs we walk through together, free.

Original Medicare generally doesn't cover routine dental, vision, or hearing, long-term custodial care, most care outside the U.S., or prescription drugs without a Part D plan. Some Medicare Advantage plans we offer add dental, vision, and hearing benefits. For drugs, you'll want a standalone Part D plan or an Advantage plan that includes them. We help you spot these gaps before they surprise you.

Medicare's Annual Enrollment Period runs October 15 through December 7 every year. During AEP you can switch between Original Medicare and Medicare Advantage, change Advantage plans, or join, drop, or change a Part D drug plan. Changes take effect January 1. This is the main window to review whether your current plan still fits your doctors and prescriptions, and we review the plans we offer with you for free.

From January 1 to March 31, anyone already in a Medicare Advantage plan can make one change: switch to a different Advantage plan, or drop Advantage and return to Original Medicare (and add a Part D plan). It's a one-time do-over each year if your January 1 plan isn't working out. It does not let people on Original Medicare switch into Advantage for the first time.

A Special Enrollment Period lets you change Medicare coverage outside the normal windows after certain life events, such as moving to a new area, losing employer coverage, qualifying for Medicaid or Extra Help, or a plan leaving your county. Each SEP has its own timing and rules. If you've had a recent change in the Sioux Falls area, ask us, it's free to find out which window applies to you.

Not always. If you have qualifying employer coverage through your own or a spouse's active job, you may be able to delay Part B without a penalty and enroll later through a Special Enrollment Period. But not all coverage counts, and small-employer or retiree plans can have different rules. Check before your 65th birthday, a wrong assumption here can trigger lifelong penalties. We'll help you confirm it for free.

If you don't sign up for Part B when first eligible and don't have qualifying employer coverage, the penalty adds 10% to your Part B premium for each full 12-month period you could have had it, and it lasts as long as you have Part B. It's lifelong, so timing matters. If you're unsure whether your current coverage lets you delay safely, ask us before the window closes.

If you go 63 days or more without Part D or other creditable drug coverage after your Initial Enrollment Period, Medicare can add a permanent penalty of about 1% of the national base premium for each month you went without (verify current figures on Medicare.gov). It's added to your drug premium for life. Even if you take no medications today, a low-cost Part D plan usually beats risking the penalty later.

A Medicare Advantage (Part C) plan is offered by a private carrier approved by Medicare. It covers everything Original Medicare does, usually adds prescription drugs, and often includes extras like dental, vision, hearing, or fitness benefits. In exchange, you typically use a network and may need referrals or prior authorization. Premiums can be low or $0 beyond your Part B premium (verify current figures on Medicare.gov), but copays and networks vary, so the details matter.

A $0 premium means you pay nothing extra to the plan beyond your regular Part B premium, which you still owe. It does not mean $0 in costs. You'll still have copays, coinsurance, and an annual out-of-pocket maximum when you use care. In Minnehaha County, $0-premium examples include Aetna Medicare Signature (PPO) and Align ChoicePlus (PPO) from Sanford (verify current plans on Medicare.gov). The network and drug list tell you far more than the premium does.

Medigap is a private policy that works alongside Original Medicare to help pay your share, things like the Part A and B deductibles, copays, and the 20% coinsurance Part B leaves you. Plans are standardized by letter (such as Plan G or Plan N), so the same letter offers the same core benefits from any carrier. You keep access to any provider nationwide that accepts Medicare. Medigap does not include drug coverage, so you'd add Part D.

Both are popular supplements. Plan G covers nearly everything Original Medicare leaves except the Part B deductible, which you pay once a year. Plan N usually has a lower premium but asks you to pay small copays for some office and emergency-room visits and doesn't cover Part B excess charges. Which fits depends on how often you see doctors and your budget. We compare the supplement options we offer so the math is clear, free.

Your best window is the 6-month Medigap Open Enrollment Period that starts when you're 65 and enrolled in Part B. During it, carriers must sell you a policy regardless of health, with no medical underwriting. Miss it and, in most cases, insurers can ask health questions and decline or charge more. A few situations grant guaranteed-issue rights later. Because this window is one-time, it's worth planning before you turn 65.

Sometimes, but it's not always guaranteed. Outside of specific guaranteed-issue situations, switching from Medicare Advantage to a Medigap policy usually means answering health questions, and a carrier can decline you or charge more based on your health. That's why the initial choice between Advantage and Medigap matters. If you're rethinking your setup in the Sioux Falls area, we'll explain your real options before you make a move, at no cost.

Part D is private drug coverage approved by Medicare, available as a standalone plan or built into many Advantage plans. Each plan has its own formulary (covered drug list), pharmacy network, and tiers that set your copays. In 2026 the standard deductible is $615 and your annual out-of-pocket on covered drugs is capped around $2,100 (verify current figures on Medicare.gov). The right plan depends on your exact medications, not just the premium.

For 2026, the standard Part D deductible is $615, though some plans we offer set it lower, around $300 to $350, or waive it on certain drug tiers (verify current figures on Medicare.gov). The deductible is what you pay before the plan starts sharing drug costs. Because plans handle the deductible differently by tier, two plans with the same premium can cost you very different amounts depending on your prescriptions.

Yes. The old coverage-gap "donut hole" has been eliminated. Starting in 2025 and continuing in 2026, Part D includes a hard annual cap on what you pay out of pocket for covered drugs, about $2,100 for 2026 (verify current figures on Medicare.gov). Once you hit that cap, you pay $0 for covered medications for the rest of the year. You can also spread those costs into monthly payments through the Medicare Prescription Payment Plan.

Beginning in 2025 and continuing for 2026, Medicare limits what you pay out of pocket for covered Part D drugs to roughly $2,100 for the year (verify current figures on Medicare.gov). After you reach it, your covered prescriptions cost $0 for the rest of the calendar year. This protects people with high drug costs from the open-ended spending the old donut hole allowed. The cap applies to covered drugs on your plan's formulary.

Start with your actual medications, then check each plan's formulary, tier placement, deductible, and preferred pharmacies, not just the premium. A cheap-premium plan can cost more overall if it puts your drugs on a high tier or doesn't cover them. We run your exact drug list against the plans we offer in your county so you can compare real annual costs, including the 2026 $615 deductible and the cap (verify current figures on Medicare.gov).

IRMAA is the Income-Related Monthly Adjustment Amount, an extra charge added to your Part B and Part D premiums if your income is above certain thresholds. Medicare uses your tax return from two years prior to decide. Most people don't pay it, but higher earners do (verify current figures on Medicare.gov). If a one-time event like selling a home pushed your income up, you may be able to appeal it after a qualifying life change.

Yes. If a life-changing event lowered your income, such as retirement, the death of a spouse, divorce, or loss of pension income, you can ask Social Security to reconsider your IRMAA using Form SSA-44 instead of your two-year-old tax return. You'll provide documentation of the event and your newer income. Many people don't realize this option exists. We can point you to the right form and process, though Social Security makes the final decision.

It depends on your path. With Original Medicare you'll pay the Part B premium, possibly a Medigap premium, and a Part D premium, plus deductibles (verify current figures on Medicare.gov). With Medicare Advantage you may pay little or nothing beyond Part B, but copays apply as you use care up to an annual out-of-pocket max. Higher earners may owe IRMAA. We'll map your likely yearly cost based on your doctors, drugs, and budget, free.

A D-SNP is a type of Medicare Advantage plan built for people who have both Medicare and Medicaid. These plans coordinate the two programs, often add benefits like extra over-the-counter allowances or transportation, and keep your out-of-pocket costs very low. In Minnehaha County, Aetna and UnitedHealthcare offer dual plans (verify current plans on Medicare.gov). If you qualify for Medicaid too, ask us, the right D-SNP can stretch your benefits significantly.

Some people qualify for both, often called being "dual eligible." You may qualify if you have Medicare and limited income and assets under South Dakota or Iowa rules. Being dual eligible can unlock Extra Help for drug costs, lower premiums, and Dual Special Needs Plans (D-SNPs) with added benefits. Eligibility depends on your specific income and assets. We can help you understand whether it's worth applying, at no cost to you.

Extra Help, also called the Part D Low-Income Subsidy, lowers or eliminates your drug plan premium, deductible, and copays if your income and assets fall under federal limits (verify current figures on Medicare.gov). It can save thousands a year for people who qualify. Many who are eligible never apply. If money is tight, we'll help you see whether you might qualify and how Extra Help works with the drug plans we offer.

In Minnehaha County, which includes Sioux Falls, there are 22 Medicare plans available for 2026 (verify current plans on Medicare.gov). They come from carriers like UnitedHealthcare (AARP), Aetna, Sanford Health (its Align and Great Plains Medicare Advantage plans), Wellmark Blue Cross Blue Shield, and Medica. With that many choices, the premium tells you almost nothing, the network and drug list are what separate the right plan from the wrong one. We compare the plans we offer with you.

In Minnehaha County, the carriers include UnitedHealthcare (AARP), Aetna, Sanford Health (with its own Align and Great Plains Medicare Advantage plans), Wellmark Blue Cross Blue Shield, and Medica Cost plans (verify current plans on Medicare.gov). Each has different networks, drug lists, and extras. Locally, UnitedHealthcare/AARP plans carry a 4.5-star rating. We help you weigh the plans we offer against your doctors at Sanford or Avera and your prescriptions, for free.

Both Sanford Health and Avera are major systems in the Sioux Falls area, and network access varies by plan. Sanford even offers its own Medicare Advantage plans (Align and Great Plains). With Original Medicare plus a supplement, you can generally see any provider that accepts Medicare, including both systems. With Advantage, the network decides. Before you enroll, we confirm whether your specific Sanford or Avera doctors are covered by the plans we offer.

Sioux County, which includes Sioux Center and much of NW Iowa, has 28 Medicare plans for 2026, even more choice than the South Dakota side of the Big Sioux (verify current plans on Medicare.gov). It adds carriers like Humana, Molina (Passport), Wellcare, Wellpoint, and Iowa Health Advantage on top of Aetna, Sanford Align, Wellmark, and Medica. More options means a careful comparison matters even more, and that's exactly what we do with you, free.

Yes. Big Sioux Benefits is based in Sioux Falls and serves the whole Siouxland region, South Dakota, northwest Iowa, and southwest Minnesota. Medicare plans and counts differ by county; for example, Sioux County, Iowa has 28 plans while Minnehaha County, South Dakota has 22 (verify current plans on Medicare.gov). Wherever you live in our area, we compare the plans we offer for your specific county, networks, and prescriptions at no charge.

Medicare rates Advantage and drug plans on a 5-star quality scale. In Minnehaha County, UnitedHealthcare/AARP plans carry a 4.5-star rating, among the highest available locally (verify current plans on Medicare.gov). In Sioux County, Iowa, 4.5-star options include Aetna Eagle (HMO-POS), Aetna Value Care, and Iowa Health Advantage. Stars reflect quality and service, but the right plan still depends on your doctors and drugs. We factor ratings into the comparison, not just price.

Several plans charge no premium beyond your Part B. In Minnehaha County, examples include Aetna Medicare Signature (PPO) and Align ChoicePlus (PPO) from Sanford. In Sioux County, Iowa, examples include Humana Gold Plus (HMO), HumanaChoice Giveback (PPO), Align ChoicePlus, and Wellcare Simple (verify current plans on Medicare.gov). Remember, $0 premium still means copays and a network. We'll show you the full cost picture of the plans we offer, not just the headline number.

An HMO usually has lower costs but a tighter network and often requires referrals and in-network care except emergencies. A PPO costs a bit more but lets you see out-of-network providers at a higher share and skips many referrals. In our area, PPO is the most common Advantage type, with several plans available. The right pick depends on how you use care and which Sanford or Avera providers you want. We'll compare both with you.

Many veterans keep both. VA coverage and Medicare don't coordinate the way two civilian plans do, the VA covers care at VA facilities, while Medicare covers care in the community. Enrolling in Part B when first eligible preserves your flexibility to use non-VA doctors and avoids lifelong penalties if your VA coverage situation ever changes. Whether to add a drug plan or Advantage depends on your situation. We'll walk through it with you, free.

With Original Medicare, you're covered anywhere in the U.S. by any provider that accepts Medicare, which suits snowbirds and frequent travelers. Medicare Advantage plans use networks, so out-of-area care may cost more or be limited to emergencies, though PPOs offer more flexibility than HMOs. Routine care abroad generally isn't covered by either. If you travel often or winter elsewhere, tell us, it shapes which of the plans we offer fits best.

Moving to a new address can trigger a Special Enrollment Period to change plans, because Medicare Advantage and Part D plans are county-specific. A plan that worked in Minnehaha County may not be offered, or may have a different network, where you're moving. Original Medicare and most Medigap policies travel with you. If you're relocating within or beyond the Siouxland area, let us know so we can line up coverage that works at your new address.

No. Unlike employer or marketplace coverage, Medicare is individual, there are no family plans. You and your spouse each enroll separately and can hold completely different plans based on your own doctors, prescriptions, and budget. It's common for spouses to land on different plans because their needs differ. We're happy to review both of your situations together in one free appointment so each of you ends up with the right fit.

Only some people are enrolled automatically. If you're already receiving Social Security or Railroad Retirement benefits before 65, you're usually enrolled in Parts A and B automatically. If you're not collecting benefits yet, you typically must sign up yourself during your Initial Enrollment Period through Social Security. Either way, Parts C and D and any supplement are choices you make. We help Sioux Falls-area folks handle the timing so nothing slips through the cracks.

It's a newer option, sometimes called "M3P", that lets you spread your out-of-pocket Part D drug costs across monthly payments instead of paying a large amount at the pharmacy all at once. It doesn't lower your total cost, but it smooths the timing, which helps people with expensive medications early in the year. Combined with the 2026 out-of-pocket cap (verify current figures on Medicare.gov), it can make budgeting easier. Ask us if it might help you.

A Cost plan is a less common type of Medicare plan, and Medica offers several in South Dakota. It blends features of Original Medicare and Advantage: you can generally use Original Medicare for services outside the plan's network without penalty, which adds flexibility. Availability is limited and the rules differ from standard Advantage plans. If you're weighing a Medica Cost plan among the options near Sioux Falls, we'll explain how it compares to the other plans we offer.

An I-SNP is a Medicare Advantage plan designed for people who live in a nursing home or need a similar level of long-term care. These plans coordinate care closely around the facility and the person's needs. In our area, Iowa Health Advantage offers an I-SNP option (verify current plans on Medicare.gov). If you or a loved one is in a care facility, this kind of plan may fit better than a standard one, and we can review eligibility with you.

Original Medicare generally does not cover routine dental, vision, or hearing care, though it covers some medically necessary services. Many Medicare Advantage plans we offer add these as extra benefits, with allowances for cleanings, glasses, or hearing aids. Coverage amounts vary widely from plan to plan. If dental, vision, or hearing benefits matter to you, tell us, it's often a deciding factor between otherwise similar plans, and we'll compare the specifics.

A benefit period measures your Part A hospital coverage. It begins the day you're admitted and ends after you've been out of a hospital or skilled nursing facility for 60 days in a row. You pay the Part A deductible each new benefit period, so more than one hospital stay in a year can mean paying it again (verify current figures on Medicare.gov). A supplement or Advantage plan can limit this exposure, which we'll factor into your comparison.

Yes, and which one pays first depends on the employer's size and whether the coverage is active or retiree. With a large employer and active employment, the group plan often pays first and you may delay Part B safely. With a small employer or retiree coverage, Medicare usually pays first, so you'll likely want Part B on time. The rules are easy to get wrong. We'll help you confirm the right order before you decide, free.

They're separate programs. ACA marketplace plans (often called Obamacare) cover people under 65 who buy individual insurance, frequently with income-based subsidies. Medicare is the federal program for people 65 and older or with qualifying disabilities, with its own parts, enrollment windows, and rules. Once you qualify for Medicare, a marketplace plan usually isn't the right tool. If you're aging into Medicare from a marketplace plan, we'll help you transition cleanly so there's no gap.

No. Working with a licensed local agent like Big Sioux Benefits costs you nothing, our compensation comes from the carrier when you enroll, and plan premiums are the same whether you sign up with us, online, or directly. What you gain is a person in the Sioux Falls area who knows the Sanford and Avera networks, compares the plans we offer side by side, and is here next year when something changes.

No, and you should be cautious of anyone who claims to. We're a licensed independent agency, so we represent and compare the plans we offer from the carriers we're contracted with in your county, not the entire universe of plans. That independence still lets us put strong options side by side rather than pushing one company. We'll always be clear about what we can and can't offer so you can make a confident choice.

Bring your Medicare card (or your start date), a list of your current medications with dosages, the names of the doctors and facilities you want to keep, such as your Sanford or Avera providers, and your preferred pharmacy. If you have other coverage like VA, employer, or Medicaid, mention it. With that, we can compare the plans we offer in your county against your real needs in one sitting. The appointment is free.

At least once a year, during the Annual Enrollment Period from October 15 to December 7. Plans change their premiums, drug formularies, networks, and benefits every year, and so do your health needs. A plan that fit last year can quietly become a poor fit. A quick annual review catches drug-tier changes or a doctor leaving the network before they cost you. We offer this review on the plans we offer at no charge, every year.

When you call a national 800 number, you reach whoever picks up, often a different person each time, with no knowledge of Sioux Falls providers. We're local, independent, and licensed in South Dakota, Iowa, and Minnesota. We know the Sanford and Avera networks, compare the plans we offer for your exact county and prescriptions, and you'll talk to the same people next year. The help is free, and it's built for our community.

Just reach out, there's no cost and no obligation. Tell us your situation, whether you're turning 65, already on Medicare and rethinking your plan, a veteran, or possibly dual-eligible for Medicaid. We'll set up a free appointment, gather your doctors and medications, and compare the plans we offer in your Siouxland county side by side. You make the decision; we make sure you understand the trade-offs first. Contact us anytime to begin.

Often, yes, but it depends on your path. With Original Medicare plus a supplement, you can see any provider nationwide that accepts Medicare, which most Sanford and Avera providers do. With a Medicare Advantage plan, your doctor must be in that plan's network, so it's worth checking before you enroll. Keeping a specific physician is one of the most common reasons people pick one plan over another. We confirm your doctors against the plans we offer, free.