Medicare and Long-Term Care: What's Covered, What's Not

ALZNavigator

A free online planning tool from the Alzheimer's Association that creates a personalized action plan for people concerned about memory changes or navigating a dementia diagnosis. Available nationally regardless of insurance. Source: alz.org.

Benefit period

Starts when you enter a hospital or SNF; ends when you have had no inpatient care for 60 consecutive days. Each new benefit period resets your Part A deductible of $1,736 in 2026.

Care Navigator (GUIDE)

A clinician-supervised professional assigned through the GUIDE Model who coordinates appointments, connects families to community resources, and helps the unpaid caregiver access training and respite. Source: CMS GUIDE Model FAQs.

Coinsurance

Your share of costs after meeting your deductible — typically 20% for Part B services.

Copayment

A fixed dollar amount you pay for a covered service (e.g., $434/day for days 61–90 in a hospital in 2026).

Creditable coverage

Drug coverage at least as good as Part D. If you have it, you can delay Part D enrollment without a penalty.

Deductible

Amount you pay before Medicare begins sharing costs. Part A: $1,736/benefit period. Part B: $283/year (2026).

Donut Hole (Coverage Gap)

Previously, Part D enrollees paid full price for drugs after reaching a spending threshold. The Inflation Reduction Act eliminated the coverage gap starting in 2025 — there is no longer a donut hole. Part D now has a flat $2,000 annual out-of-pocket cap with no gap in coverage.

Formulary

A plan's list of covered drugs, organized into tiers that determine how much you pay.

General Enrollment Period (GEP)

Jan 1–Mar 31 each year. For people who missed their Initial Enrollment Period with no Special Enrollment Period.

GUIDE Model

Medicare's Guiding an Improved Dementia Experience program. A free Part B benefit (launched July 2024) that provides people with dementia and their unpaid caregivers a dedicated Care Navigator, 24/7 support line, caregiver education, and up to $2,500/year in respite services. Requires Original Medicare and a confirmed dementia diagnosis. Source: CMS Innovation Center, March 2026.

Initial Enrollment Period (IEP)

Your personal 7-month window to sign up — 3 months before, the month of, and 3 months after your 65th birthday.

IRMAA

Income-Related Monthly Adjustment Amount. Higher-income beneficiaries pay more for Parts B and D. In 2026, Part B IRMAA ranges from $284.10 to $689.90/month based on 2024 tax return income.

Late enrollment penalty

A permanent premium increase for delaying Part B (10% per year) or Part D (1% of $38.99 base per month) without creditable coverage.

Medicaid

A joint federal/state program for people with limited income. Different from Medicare — some people qualify for both (dual eligible).

Medicare Advantage (Part C)

An alternative to Original Medicare — private plans approved by Medicare that must cover everything Parts A and B cover, often with extras like dental, vision, and hearing.

Medigap

Supplemental insurance sold by private companies to fill the gaps in Original Medicare (deductibles, coinsurance). Also called Medicare Supplement. In 2026, popular Plan G premiums typically range from $100–$300/month depending on age, location, and insurer. Plan N is often $50–$150/month lower but adds small copays.

Original Medicare

The federal health insurance program: Part A (hospital) and Part B (medical). No network limits; you pay 20% coinsurance with no annual out-of-pocket cap.

Out-of-pocket maximum

The most you pay in a year for covered services. Original Medicare has no cap; Medicare Advantage plans must have one. Part D drug costs are capped at $2,000 in 2026.

Premium

What you pay monthly for coverage. Part A is usually free; Part B is $202.90/month standard in 2026.

Primary payer

The insurance that pays first. Medicare is usually primary for Medicare beneficiaries unless employer or COBRA coverage applies.

SEP (Special Enrollment Period)

Allows you to enroll outside normal windows due to specific life events — like losing employer coverage, moving, or qualifying for Extra Help.

Skilled nursing facility (SNF)

A facility providing short-term rehabilitation after a hospital stay. Part A covers up to 100 days per benefit period (after a 3-day hospital stay). Days 21–100 cost $217/day in 2026.