What are the basic Medicare eligibility requirements?

To be eligible for Medicare, you must be at least 65 years old and a U.S. citizen or a permanent legal resident who has lived in the United States for at least five continuous years.

How does my work history affect my Medicare eligibility?

If you have paid Medicare taxes for about 10 years, you typically qualify for premium-free Part A hospital insurance. Those with shorter work histories may still qualify by paying monthly premiums.

Can individuals under 65 qualify for Medicare?

Yes. Individuals under 65 can qualify if they have received Social Security Disability Insurance (SSDI) benefits for 24 months or have specific medical conditions such as End-Stage Renal Disease (ESRD) or ALS.

What is the Initial Enrollment Period for Medicare?

The Initial Enrollment Period begins three months before your 65th birthday and ends three months after it—a seven-month window that allows you to enroll without late-enrollment penalties.

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

Original Medicare is administered by the federal government and includes Part A and Part B. Medicare Advantage (Part C) is offered by private insurers and combines hospital, medical, and often drug coverage with different cost structures and networks.

How does hospitalization coverage differ under each program?

Original Medicare uses benefit periods with deductibles and coinsurance after 60 days, while Medicare Advantage typically charges daily copays for a limited number of days and caps annual out-of-pocket costs.

What is the 90-day hospitalization rule under Original Medicare?

After 90 days in one benefit period, you begin using 60 lifetime reserve days at a higher daily cost. Once those are used, you pay all remaining hospital costs yourself.

Does Medicare Advantage have an annual spending limit?

Yes. Every Medicare Advantage plan includes a maximum out-of-pocket (MOOP) limit. In 2025 it can be up to $8,850 for in-network care, after which the plan pays 100% of covered services.

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

Original Medicare is administered by the federal government and includes Part A and Part B. Medicare Advantage (Part C) is offered by private insurers and combines hospital, medical, and often drug coverage with different cost structures and networks.

How does hospitalization coverage differ under each program?

Original Medicare uses benefit periods with deductibles and coinsurance after 60 days, while Medicare Advantage typically charges daily copays for a limited number of days and caps annual out-of-pocket costs.

What is the 90-day hospitalization rule under Original Medicare?

After 90 days in one benefit period, you begin using 60 lifetime reserve days at a higher daily cost. Once those are used, you pay all remaining hospital costs yourself.

Does Medicare Advantage have an annual spending limit?

Yes. Every Medicare Advantage plan includes a maximum out-of-pocket limit. In 2025 it can be up to 8850 dollars for in-network care, after which the plan pays 100 percent of covered services.

What are the key parts of family health insurance?

Premiums, deductibles, copays, and out-of-pocket maximums determine how much a family spends on health insurance each year.

How do I find affordable ACA coverage?

Visit GenerationHealth.me/aca-marketplace-quotes to compare ACA plans and see if you qualify for subsidies that lower your monthly premium.

Do family health plans include dental and vision?

Most standard health plans do not include dental and vision. Families should add standalone coverage to complete their protection.

What is the main difference between Medicare Plan G and Medicare Advantage?

Medicare Plan G works with Original Medicare to cover most out-of-pocket costs after the Part B deductible. Medicare Advantage replaces Original Medicare with a private plan that includes copays, networks, and often drug and extra benefits.

Is Medicare Plan G better than Medicare Advantage?

Plan G is better if you want predictable costs and doctor freedom. Medicare Advantage can be better if you want lower premiums and built-in extras like dental and vision.

What are the four main parts of Medicare?

Medicare consists of four primary parts: Part A (Hospital Insurance), Part B (Medical Insurance), Part C (Medicare Advantage), and Part D (Prescription Drug Coverage). Each part covers different aspects of healthcare needs.

How do I enroll in Medicare, and what are the important enrollment periods?

You can enroll in Medicare during your Initial Enrollment Period, which begins three months before your 65th birthday and lasts for seven months. There are also General Enrollment Periods from January 1 to March 31 each year and Special Enrollment Periods for unique circumstances like continued employment or qualifying life events.

What are the costs associated with each Medicare part?

Part A is often premium-free for most beneficiaries but includes a $1,676 deductible per benefit period. Part B has a standard $185 monthly premium and a $257 annual deductible in 2025. Costs for Part C (Medicare Advantage) and Part D (drug coverage) vary by plan and include potential copays and premiums.

What are the penalties for missing Medicare enrollment deadlines?

Missing Medicare enrollment deadlines can result in permanent financial penalties. For Part D, the penalty adds 1% of the national base beneficiary premium for each month without coverage, applied permanently. Late enrollment in Part B also triggers ongoing higher monthly premiums.

Medicare & Health Insurance Plans in Durham, NC

Local Help Comparing Medicare Advantage, Supplement, and ACA Plans

Finding the right health coverage in Durham doesn’t have to be confusing. Generation Health, led by licensed agent Rob Simm, helps seniors and families compare Medicare Advantage (Part C), Medicare Supplement (Plan G), and Marketplace ACA health insurance plans.

Why Durham Residents Choose Generation Health

Personalized help comparing plan benefits, premiums, and networks
Guidance on Medicare Part D drug coverage and dual Medicare & Medicaid plans
Support for residents of Durham County, Chapel Hill, Raleigh, and the Triangle area
Free plan reviews with no obligation — trusted, local, and confidential

Medicare Plan Options in Durham

Medicare Advantage (Part C)
Zero-premium plans that include hospital, medical, and prescription coverage — often with extras like dental, vision, hearing, and fitness benefits.

Medicare Supplement (Plan G) (Plan N)
Low-deductible coverage that pays the costs Original Medicare doesn’t, such as copays, coinsurance, and hospital stays.

Marketplace (ACA) Health Insurance
Affordable Care Act plans for individuals and families under 65, with income-based savings.

Talk with a Local Licensed Agent

If you’re turning 65 or reviewing your 2026 Medicare options, let Rob Simm simplify your choices. Get a free quote, compare doctors in your network, and find coverage that fits your budget.

📞 Call 828-761-3324 | 🌐 Visit GenerationHealth.me

Frequently Asked Questions (FAQ)

Q1: What’s the difference between Medicare Advantage and Medicare Supplement in Durham, NC?
A: Medicare Advantage (Part C) plans replace Original Medicare and often include drug coverage and extras like dental or vision. Medicare Supplement Plan G works with Original Medicare, covering most out-of-pocket costs like copays and coinsurance.

Q2: Can I switch from my employer plan to Medicare in Durham without penalties?
A: Yes — but timing is crucial. You must enroll in Medicare Part B within 8 months after your employer coverage ends to avoid late penalties.

Q3: Are there $0 premium Medicare plans available in Durham, NC?
A: Absolutely. Several carriers in Durham offer $0 premium Medicare Advantage plans that include hospital, doctor, and prescription benefits, depending on your ZIP code and eligibility.

Q4: Does Generation Health charge for Medicare plan comparisons?
A: No. Our Medicare consultations are 100% free. You’ll get personalized help reviewing your doctors, prescriptions, and plan options — no sales pressure.

About the Author

Written by Rob Simm
Licensed Health Insurance Broker – Founder of Generation Health

Rob Simm is a licensed Medicare and health insurance broker with extensive experience helping seniors and families across North Carolina, Virginia, Georgia, and Texas. Through GenerationHealth.me, Rob simplifies the complexities of Medicare Advantage, Medigap, and Marketplace insurance — ensuring every client understands their coverage and makes informed, confident decisions.

When he’s not helping clients, Rob enjoys community outreach events, senior seminars, and mentoring other agents on compliance and client care.

📍 Learn more or schedule your free Medicare review at GenerationHealth.me
📞 Call or text Rob directly at (828) 761-3324