In Part 1 of our Medicare series, we outlined the four parts of Medicare and how each affects healthcare delivery and patient access. In this second part, we focus on coverage gaps, strategic enrollment timelines, and how stakeholders can align their programs to support the evolving needs of Medicare beneficiaries.

Enrollment Timelines Impact Care Transitions

The Initial Enrollment Period (IEP) spans 3 months before and after the month a person turns 65. Delays in enrollment, particularly for Parts B and D, can create coverage gaps or penalties, affecting continuity of care.

Why it matters for stakeholders: Aligning patient outreach and medication education efforts with key enrollment windows can significantly improve engagement, adherence, and patient satisfaction.

What’s Missing? Recognizing the Gaps in Medicare Coverage

Even with robust benefits, traditional Medicare doesn’t cover:

• Long-term custodial care
• Routine dental, vision, and hearing
• Care received outside the U.S.
• Cosmetic procedures
  

Why it matters: These gaps can lead to underdiagnosis, fragmented care, or deferred treatments, presenting opportunities for supplemental services, education, and engagement programs.

Medigap: Filling the Financial Gaps

For those enrolled in Original Medicare (Parts A & B), Medigap policies help manage deductibles, coinsurance, and other out-of-pocket costs. However, they cannot be used with Medicare Advantage plans.

Strategic opportunity: Providers and support teams can play a pivotal role in helping patients navigate these complex choices to balance affordability, access, and long-term value.

Medicare’s Strategic Impact on Healthcare Innovation

Medicare is not just a payer—it’s a catalyst for healthcare innovation. Its structure affects:

• How new therapies are evaluated and reimbursed
• Patient access pathways and market entry strategies
• Design of value-based and preventative care programs
  

By understanding the Medicare landscape, stakeholders can:

• Anticipate access barriers
• Tailor messaging and support materials
• Design patient support programs aligned with reimbursement realities
• Enable better outcomes for aging populations
  

Final Thoughts

Medicare’s role in the healthcare ecosystem will only become more significant as the U.S. population continues to age. Whether you’re driving clinical innovation or optimizing commercial strategies, knowing how Medicare works—and where it falls short—will be essential.

At Connexio Health, we help stakeholders navigate this landscape with actionable data, engagement strategies, and insights that empower better access and outcomes.

Let’s collaborate to fill the gaps, support smarter decision-making, and deliver more for Medicare beneficiaries.

As over 66 million Americans now rely on Medicare for their healthcare needs, understanding how this complex program works isn’t just a personal necessity—it’s a strategic imperative for healthcare leaders. For providers, manufacturers, and pharmaceutical teams, the Medicare landscape shapes everything from patient engagement to market access strategies.

Whether you’re advising patients approaching retirement or developing programs and therapies for a 65+ population, here’s what you need to know.

Medicare Basics: A Quick Refresher

Medicare is the U.S. federal health insurance program primarily for individuals aged 65 and older, though it also covers younger individuals with certain disabilities or chronic conditions. It’s divided into four parts, each with unique implications for healthcare access and financial planning.

Fast Facts for Healthcare Leaders:

• 66M+ Americans are currently enrolled in Medicare (2024).
• The average out-of-pocket cost per beneficiary is around $6,500 annually.
• Coverage gaps (like dental, vision, and long-term care) can influence patient behavior and outcomes.
  
  

The Four Parts of Medicare—and What They Mean for Engagement

Part A: Hospital Insurance

Covers: Inpatient hospital stays, short-term skilled nursing care, hospice, and limited home health services.
Implications: Most beneficiaries qualify for $0 monthly premiums, but rising deductibles ($1,632 in 2025) may drive cost sensitivity, especially among fixed-income patients.

Part B: Medical Insurance

Covers: Outpatient services, preventive care, diagnostics, mental health, and medical equipment.
Implications: Patients are responsible for 20% of most services post-deductible, highlighting the need for education around cost-sharing and financial assistance.

Part C: Medicare Advantage

Covers: All Part A and B services, usually Part D, and often extras like dental, vision, and wellness benefits.
Implications: Plans vary widely by region and provider network. Manufacturers and providers must align access strategies with local plan details.

Part D: Prescription Drug Coverage

Covers: Most outpatient prescription medications and some vaccines.
Implications: Formularies and coverage vary by plan. Understanding patient affordability and access is essential, especially for specialty medications.

Coming Up in Part 2…

We’ll explore Medicare’s impact on enrollment timing, care transitions, and innovation—as well as what’s missing from coverage and how the healthcare industry can help fill the gaps.