Before you can choose the Medicare Advantage plan that is best for you, it’s important to understand the basics of Original Medicare.

Medicare is a federal health insurance program. In order to qualify, you must be a U.S. citizen or lawfully present in the United States. You also must be age 65 or older; or be under age 65 with certain disabilities; or have permanent kidney failure requiring dialysis.

Medicare has four parts: Part A hospital coverage, Part B medical coverage, Part C Medicare Advantage plans and Part D prescription drug plans.

Part A hospital coverage

Most people do not pay a monthly premium for Part A. If you or your spouse worked for 10 years and paid Medicare taxes, you will not have to pay a premium.

Part A helps cover inpatient hospital care; skilled nursing facility care; home health care; and hospice care.

Your costs under Part A include inpatient hospital deductible; inpatient hospital copays; skilled nursing copays; and your monthly plan premium, if applicable.

Part B medical coverage

Part B requires you to pay a monthly premium along with a yearly deductible before coverage begins. You also are responsible for paying part of the costs that Part B does not cover. Services that are NOT covered by Medicare include: routine hearing, dental and vision exams; hearing aids or glasses (except for glasses after cataract surgery); emergency assistance while traveling outside the United States; fitness club membership; long-term care (such as a nursing home); and prescription drug coverage.

Part B helps cover doctor and other healthcare provider services; outpatient surgery; lab and X-ray services; ambulance services; preventive services; and durable medical equipment like prosthetics, wheelchairs and hospital beds.

What costs are you responsible for under Part B? Part B includes the following costs: your Medicare Part B monthly premium, if applicable; yearly deductible (paid before Medicare begins paying); and coinsurance (percentage of the cost that Medicare does not pay).

Part C Medicare Advantage plans

Part C is referred to as Medicare Advantage plans. Medicare Advantage plans are Medicare-approved private health plans. Medicare Advantage plans work differently from supplement plans. They allow you to get all of your Part A Hospital, Part B Medical and, sometimes, Part D Prescription Drug coverage combined into one plan. They also can provide you with some additional benefits and services that Original Medicare does not cover. Medicare Advantage plans can have lower out-of-pocket costs than Original Medicare.

When enrolled in a Part C Medicare Advantage plan, you can get coverage for: Medicare Part A (hospital coverage) and Medicare Part B (medical coverage).

To join a Medicare Advantage plan, you must: be a U.S. citizen or lawfully present in the United States; be enrolled in Medicare Parts A and B; live for six months or more each year in the plan’s service area; and not have permanent kidney failure (some exceptions may apply).

Medicare Advantage plans help cover all services that Parts A and B cover, except hospice care (which is covered by Medicare). Additional benefits and services that Medicare does not cover include hearing, dental, vision, travel and fitness.

You will have some costs when enrolled in a Medicare Advantage plan. You will pay your Part A monthly premium (if applicable) and Part B monthly premium, if applicable. You also will pay your Medicare Advantage plan monthly premium, if applicable. You are responsible for any out-of-pocket costs such as copays, deductibles and coinsurance that come with the Medicare Advantage plan you chose.

Additionally, there are two types of Medicare Advantage plans: Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO). HMO plans use a network of participating hospitals and doctors for your care. With an HMO plan, you must receive services from participating hospitals and doctors, except for emergency care, out-of-area urgent care and out-of-area kidney dialysis. Make sure your current doctors are included in the plan’s provider network before joining a plan.

PPO plans offer coverage for services received both in and out of the plan’s provider network. With a PPO plan, you may pay a higher coinsurance, copayment, or deductible for care received outside of the plan’s participating provider network.

Part D prescription drug coverage

Part D coverage is offered through Medicare-approved private insurance companies. You can receive Part D coverage through a prescription drug plan (PDP) or by including it in a Medicare Advantage prescription drug plan (MAPD).

Part D helps cover brand-name and generic medications. Prescription coverage varies by plan; each plan has a formulary that lists the drugs that are covered by that plan. Your costs when enrolled in a Part D plan include: your Part D plan monthly premium, if applicable, any out-of-pocket costs such as copays, coinsurance and deductibles included with the prescription drug plan that you choose, and a late enrollment penalty (this only applies if you have a period of 63 days without Part D coverage).

Some Medicare Advantage plans cover prescription drugs. If your plan does not cover your prescriptions, or you do not have a Medicare Advantage plan, you may want to consider adding Part D coverage.

You want to make sure you get the most out of your Medicare benefits. Keep these helpful thoughts in mind as you weigh your Medicare coverage options.

Look for a plan that helps you save with low cost doctor visits. This cost is a called a copay. This will be very important if you think you will visit the doctor often. Many Medicare Advantage plans offer options with savings at the doctor’s office.

Ask yourself, does this plan offer care from respected doctors and hospitals in my area? Many plans offer cost savings by requiring you to get your medical care from doctors and hospitals in a set network of providers that accept the plan. Ask about the network of any plan you are considering. Find out if it offers high quality care from the most trusted doctors and hospitals in your community.

Look for a plan that gives you the coverage you need AND fits your monthly budget. This is why it is important to compare your options. While some options may have lower costs for hospital stays or specialist visits, they may come with a steep monthly premium. Determine what your actual health needs are and find the plan that is right for you and your budget.

DO NOT assume the plan you have now will remain the same. Check to see what is changing about your current coverage. The benefits you have now may change. This means you may be able to get more savings and value by switching to a new option. Find out what about your current health plan is going to change. Start learning about your options now so you have time to make a smart decision.

Consider if it is important for you to have doctor, hospital and prescription coverage in one plan. Having prescriptions included with your medical coverage may help you from having to take more than one card to the doctor, hospital and pharmacy. A Medicare Advantage plan allows you to get all three types of coverage for one monthly premium with one card to carry.

Make sure you know how the company you are considering works with Medicare. Medicare Advantage plans are Medicare-approved plans offered by companies with a Medicare contract. Unlike Medicare Supplement plans, Medicare Advantage plans allow you to get all your Part A hospital, Part B medial, and sometimes, Part D prescription drug coverage combined into one plan. They also can provide you with some extra benefits and services that Original Medicare does not cover.

Find out if the coverage option you are considering would require you to buy extra coverage for other needed services such as preventive dental, routine vision, fitness and world travel. Medicare Advantage offers important extra benefits you don’t get from Original Medicare alone. You pay one premium and get all your coverage under one plan. These extra benefits add more value to your healthcare coverage and can help you stay healthy.

Request information about your options so you can start to review your choices. Requesting this information ensures that you will be able to review all your options and select a choice you can feel confident in without feeling pressured to make a decision. Always make sure the information you request is FREE, and that there is no obligation to buy anything for responding.

Author profile
Namita Ahuja, MD

Dr. Ahuja is the current president of the Pennsylvania Geriatric Society – Western Division. She is board certified in Geriatrics and Hospice & Palliative Medicine and is senior medical director of Medicare at UPMC Health Plan and a clinical assistant professor with the Division of Geriatric Medicine at University of Pittsburgh.