If you or someone in your care is approaching the age of sixty-five, Medicare is, or at least should be, a frequent topic of conversation. As you likely are aware, for all of its benefits, Medicare has many moving parts and requires some big decisions. One of the biggest decisions a senior will have to make regarding Medicare is choosing between Original Medicare (consisting of Medicare Part A and Medicare Part B) or Medicare Advantage – sometimes referred to as Medicare Part C.
While both have unique benefits and limitations, many people are unsure of what Medicare Advantage really is, what it covers, and how it differs from Original Medicare.
We’ve all waited a long time to reach retirement age—literally our whole lives! Navigating healthcare options in this stage of life can feel daunting, and it’s natural to feel anxious about the complexities of Medicare. Our goal is to help you understand exactly what Medicare Advantage is, how it differs from Original Medicare, and to provide the information you need to make the best decision for you or your loved one.
What is Medicare Advantage? An Overview
According to a recent report, more than half of those who qualify for Medicare are enrolled in Medicare Advantage. As of 2024, that number is about 32.8 million older Americans.
Medicare Part C Basics
So, what exactly is Medicare Advantage, a.k.a. Medicare Part C? Let’s start with the basics. Medicare Advantage essentially bundles other parts of Medicare—Part A, Part B, and, in many cases, Part D—into one plan. Like traditional Medicare, Medicare Advantage is available to anyone who is at least sixty-five years old, as well as younger individuals with disabilities and those suffering from specific conditions like amyotrophic lateral sclerosis (ALS) or end-stage renal disease.
What is the main difference between Medicare Original and Medicare Advantage?
There are many differences between the two in terms of what they cover, which we’ll explore in greater depth. However, one significant difference to note is that Original Medicare is provided by the federal government, whereas Medicare Advantage is offered by Medicare-approved private insurance companies. According to Medicare’s official website, “Medicare works with private insurance carriers either by contracting with them to enhance or expand on existing Medicare benefits or by coordinating payment of claims for recipients who have ongoing coverage outside of Medicare.”
Because Medicare works with private insurance companies, individuals qualifying for Medicare have options when selecting the coverage that best fits their personal needs.
Key Features of Medicare Advantage
For those considering Medicare Advantage, it’s worth noting that it is a growing choice among older Americans for several reasons. Medicare Advantage combines multiple benefits into one package, which can simplify coverage. It also may include additional benefits not provided by Original Medicare, such as dental, hearing, and vision care. Some Medicare Advantage plans even offer coverage for over-the-counter medications, gym memberships, and transportation to medical appointments, which may be beneficial for individuals without regular access to a vehicle.
That said, by law, both Medicare Advantage and Original Medicare cover essential services like doctor visits, hospitalizations, outpatient surgery, blood work, x-rays, and other scans.
What Does Medicare Advantage Cover?
Part A and Part B Coverage in Medicare Advantage:
It’s important to know that you will not lose either Part A (Hospital Coverage) or Part B (Medical Coverage) if you choose to go with Medicare Advantage, whether during Medicare’s Initial Enrollment Period (when you first qualify for Medicare) or the Medicare Open Enrollment Period (a yearly time when you can adjust your coverage options). Under federal law, Medicare Advantage is required to cover both Part A and Part B.
What Part A and Part B Cover
When you or a loved one enrolls in Medicare, you’re automatically covered by Medicare Part A. In the event you need to spend time in the hospital, Part A covers services such as a semi-private room (meaning you may have a roommate during your hospital stay), hospital meals, general nursing needs, certain blood transfusions, prescribed drugs, and other basic hospital necessities. Part A also provides for inpatient rehabilitation, like physical rehab, which helps restore physical movement or abilities (for instance, relearning how to walk after a leg or spine injury).
Part B, which is also part of Original Medicare, covers a range of medical services. Although optional, if you do take Part B coverage, it includes things like doctor visits, imaging tests (MRIs, X-rays, CT scans), and screenings (like EKGs to monitor your heartbeat). It also provides coverage for diabetes care, some medical equipment (e.g., wheelchairs, walkers), and preventive services, including flu shots, mammograms, and routine blood and urine tests.
To clarify, all of these services are covered if you go with Original Medicare and keep Part B, and they are also included under Medicare Advantage.
Prescription Drug Coverage (Part D):
Part D is one area where Medicare Advantage can differ significantly from Original Medicare. Original Medicare does not include Part D prescription drug coverage, while Medicare Advantage often includes it. Part D provides coverage for medications prescribed by your doctor, including those for chronic conditions like diabetes (e.g., insulin). Launched in 2006, Part D was added to address the need for drug coverage, as it was not part of the Original Medicare package, which began in 1965. For those who don’t require prescription drugs regularly, Part D is optional and can be added separately during open enrollment if needed. In many Medicare Advantage plans, Part D is bundled as part of the overall coverage.
How to Choose the right Medicare Advantage Plan For You
For all the options available, Medicare Advantage Plans offer a variety of “flavors” to choose from, each with its own set of benefits. While this variety can be helpful, it may also feel overwhelming when trying to figure out which option best suits you. As with any significant decision, it’s important to carefully weigh your specific needs and preferences.
Assessing Your Coverage Needs
For many Americans, Original Medicare provides the coverage they need. Consider questions like: Do you require prescription medications? Do you anticipate needing frequent doctor visits? Are additional benefits such as dental, vision, or hearing care important to you? If the answer to these questions is mostly “no,” then Original Medicare may be a good fit. Taking the time to assess your needs is essential when comparing the different plans available.
The Costs Involved:
Cost is another major consideration. Deductibles and out-of-pocket costs can change exactly how much you pay for insurance because those numbers can vary depending on which plan you choose. According to an article on investopedia.com, in 2024, the average Medicare Advantage premium is $18.50 per month; on top of that, people with MA pay any plan premium on top of the Medicare Part B Premium of $174.70 per month. Some plans can have Premiums covering MA and Part D that are as low as $5.50 per month, while others are as high as $44.12. Because the costs can vary per plan, it’s important to consider how much you can afford.
Availability Of Coverage:
The final thing to consider is whether the plan you want is even available in your state. For example, Alignment Health, while very good, is only available in five states. Meanwhile, other plans, such as Aetna and Humana, are both available in forty-eight states. To be clear, we’re not recommending one over the other. The reason we mention them is to give you a better idea of your options and how the area covered by those plans can be different.
You should also consider if your preferred doctors or hospitals are also covered by the Medicare Advantage network you choose to go with. Finding a good Doctor, not just in terms of skill but someone you’re comfortable with, is very important, especially as we get older, and vital to keep in mind when choosing the right plan for you.
Resources for Comparing and Choosing Medicare Advantage Plan
When you or your caregiver are considering which Medicare Advantage plan, if any, is the best option for you, it’s understandable to feel anxiety. Thankfully, there are some great resources available to help you out.
Medicare.gov, the official website of Medicare, has a fantastic plan finder tool, which you can access by clicking here. This tool can help you compare costs, coverage types, and benefits to find your ideal plan. Best of all, it’s laid out in an easy-to-read chart. If you have any additional questions regarding Medicare, you can contact Medicare 24 hours a day, seven days a week by calling 1-800-MEDICARE (1-800-633-4227).
The State Health Insurance Assistant Program (SHIP) website also has a tool that will help you connect to someone in your state who can answer any questions or concerns you may have. Finally, we also recommend looking into brokers and agents within your area who can provide additional guidance and support in finding a plan that works for you and offer information on the Medicare Advantage plans that are available to you.
Finally, if you are looking to change your coverage during the Medicare open enrollment period, we have previously posted guides for seniors and caregivers on open enrollment.
How to Enroll in a Medicare Advantage Plan
Once you and your caregiver have done the research to determine if a Medicare Advantage Plan is right for you, the last thing to do is officially sign up for the plan of your choice. However, there are some elements to keep in mind first.
When to enroll/change your current coverage:
If you have already reached retirement age but don’t yet have Medicare, you can sign up for Medicare Advantage during your Initial Enrollment Period, which is a seven-month window starting three months before your sixty-fifth birthday and ending three months after. If you currently have Original Medicare and want to change over to Medicare Advantage, you can opt for the Open Enrollment Period, which runs from October 15th to December 7th every year.
Finally, you can also change your coverage during Special Enrollment Periods. Please note that SEPs only happen under certain conditions, such as if you move to an address outside of your current Medicare Plans area, or if there is an addition to your household through marriage, childbirth, or adoption, to name a few. Even then, you/the older person in your care only have a short window to make the requested change.
A Step-by-Step Enrollment Guide To Enroll:
When you are officially ready to make the change, simply go to Medicare’s plan comparison site by clicking here. Thankfully, Medicare.org has made it very easy to find what you are looking for. First, you enter your zip code, then select the type of plan you want, such as Medicare Advantage, Medicare Part D, or Medigap. Once you’ve made your choice, click “Find Plans.”
You can select which program helps with your Medicare health or drug costs, such as Medicaid, the Medicare Savings Program, or Supplemental Security Income. If none apply to you, simply continue on. Then, you can see what your drug costs would be when you compare various plans. To do this, you would enter the name, dosage, and quantity of the drug you take, along with how often you take it. From there, just continue following the steps until you’ve found the plan for you. Then click “enroll,” and you’re done.
Conclusion:
As we’ve covered in this blog, Medicare Advantage offers several potential benefits by combining Original Medicare with Part D in one package, along with some additional features. However, as with any major decision, we recommend conducting thorough research before choosing a plan. If you’re currently on Original Medicare and find that it covers what you need, that may be a suitable choice as well.
Exploring all your options on medicare.gov is a good step for gathering information and making the best choice for your needs. You can also contact Medicare directly at 1-800-MEDICARE (1-800-633-4227) for any questions. Thank you for reading, and we wish you good health and happiness!
