What perks come with Medicare? A breakdown of coverage options

According to the Centers for Medicare & Medicaid Services, over 67 million Americans were enrolled in Medicare in 2024, highlighting its critical role in senior healthcare. For many, understanding what perks come with Medicare is the first step toward maximizing their benefits and making informed healthcare decisions.

Quick Summary

Medicare offers comprehensive health coverage options, including inpatient and outpatient services through Original Medicare (Parts A and B), plus additional benefits like vision, hearing, and dental through private Medicare Advantage plans (Part C). Supplemental Medigap policies can help with out-of-pocket costs, while Part D provides prescription drug coverage.

Key Points

• Core Hospital and Medical Coverage: Original Medicare (Parts A and B) provides foundational benefits for inpatient hospital care, skilled nursing, doctor services, and preventive care.

• Expanded Benefits with Advantage: Medicare Advantage plans (Part C) offer perks beyond Original Medicare, often including vision, hearing, dental, and fitness programs.

• Financial Protection: Unlike Original Medicare, Medicare Advantage plans are required to provide a yearly cap on out-of-pocket expenses for Part A and Part B services.

• Medigap Fills Gaps: For Original Medicare recipients, Medigap policies help cover out-of-pocket costs like copayments and deductibles, though they do not include prescription drugs.

• Prescription Drug Coverage: Part D plans, available separately or as part of a Medicare Advantage plan, help lower the costs of prescription medications.

• Preventive Services at No Cost: Both Original Medicare and Medicare Advantage cover many preventive services, such as annual wellness visits and screenings, often at no cost.

Original Medicare: Parts A and B

Original Medicare, the federal health insurance program, consists of Part A (Hospital Insurance) and Part B (Medical Insurance). Most individuals who have paid Medicare taxes for at least 10 years receive premium-free Part A. Part B requires a monthly premium.

Medicare Part A (Hospital Insurance)

Part A primarily covers inpatient care, including hospital stays, skilled nursing facility care after a qualifying hospital stay (though not long-term custodial care), hospice care, and some home health care.

Medicare Part B (Medical Insurance)

Part B covers medically necessary services and supplies for diagnosis and treatment, as well as many preventive services. Perks include doctor and outpatient services, a range of preventive care like annual wellness visits and screenings, durable medical equipment, and mental health services.

Medicare Advantage (Part C): Expanded Perks from Private Insurers

Medicare Advantage plans (Part C) are offered by private insurance companies approved by Medicare. These plans provide all the coverage of Original Medicare and often include additional perks.

Medicare Advantage plans commonly offer extra benefits such as vision, hearing, and dental coverage. Many also integrate Part D prescription drug coverage. A significant perk of these plans is an annual out-of-pocket maximum, which limits how much you pay for covered Part A and Part B services. Additional perks can include wellness programs like gym memberships and other non-medical benefits.

Medicare Part D and Medigap: Specialized Perks

For those with Original Medicare, supplemental options provide specialized perks, especially for prescription drugs and out-of-pocket costs.

Medicare Part D (Prescription Drug Coverage)

Part D is optional coverage from private insurers to help cover prescription drug costs and many recommended vaccines. Enrollment requires having Part A and/or Part B.

Medigap (Medicare Supplement Insurance)

Medigap policies are sold by private companies to help cover costs not paid by Original Medicare, like copayments, coinsurance, and deductibles. These policies work alongside Original Medicare.

Comparison Table: Original Medicare vs. Medicare Advantage

Feature	Original Medicare (Parts A & B)	Medicare Advantage (Part C)
Core Coverage	Inpatient hospital (Part A) and outpatient medical services (Part B).	Includes all Part A and Part B benefits, plus extra perks.
Extra Benefits	Does not cover routine dental, vision, or hearing.	Often includes routine dental, vision, hearing, and fitness programs.
Prescription Drugs	Requires a separate Part D plan for most prescription drugs.	Typically bundles Part D coverage into the plan.
Out-of-Pocket Maximum	No annual cap on out-of-pocket expenses.	Offers a yearly limit on what you pay for Part A and Part B services.
Provider Networks	Can use any doctor or hospital nationwide that accepts Medicare.	Typically uses a network of doctors and hospitals, limiting your choices.
Referrals	No referrals needed for specialists.	Many HMO-type plans require referrals for specialist care.

Making the Best Choice for Your Needs

Choosing between Original Medicare and Medicare Advantage involves evaluating your health and financial situation. Original Medicare offers flexibility in choosing providers, while Medicare Advantage can provide a wider range of benefits and an out-of-pocket maximum, often within a network.

To make an informed decision, assess your healthcare needs, compare the total costs including premiums and potential out-of-pocket expenses, and check provider networks for Medicare Advantage plans. Seeking unbiased advice from resources like your local State Health Insurance Assistance Program (SHIP) can also be beneficial.

Conclusion

Medicare provides a variety of coverage options, from the essential benefits of Original Medicare to the expanded perks and bundled services of Medicare Advantage. Understanding the benefits of each part and considering supplemental options like Part D and Medigap is key to selecting the plan that best fits your individual needs and priorities. For comprehensive details, the official Medicare website is a valuable resource.

Frequently Asked Questions

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

Original Medicare includes Part A (hospital insurance) and Part B (medical insurance), while Medicare Advantage (Part C) is an all-in-one alternative from private insurers that often bundles in prescription drugs and extra benefits like dental and vision.

Does Medicare cover dental, vision, or hearing?

Original Medicare generally does not cover routine dental, vision, or hearing care. These extra perks are most commonly found in private Medicare Advantage plans.

What is a Medigap policy and what does it cover?

Medigap, or Medicare Supplement Insurance, is extra coverage sold by private companies to help pay for out-of-pocket costs not covered by Original Medicare, such as copayments, coinsurance, and deductibles.

Are preventive services free with Medicare?

Many preventive services, such as flu shots, annual wellness visits, and various cancer screenings, are covered by Medicare with no out-of-pocket cost, as long as you see a provider who accepts Medicare.

How do I get prescription drug coverage?

Prescription drug coverage (Part D) is available through private insurance companies. You can enroll in a stand-alone Part D plan if you have Original Medicare, or receive it bundled with a Medicare Advantage plan.

Can I have both a Medigap policy and a Medicare Advantage plan?

No, you cannot have both. A Medigap policy only works with Original Medicare, not with a Medicare Advantage plan.

What if I can't afford my Medicare premiums?

Several government programs, such as Medicare Savings Programs and the Extra Help program, exist to assist people with limited income and resources in paying for Medicare costs like premiums, deductibles, and copayments.