Medicare Benefits 101

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Information in this section is meant to provide your simple easy to read information to educate you on the basics of Medicare

We hope that this information will educate you well enough that you will return to use these simple and easy guides to Medicare.

Medicare originated in 1965 as part of the Social Security Act to assure Older Americans that they would have continued health insurance.   Initially, original Medicare just offered the core basics, which include Medicare Part A (Hospital) and Part B (Doctor Visits -Out Patient).

1997, the Balanced Budget Act  Medicare benefits expanded to offer Medicare Advantage through private health insurance plans.  In 2003 Medicare Part D (Prescription Coverage), was populated under the Medicare Modernization Act.

Today, 48 million Americans enjoy the benefits of Medicare.  Medicare is offered to the following Americans;

  1.  Americans ages 65+
  2.  Disabilities – all age groups
  3.  Americans with End Stage Renal Disease (ESRD) all age groups
  4.  Americans with Amyotrophic Lateral Sclerosis(ALS or Lou Gehrig’s Disease)

Medicare Core Basics are outlined below:

Medicare Part A (Hospital Insurance) Traditional

  1. Inpatient care in Hospital
  2. In patient care for convalescence in a skilled nursing facility
  3. Hospice care
  4. Home health care

** Covered services pays 80% while you pay 20%

 Medicare Part B  (Medical Insurance) Traditional

  1. Doctors and other health care providers
  2. Outpatient care
  3. Home health care
  4. Durable medical equipment
  5. Approved preventive services

**  Part B is optional if the beneficiary and/or spouse is currently working and receiving health coverage through employer.  If not enrolled in Medicare Part B and not receiving Insurance through work a lifetime penalty of 10% can be assessed per year.

** Covered services pays 80% while you pay 20%

Medicare Part C (Medicare Advantage aka MA)

  1. Offers a choice of HMO or PPO Like medicare plan
  2. Includes all services provide under Part A and Part B except Hospice Care
  3. Usually included is Part D (Prescriptions Coverage)

**Medical benefits are covered in full.

Medicare Part D (Prescriptions)

  1. Operated by a Medicare approved private insurance with strict guidelines.
  2. Assists in the coverage of beneficiary prescriptions costs
  3. Protects future inflationary costs

Unraveling The Difference: Between Medicare & Medicare Advantage.

Option 1 Option 2
Medicare Medicare Advantage
Medicare Part A (Hospital Insurance) Medicare Part C (combinations of Part A & Part B)
Medicare Part B (Medical Insurance)
Medicare Part D (Coverage of cost for your prescriptions) Medicare Part D (most Medicare plans include coverage of prescriptions
Medigap (supplemental insurance) Medigap is NOT available for Medicare Advantage

 What is not Covered by Traditional Medicare Part A & Part B

  • Most care while traveling out side of U.S.
  • Long Term Care
  • Routine Eye Care
  • Most dental Care
  • Dentures
  • Hearing examinations for fitting hearing aids
  • Routine foot care
  • Alternative Medicine i.e. acupuncture and Chiropractic
  • “Long Term Care” or “Custodial” i.e. bathing,toileting and dressing.
  • Maintaining Services i,e, shopping, meal preparation and cleaning
  • Non-Medical Services i.e. private room, in-room television, telephone, copies of x-rays

PROS OF Medicare Advantage 

  1. Prescription Coverage is included in most plans.  Medicare Original has you pay an additional $40/mo for Medicare Part D
  2. Medicare Advantages has an Out-Of-Pocket Max (OOPM),  Medicare Advantage (OOPM) $6,700, where as Medicare Original you keep paying your 20%portion.
  3. Medicare Advantage includes most of the supplements offered by Medigap (Medical Supplement)
  4. Medicare Advantage plans assist in deductibles, coinsurance and out of pocket max.  However, Medicare Original offers Medigap (Supplements) for additional costs to counter act the costs of deductibles, coinsurance.  Keep in mind Medicare Original has 20% Coinsurance.
  5. 20-percent Coinsurance
  6. Medicare Advantage structure fixed costs for services.
  7. Medicare Original has 20% coinsurance unless Medigap fills in at a per month cost
  8. Medicare Advantage offers assisted living or nursing home care when your at home.  However, Original Medicare will only provide Long-term care if you are in a assisted living or nursing home care.

 Pros of  Medicare Original 

  1. Original Medicare is accepted by a large population of doctors than Medicare Advantage.  Therefore, medical options are greater with Medicare Original.
  2. Medicare Advantage has more restrictions on doctors as the HMO’s have specified doctors that you have to use.  PPO’s have a network you can choose from otherwise an additional cost ma ybe charged to use out-of-network doctor/specialist.
  3. Medicare Original has a reduced cost for premiums because you choose whether to pay for other Medicare Parts separately or not choosing some at all.
  4. With Medicare advantage HMOs a referral is required.  Where as Medicare Original you would just go.
  5. If presently employed and medical insurance is offered then Medicare Advantage is a full package therefore it doesn’t make sense to pay more.  Medicare Original is offered in parts.
  6. Medicare Original makes more sense if you qualify for Medicaid or Medicare Savings Program.
  7. Medicare Original makes more sense if you have End-Stage Renal Disease (ESRD).  Medicare Advantage will not take you if you have End-Stage Renal Disease (ESRD).  Unless you currently have Medicare Advantage when ESRD is diagnosed or if you have had a successful kidney transplant.

The Essence of Time…… Enrollment Periods

Medicare Enrollment time constraints are very strict and can add additional pressure to an already confusing situation.

  1. First enrollment falls with in a 7 month time frame.  This begins 3 months prior to your 65th birthday and includes the month you turn 65, then includes the 3 months past your birthday month.
  2. Second, if you get Medicare Due to Disability.  Enrollment period is 7 months.  If you a coming up on the 25th month of disability then you have the option of enrolling between the 3 months prior to the 25th month anniversary, then the anniversary month and including 3 months post the 25th anniversary month.
  3. Third, Open Enrollment begins  October 15 – December 7.  Anyone can join, switch or drop a plan during this time.  Coverage will begin January 1.
  4.  Fourth, only changes to Medicare Advantage can occur between January 1 – February 14.


MedicareBenefits.us is not associated with the federal government. All plan information provided on this site is collected from public sources (e.g., cms.gov, carrier's website, plan brochures, etc.). Rates shown are for comparison purpose only. Contact your Medicare agent or Medicare.gov for a binding quote.