A BEGINNER’S GUIDE
Understand what it is, how it works with Original Medicare, what to check, and when you may be able to enroll.
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I’m Maninder (Manny) Dhillon, a licensed insurance agent. I can help explain Medicare choices in English, Punjabi, and Hindi. Call 443-454-0882 with questions. You can also review plans yourself at Medicare.gov.
The short answer: Medicare is health insurance, usually for people 65 or older. After you have Medicare’s hospital and medical coverage, you can receive that coverage in one of two main ways: Original Medicare or a Medicare Advantage plan. Medicare Advantage is a Medicare-approved plan run by a private company. It is still Medicare, but the plan may have its own doctor network, rules, and costs. Neither choice is best for everyone. [Source: How Medicare works]
| Name | What it means |
|---|---|
| Part A | Hospital insurance. It helps cover inpatient care—when a hospital formally admits you to stay—and certain other services. |
| Part B | Medical insurance. It helps cover doctors’ services, outpatient care (care when you are not admitted to stay in a hospital), medical supplies, and many preventive services (care such as screenings and vaccines meant to help prevent illness or find it early). |
| Part C | Another name for Medicare Advantage. A Medicare-approved private plan provides most of your Part A and Part B-covered care. |
| Part D | Medicare prescription-drug coverage. Most Medicare Advantage plans include it; with Original Medicare, you can choose a separate Part D plan. |
Original Medicare = Parts A and B. With Part C, you choose a Medicare Advantage plan. For most covered care, you use that plan instead of Original Medicare; some exceptions remain. You must have both A and B to join a Medicare Advantage plan. Some people get A and B automatically; others must sign up. [Sources: Medicare basics, Coverage options]
A simple picture to share with a child: Imagine two roads to your doctor. Both roads are part of Medicare. One road is Original Medicare; the other is a Medicare Advantage plan run by a company Medicare approves. Before choosing, an adult checks the doctors, medicines, rules, and costs on each road. This picture is only a starting point; the rest of this guide explains the details. [Source: Compare the two choices]
First you get Medicare Parts A and B. Then you choose an available Medicare Advantage plan in the area where you live. To join, you generally must have both A and B, live in that plan’s service area (the places where it accepts members), and be a U.S. citizen or lawfully present in the U.S. The plan gives you a member card to use for most covered care. Keep your red, white, and blue Medicare card; you may need it for some services, and if you return to Original Medicare. Medicare-approved private companies run these plans under Medicare rules. [Sources: Joining a plan, Understanding Medicare Advantage]
What is covered? Plans must cover almost all medically necessary care—care needed to diagnose or treat a health problem under Medicare’s medical standards—that Original Medicare covers, including emergency and urgent care. Original Medicare still covers certain exceptions for a plan member, such as hospice care and some clinical research costs. What is offered, who qualifies, and the limits differ by plan. Most, but not all, plans include Part D drug coverage. Check each plan’s official Evidence of Coverage (the detailed coverage document) and Summary of Benefits (the shorter overview). [Sources: What Part B covers, How Medicare works, Understanding Medicare Advantage, Evidence of Coverage]
What can differ? One plan may include your doctor and another may not. One may cover a medicine differently or use a different pharmacy network. Plans can have different monthly charges, charges when you use care, and rules for getting referrals or approval. Check the exact plan for the exact year—not just the company name. [Sources: Review coverage choices, Review plan types]
| Your question | Original Medicare | Medicare Advantage |
|---|---|---|
| Who can treat me? | Generally any doctor or hospital in the U.S. that takes Medicare. | For routine care, you may need providers in the plan’s network (its list of participating doctors and facilities). Some plans allow out-of-network care at a higher cost. |
| Will I need permission first? | Usually no referral to see a specialist; in most cases, no prior approval for covered care, but check exceptions. | Some plans require a referral (your doctor sends you to a specialist) or prior authorization (plan approval before certain care). Rules depend on the plan and service. |
| How do I get prescription coverage? | You may join a separate Part D drug plan. | Most plans include Part D, but not all do. Check your exact drugs and pharmacy. |
| What might I pay? | Part B premium and a share of covered service costs; no yearly out-of-pocket limit with Original Medicare alone. Other insurance may help. | Part B premium (some plans help pay it), possibly plan monthly costs, and a share of service costs. Plans have a yearly limit for covered Part A/B medical services, but it does not cap every expense. |
| Could I use Medigap? | You may be able to buy a Medigap policy, separate insurance that helps pay some Original Medicare costs. | Medigap cannot pay Medicare Advantage costs. Leaving Medicare Advantage later does not always mean you can buy the Medigap policy you want. |
People may choose Medicare Advantage for a particular network, included drug coverage, a medical out-of-pocket limit. Others may prefer Original Medicare for broader access to Medicare-accepting providers and the option to add Medigap and a separate drug plan. These are reasons to review, not promises that one choice will cost less or work better for you. [Sources: Official comparison, How Medigap works]
A Medigap timing warning: Your one-time, six-month Medigap Open Enrollment Period generally starts the first month you are 65 or older and have Part B. During this period, you have important rights to buy a Medigap policy. If you join Medicare Advantage and later return to Original Medicare, those same rights may not be available; other federal or state protections can sometimes apply. Check before switching. [Source: When to buy Medigap]
A simple cost comparison: Imagine Plan X advertises a $0 monthly plan premium. You still may owe the Part B premium and a copay at each doctor visit. If your doctor is outside Plan X’s network, your cost or ability to use that doctor may differ. Now imagine Plan Y has a monthly plan premium but lower copays for the services you expect to use. To know which might cost less, add the real plan monthly costs, expected visit costs, prescription costs, and any other coverage you have. Do not choose by the large “$0” alone. Use Medicare’s Plan Finder for actual local plan figures. [Sources: Medicare costs, Understanding health plan costs, Official comparison]
Doctors and hospitals. Before joining, ask whether each doctor and hospital you use is in the specific plan’s network for the coming year. A plan that covers a service may still set rules about where you receive routine care. A referral is a doctor’s direction to a specialist; prior authorization is the plan’s approval before certain care. Some plans need one or both, others do not. [Source: Compare Medicare Advantage plan types]
Prescription drugs. A formulary is a plan’s list of covered medicines. Check the exact drug name, dose, and any restrictions, then check whether your preferred pharmacy is in the plan’s network and what it may charge. Most Medicare Advantage plans include Part D, but not all do; depending on plan type, joining a separate Part D plan may not be allowed. [Sources: Drug coverage choices, Plan comparison steps]
Emergencies. Medicare Advantage plans must cover emergency and urgent care. You can get needed emergency or urgent care even when the provider is outside the plan network; routine non-emergency care can have different network rules. [Sources: How Medicare works, How to get services]
Travel. In the U.S., Original Medicare generally lets you use any provider who takes Medicare. With Medicare Advantage, check the plan’s service area, routine-care network, and travel rules before a trip. Outside the U.S., Medicare generally does not cover care, though exceptions and some plan or Medigap benefits may apply. Do not assume foreign-travel coverage. [Sources: Official comparison, Travel outside the U.S.]
Step 1: Get Medicare Part A and Part B. Some people are enrolled automatically; others sign up through Social Security. Your Medicare card shows your coverage start dates. Step 2: Choose how to receive coverage. You can stay with Original Medicare or, during a permitted plan sign-up window, join a Medicare Advantage plan available where you live. You need both A and B for Medicare Advantage. A chance to join a plan does not itself sign you up for missing Part B. [Sources: How do I sign up?, Joining a plan]
New to Medicare around 65: The first Part A/B window is usually seven months: three months before your birthday month, that month, and three months after. Check whether Social Security will enroll you automatically; a first-of-month birthday shifts the dates earlier. For Part B, signing up before your birthday month generally starts coverage on the first day of that month. Signing up in the birthday month or the next three generally starts it the following month. Once A/B dates are known, use your first plan-choice window to review Original Medicare and available Medicare Advantage plans. A plan requested before Medicare begins can start with Medicare; a later request generally starts the first of the following month. [Sources: When coverage starts, Joining a plan]
New to Part B after already having Part A: A separate plan-choice window may let you join Medicare Advantage. It generally starts three months before you first have both A and B and ends two months after. Check your exact dates. If you request the plan before Part B begins, plan coverage generally starts when Part B starts. If you request it after Part B begins, coverage generally starts the first day of the following month. [Source: Understanding enrollment periods]
Changing next year’s coverage: Annual Open Enrollment is October 15–December 7. You can join, drop, or switch a Medicare Advantage plan; change between Original Medicare and Medicare Advantage; and make allowed drug-plan changes. A request received by December 7 generally takes effect January 1. This window does not sign you up for a missing Part B. [Source: Joining a plan]
Already in Medicare Advantage after New Year: Medicare Advantage Open Enrollment is January 1–March 31. You can generally make one change: switch to another Medicare Advantage plan or return to Original Medicare, with an option to join separate Part D. The change generally begins the first of the next month. This is not a general January–March chance for a person with only Original Medicare to join Medicare Advantage. If you first joined a Medicare Advantage plan when you first got Medicare, you may also be able to change plans or return to Original Medicare during your first three months with Parts A and B; check your dates with Medicare. [Sources: Joining a plan, Understanding enrollment periods]
A major life change: A Special Enrollment Period is a time-limited chance to make specific changes after a qualifying event. A move outside your plan’s service area or loss of employer/union coverage can qualify. Medicaid is a federal-state health coverage program for eligible people with limited income. Extra Help helps eligible people pay Medicare Part D drug costs. If you have Medicaid or Extra Help, certain additional drug-plan changes or a move to a plan designed for people who have both Medicare and Medicaid may be possible, but not unlimited switches to any plan. Deadlines and start dates depend on the event; often a new plan begins the first of the month after the request. [Sources: Plan special periods, Medicaid, Extra Help]
Missed the first Part B window without an exception: The Part B General Enrollment Period is January 1–March 31. Part B generally starts the first day of the month after you sign up. A penalty or coverage gap may apply. This signs you up for Part B; it is not the January–March Medicare Advantage Open Enrollment Period. Ask about your separate new-to-Part-B plan-choice window once you have A and B. [Sources: When coverage starts, Joining a plan]
Important if you work past 65: Qualifying current-employment group coverage means health insurance from a job you or your spouse is working at now. It may let you delay Part B without a penalty. Ask the employer benefits office how its coverage works with Medicare before delaying.
Once work or that coverage ends—whichever comes first—you generally have an eight-month Part B sign-up window. A separate, often shorter window may apply to joining a Medicare Advantage or drug plan after job coverage ends.
COBRA lets some people temporarily keep job-based insurance after employment or eligibility ends; it does not extend that Part B window. Retiree coverage is health insurance from a former employer after retirement. Retiree, Marketplace, Veterans, and other coverage may follow different rules. Do not assume they protect the same Part B window. [Sources: Working past 65, COBRA and Medicare]
Examples: If you turn 65 on June 2, the usual A/B window runs March through September. If you have Original Medicare and want Medicare Advantage in February, the January–March Medicare Advantage change period alone does not let you join. A new-to-Medicare, new-to-Part-B, or Special Enrollment Period might apply; check your dates. Otherwise, review plans. If you are already in Medicare Advantage in February, you may be able to make one allowed change. If you move in June, check a move-related Special Enrollment Period promptly. These are not individual eligibility decisions. [Sources: When Medicare starts, Joining a plan, Special periods]
[Sources: Joining a plan, Understanding Medicare Advantage]
All 24 questions are available below. Select a question to read its answer.
It is a way to receive Medicare coverage through a Medicare-approved private plan. You still have Medicare Parts A and B. [Source: How Medicare works]
No. You keep Medicare, but for most care you use the plan’s card and follow its rules. Keep your Medicare card too. [Source: Understanding Medicare Advantage]
Yes. You must have both to join a Medicare Advantage plan, and you generally must live in its service area. [Source: Joining a plan]
No. Many people qualify at 65, but some qualify earlier due to disability, ALS, or End-Stage Renal Disease. Their timing may be different. [Source: Get started with Medicare]
No. “$0-monthly cost” refers only to the plan’s separate monthly charge. You generally still pay the Part B premium and may pay for visits, hospital care, or drugs. [Source: Medicare costs]
Medicare Advantage covers almost all medically necessary services Original Medicare covers, but the plan may have network and approval rules. Verify a specific service with the plan; Original Medicare handles some exceptions such as hospice. [Source: How Medicare works]
No. Check the exact plan documents. [Source: Understanding Medicare Advantage]
Maybe. Check whether the doctor is in the specific plan’s network for the year you want coverage. Ask the doctor and check the plan’s current directory. [Source: Official comparison]
It is a plan’s group of participating doctors, hospitals, and other providers. Routine care outside it may cost more or not be covered under plan rules. [Source: Compare plan types]
Medicare Advantage plans must cover emergency and urgent care, including needed care outside the network. Routine care while away can have different rules, so check before travel. [Source: How to get services]
It depends on the plan. Some require a referral from your regular doctor, or prior approval for certain care. [Source: Compare plan types]
Not automatically. Check each medicine and dose on the plan’s covered-drug list and check your pharmacy and expected cost. Most, but not all, Medicare Advantage plans include drug coverage. [Source: Plan comparison steps]
Often not if your Medicare Advantage plan already includes drug coverage; the rule depends on plan type. Check with Medicare or the plan before enrolling in separate Part D, because it may affect your health-plan enrollment. [Source: Coverage options]
Medigap is separate insurance designed to help with some Original Medicare costs. It cannot pay your Medicare Advantage copays or monthly costs. If you leave Medicare Advantage later, your Medigap purchase rights may be limited. [Source: How Medigap works]
Yes, during an allowed change window. If you want drug coverage or Medigap afterward, check those separate rules before switching. [Sources: Joining a plan, How Medigap works]
October 15 through December 7 each year. Allowed plan changes generally start January 1. This window does not sign you up for a missing Part B. [Source: Joining a plan]
If you are already in a Medicare Advantage plan, January 1 through March 31 generally lets you make one allowed switch or return to Original Medicare. It is not a general chance for someone with only Original Medicare to join Medicare Advantage. [Source: Joining a plan]
Your own first Medicare and plan-choice windows can apply even outside October–December. Check your personal seven-month A/B window and when you first have both A and B. [Sources: When coverage starts, Joining a plan]
Do not guess. Current-employment group coverage may let you delay Part B without penalty, but employer size and how the plan pays matter. Ask the benefits office and Medicare before you delay. COBRA and retiree coverage are not the same as current-job coverage for the Part B window. [Source: Working past 65]
You may get a time-limited Special Enrollment Period. The allowed change and deadline depend on the event, so check promptly instead of waiting for fall. [Source: Special Enrollment Periods]
Not necessarily. Read your Annual Notice of Change, which explains changes due in January, and recheck doctors, drugs, pharmacies, and costs each fall. [Source: Annual Notice of Change]
Medicare.gov and 1-800-MEDICARE offer official information. Your State Health Insurance Assistance Program (SHIP) gives free, personalized counseling and is not connected to an insurance company or plan. [Source: Medicare helpful tools]
Yes. A pre-existing condition by itself does not prevent you from joining if you meet the plan’s other eligibility rules. Check that the plan’s doctors, medicines, costs, and care rules fit your needs. [Source: Understanding Medicare Advantage]
Ask the plan for its coverage decision and instructions to appeal. An appeal is a request to review a decision you disagree with. Deadlines apply, so read the notice and act promptly. [Source: Medicare appeals]
[Sources: Medicare & You handbook, Compare coverage choices]