Medicare Basics
Medicare Basics: Understanding the Two-Sided Coin
When you first become eligible for Medicare, it can feel like you’ve been handed a complicated puzzle. There are Parts A, B, C, and D, along with terms like “Original Medicare,” “Advantage plans,” and “Medigap.” No wonder many seniors feel overwhelmed.
But let’s simplify things by thinking about Medicare as a two-sided coin. On one side, you have Original Medicare (Parts A and B), and on the other side, you have Medicare Advantage (Part C). Both cover your healthcare needs, but they do so in very different ways. Understanding how these two sides work will help you make the best choice for your health and budget.
Generally it begins the first of the month that you turn 65, unless your birthday is the first of the month. In which case your Medicare starts the first of the month prior to the month you turn 65. (ex 1: if birthday is May 15th, then Medicare starts May 1st) (ex 2: if birthday is May 1st, then Medicare starts April 1st)
However, there is a way in which one gets Medicare under age 65, and that's when they've received Social Security Disability for 24 consecutive months (including any backdating). If that's the case then make sure you find out what your Part A and Part B so you can coordinate your existing coverage with the switch to Medicare to ensure not gap nor overlap in coverage.
Side One: Original Medicare
Original Medicare is the traditional program run directly by the federal government. It has two main parts:
Part A (hospital insurance): Covers inpatient care in hospitals, skilled nursing facilities (for a limited time), hospice care, and some home health care.
Part B (medical insurance): Covers doctor visits, outpatient care, preventive services, lab tests, and durable medical equipment.
Original Medicare allows you to see any doctor or hospital in the United States that accepts Medicare (over 85% of all providers and facilities throughout the US)—no networks, no referrals. But while it provides a wide safety net, it does not cover everything. You pay a 20% coinsurance indefinitely. (example: a $300,000 cancer claim would potentially cost you around $60,000.)
Filling the Gaps with Medigap
The solution?! That’s where a Medicare Supplement (also called Medigap) plan comes in. Medigap plans are offered by private insurance companies and are designed to help pay the “gaps” in Original Medicare—things like deductibles, copayments, and the 20% coinsurance. If you stick with Original Medicare, most seniors also purchase a Part D plan (for prescription drugs) and a Medigap plan for extra protection. (example: that same cancer claim would then cost you a negligible amount as low as $250.)
Pros of Original Medicare (with Medigap)
Freedom to Choose Doctors Nationwide
You can see any doctor, specialist, or hospital in the U.S. that accepts Original Medicare (your Red, White, and Blue card). There are no provider networks or referrals to worry about. This is especially helpful if you travel or spend time in more than one state during the year.Predictable Costs with Medigap
Adding a Medigap plan can take much of the uncertainty out of healthcare costs. Many Medigap plans cover nearly all out-of-pocket expenses, meaning you won’t be surprised by big medical bills. This can bring peace of mind, especially if you have ongoing health issues.
Con of Original Medicare (with Medigap)
Higher Monthly Premiums
Original Medicare alone does not have a limit on out-of-pocket costs, so most seniors buy both a Medigap plan and a Part D drug plan. While this gives excellent coverage, the monthly premiums for these extra plans can add up. If you’re on a tight budget, this side of the coin may feel heavy on your wallet.
Side Two of the Coin: Medicare Advantage
On the other side of the coin is Medicare Advantage (Part C). These are plans offered by private insurance companies that contract with Medicare. When you join an Advantage plan, you still have Medicare, but the private company manages your benefits.
Most Medicare Advantage plans bundle your coverage into one package. They typically include:
Parts A and B coverage (hospital and medical)
Prescription drug coverage (Part D)
Extra benefits not covered by Original Medicare, such as dental, vision, hearing aids, gym memberships, over-the-counter stipend, Part B premium reduction, or transportation to appointments.
Instead of paying separate premiums for a Medigap and Part D plan, Advantage plans often offer everything in one, and very often the premium is $0!
Pros of Medicare Advantage
Lower Monthly Costs
Many Medicare Advantage plans have low or even $0 monthly premiums. For seniors who don’t want to pay for Medigap and Part D separately, this can feel like a budget-friendly option.Extra Benefits
Original Medicare doesn’t cover things like dental checkups, eyeglasses, hearing aids, or wellness perks. Many Advantage plans include these extras, making them appealing if you want more well-rounded coverage.
Con of Medicare Advantage
Limited Provider Networks
Unlike Original Medicare, most Advantage plans use provider networks (such as HMOs or PPOs). That means you may need to see doctors and hospitals within the plan’s network to get the best coverage. If you travel often or live part of the year in another state, you may find this limiting. Out-of-network care can be more expensive—or not covered at all, depending on the plan.
Choosing the Side That’s Right for You
Both sides of the Medicare coin provide important coverage, but your decision depends on your needs, lifestyle, and budget. Let’s look at some factors that can help guide your choice:
Choose Original Medicare with Medigap if you:
Travel often or live in different places during the year.
Want the widest choice of doctors and hospitals across the U.S.
Prefer predictable medical costs, even if it means paying higher premiums.
Don’t mind managing multiple plans (Medigap + Part D).
If, when you turn 65, you have a high health risk of of needing a lot of medical care.
Choose Medicare Advantage if you:
Want an “all-in-one” plan that includes drug coverage and extra benefits.
Are comfortable using provider networks and don’t travel much.
Prefer lower monthly premiums, even if it means paying more when you use care.
Want extras like dental, vision, or fitness memberships.
Are on both Medicare and Medicaid (dual eligible).
A Word About Prescription Drugs
It’s important to note that Original Medicare does not cover prescription drugs. That’s why you need a separate Part D plan if you choose that side of the coin. On the Advantage side, most plans automatically include drug coverage. Always check the plan’s drug formulary (the list of covered medications) to make sure your prescriptions are included.
Don’t Forget: Both Sides Have Annual Changes
Whether you choose Original Medicare or Medicare Advantage, keep in mind that plans and costs can change from year to year. Premiums, drug formularies, provider networks, and benefits may shift. That’s why it’s important to review your coverage every fall during Medicare’s Annual Enrollment Period (October 15 – December 7).
Final Thoughts
Medicare really is like a two-sided coin. On one side, Original Medicare with a Medigap plan gives you broad freedom and predictable costs, though it usually comes with higher monthly premiums. On the other side, Medicare Advantage may offer lower monthly costs and extra perks, but often with slightly limited provider networks.
Neither side is “better” for everyone. Instead, the best choice depends on your health needs, travel habits, and financial situation. The most important step is understanding how both sides work so you can make an informed decision that gives you confidence and peace of mind.
Keep in mind, you're not making a permanent decision as there are times and reasons we can make changes as life continues.
Remember, you’re not alone in this. I am a licensed Medicare advisors and resources for you. Also you can use Medicare.gov to provide guidance tailored to your personal situation. Or, should you want to enroll yourself, using my Advantage / Part D enrollment portal to make it as easy as possible to find the right plan and enroll. With the right information, you’ll be ready to flip the coin and choose the side that works best for you.
If you'd like to schedule a time to discuss your situation and what might be best for you, let's set an appointment by using this calendar link.
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