What does original Medicare cover?

Critics and beneficiaries advise caution with Medicare Advantage plans because of restrictions on care, unexpected costs, and administrative hurdles. While these private plans often feature low or zero monthly premiums and extra perks like dental or vision, they come with significant trade-offs.

Restricted Provider Networks

• Local limitations: Most plans use specific HMO or PPO networks, meaning you must see doctors and go to hospitals within the plan’s local area.
• No nationwide freedom: Unlike Original Medicare, which lets you see any accepting doctor nationwide, Medicare Advantage offers very limited coverage when traveling.
• Frequent changes: Provider lists can change annually or even during the year, meaning your favorite doctor might leave the network unexpectedly.

Prior Authorization and Denials

• Approval delays: Private insurers often require "prior authorization" (advance permission) for specialized care, MRIs, surgeries, or rehabilitation.
• Care obstacles: This review process can delay or block medically necessary treatments.

High Out-of-Pocket Costs

• Cost-sharing for serious illnesses: While plans have annual out-of-pocket maximums (up to thousands of dollars), treatments like chemotherapy or expensive infusions can trigger steep 20% coinsurance charges before you reach that cap.
• End-of-life complications: High utilization during severe or chronic illness can result in major expenses or coverage friction.

The "Medigap" Trap

• Locked-in coverage: If you try to switch back to Original Medicare after a 12-month trial period, moving to a Medicare Supplement (Medigap) plan often requires passing medical underwriting. Pre-existing health conditions can make it difficult or impossible to qualify for a good supplement later.

Yes, you can drop your Medicare Advantage plan and return to Original Medicare, but you can usually only make this change during specific times of the year.

When You Can Switch

• Annual Enrollment Period (October 15 – December 7): You can switch from a Medicare Advantage plan back to Original Medicare. The change takes effect on January 1 of the next year.
• Medicare Advantage Open Enrollment Period (January 1 – March 31): If you already have a Medicare Advantage plan, you can drop it and return to Original Medicare during these months. The change takes effect the first of the month after the request is received.
• Special Enrollment Periods: You can change plans outside these windows if you experience a qualifying life event, such as moving out of your plan's service area.

Important Things to Consider

• Prescription Drug Coverage: Original Medicare does not include prescription drug coverage. If you leave Medicare Advantage, you should sign up for a stand-alone Medicare Part D prescription drug plan to avoid late enrollment penalties.
• Medigap (Supplement Insurance): Original Medicare leaves out-of-pocket costs like co-pays and deductibles. You may want a Medigap policy to help pay these costs. However, outside your initial enrollment window or specific trial periods, insurance companies in most states can use medical underwriting to deny you a Medigap policy or charge higher rates based on your health.

How to Make the Switch

• Call 1-800-MEDICARE (1-800-633-4227) for live assistance.
• Contact your current Medicare Advantage plan to request cancellation.

The single biggest and most costly mistake people make with Medicare is missing enrollment deadlines, leading to permanent late-enrollment penalties and gaps in coverage.

Missing Enrollment Deadlines

• Initial Enrollment Period (IEP): This window lasts for seven months. It starts three months before the month you turn 65, includes your birthday month, and ends three months after.
• Late Penalties: Failing to sign up for Part B or Part D on time can trigger permanent monthly or yearly financial penalties added to your premiums.
• Delayed Enrollment Confusion: Many people wrongly assume they can delay Medicare past age 65 just because they have health coverage like COBRA, a marketplace plan, or small-employer insurance.

Other Costly Medicare Mistakes

• Ignoring Annual Changes: Sticking with automatic renewal without reading the Annual Notice of Change (ANOC) can result in unexpected costs, as drug lists and doctor networks shift every year.
• Choosing Solely by Low Premiums: Picking a plan based only on a low monthly cost while ignoring total out-of-pocket expenses like deductibles, copays, and coinsurance.
• Missing the Medigap Window: Forgetting to apply for a Medigap (Medicare Supplement) policy during your open enrollment window. After this six-month period, insurers can use medical underwriting to charge more or deny coverage.
• Skipping Financial Assistance: Overlooking programs like Medicare Savings Programs or Part D Extra Help that assist with out-of-pocket medical and prescription expenses.

No, Medicare does not cover 100% of hospital bills for seniors.

While Original Medicare Part A covers inpatient hospital care, you still have out-of-pocket costs.

Part A Hospital Costs (2026)

• Deductible: You must pay a Part A deductible of $1,736 per benefit period before Medicare starts paying.
• Daily Coinsurance: Days 1 through 60 have $0 additional costs after the deductible. However, stays from days 61 to 90 require a $434 daily coinsurance, and days 91 to 150 (lifetime reserve days) cost $868 per day.
• After 150 Days: You must pay 100% of all costs.

Doctor and Outpatient Bills

• Part B Services: Doctors who treat you in the hospital bill separately under Part B. You must pay an annual deductible ($283) plus a 20% coinsurance for doctor services.
• Observation Status: If a hospital places you under "observation" instead of admitting you as an official inpatient, your stay is billed under Part B. This means you pay 20% for each individual service, and it may not qualify you for subsequent skilled nursing coverage.

How to Reduce Out-of-Pocket Expenses

• Medigap: You can purchase a private Medicare Supplement Insurance policy to cover deductibles and coinsurance.
• Medicare Advantage (Part C): These private plans replace Original Medicare and include a yearly out-of-pocket maximum limit.

Medicare does not cover bloodwork that lacks a documented medical necessity, such as routine wellness panels ordered during a standard annual physical exam.

Uncovered Blood Tests

• Routine Wellness Panels: Comprehensive blood checks done out of general curiosity or routine monitoring without specific symptoms, risk factors, or a concrete diagnosis.
• Self-Requested Tests: Direct-to-consumer lab orders, walk-in requests, or mail-order kits purchased without a doctor's formal prescription.
• Employment or Licensing Tests: Screenings required by an employer, for insurance applications, or for legal/administrative certifications.
• Experimental Markers: Investigational or alternative functional medicine blood tests not yet recognized by Medicare as safe and effective.
• Over-Frequent Testing: Repeat bloodwork ordered more often than Medicare's established frequency limits allow for a specific condition.