If you’re paying attention to all the television advertising for Medicare Advantage plans, you’ll know that Medicare Open Enrollment ends Dec. 7 – which means you have only a little bit of time before you can choose between original Medicare and one of those super-hyped Medicare Advantage plans.

If you’re 65 or older, you qualify for Medicare coverage, so you’ll want to pay attention. You also may qualify for coverage if you are under 65 with a qualifying disability or have amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease. You also could be eligible if you have end-stage renal disease requiring dialysis or a kidney transplant.

But how and whether to choose? What’s with this alphabet soup – A, B, C and D? What is Medicare Advantage, and what are those touted advantages? What happens if you do nothing? Given that Medicare and Medicare Advantage plans cover your hospital, physician and potentially prescription medications, but possibly in different ways, understanding it all is critical.

Joan Adler, a certified Medicare adviser, retired physician and occasional guest presenter at Center on the Hill, has a thing or two to say about all of it.

Adler volunteers for PA MEDI – Pennsylvania’s version of the State Health Insurance Assistance Program (SHIP) – and the opinions she expresses here are hers, and not those of PA MEDI.

Note that if you do nothing, you will receive traditional Medicare by default. (It also should be noted that if you’re just turning 65, you get Part A by default if you’re already collecting Social Security. If not, depending on whether you have employer insurance, you may have to sign up for it or potentially be penalized.)

But what if you want Medicare Advantage? Here’s how to make sense of it all.

Medicare

Original or traditional Medicare includes Part A and Part B coverage, and that will pay 80 percent of your medical bills, Adler explains. Part A covers inpatient hospital care, and Part B provides coverage for doctor visits, labs, X-rays, outpatient procedures and medical equipment. “Most people then attach a Medigap supplement, which is an extra insurance plan that you pay a monthly premium for, and that covers almost the entire rest of the 20 percent that Medicare doesn’t cover,” she says. You may also purchase an independent drug plan – that’s Part D – and the cost for that varies depending on what medications you’re taking.

As with all things related to health care in the United States, there are pros and cons to Medicare.

First, the advantages.

Perhaps most important – there are no networks. “You can go to any provider anywhere in the country that takes Medicare,” Adler said. “You don’t need referrals. You don’t need to be in your home county. And usually what your doctor orders, you get. There is very little of what is called “prior authorization,” where someone looks at what your doctor wants you to get and then says whether or not they’re going to give it to you.”

The disadvantage? A monthly premium, which can be expensive for some people.

The premium for Part A is typically zero, assuming you paid Medicare taxes for at least 10 years, according to Medicare.gov, which most people have done. There is a deductible, however — $1,736 in 2026 — for each hospital stay.

Part B’s premium is $202.90 in 2026, or higher depending on your income. There is a deductible (the amount you have to pay out of pocket before Medicare takes over) and that’s $283 in 2026.

Parts A and B do not cover the cost of prescription medications. For those, you need a Part D drug plan, which you purchase separately, Adler said. (Visit the Medicare website to search for available plans in your area, as well as compare Medicare and Medicare Advantage plans: medicare.gov/plan-compare) Monthly premiums and deductibles for Part D vary widely, depending in part on which and how many medications you are taking.

On the downside, the premium costs of traditional Medicare could be a barrier to those who do not have much of an income, Adler noted.

Medicare Advantage

So, we’ve talked about Medicare A, B and D. Where’s Part C?

That’s Medicare Advantage, which bundles Parts A and B and often includes Part D drug coverage.

So, are there any advantages, so to speak, to Medicare Advantage plans? Well, again, if you’ve been paying attention to those TV ads, there can be one big plus, Adler said. Some Medicare Advantage plans offer zero monthly premiums. Many Medicare Advantage also include some vision, dental, fitness, transportation and telehealth benefits.

But there are many potential disadvantages, she adds.

“Medicare Advantage plans are managed care – HMOs (health maintenance organizations) and PPOs (preferred provider organizations),” Adler said. “There are plans for zero monthly premiums and plans that will cost you money. We usually recommend that if you’re going to get an Advantage plan, get a plan with zero monthly premiums because the plans you pay for usually don’t give you much better benefits, anyway. Sometimes they give you worse benefits, and most of the services you get will require a copay. All of these plans have networks, and if you have an HMO and you go outside the network, they will not cover you. If you have a PPO and you go outside the network, they will cover you, but you will pay a higher copay.”

With Medicare Advantage plans, you also may be charged for specialist visits, urgent care, hospital stays, outpatient procedures, and more, Adler said. And they generally provide coverage within your county. “If you go outside the county, you have to call your plan to see if there are any providers in the network that they will let you see if you go outside the county,” she added.

Ultimately, the companies that provide managed care are in it to make a profit, so their motivation is very different from traditional Medicare, Adler said.

That profit motive shows up in unexpected ways.

“There are hundreds, if not thousands of articles that have been written about how Medicare Advantage takes advantage of Medicare by overcharging or overbilling or overdiagnosing,” Adler said. “The model of the Medicare Advantage plan is that they get a part of the money for every year of your capitated life, and they’re supposed to use that money during the year to pay for all of your medical care and whatever is left at the end of the year, they get to keep. So you can see that the motivation would be to give as few services as possible, so they get to keep most of the money.”

Those plans also frequently require prior authorization. The doctor may order a test or procedures, for example, but the plan might deny coverage for it. Patients can appeal, Adler said, and while there is an 80 percent chance that you will win on appeal, only about 11 percent of patients actually do challenge the refusal.

Finally, Medicare Advantage plans frequently use brokers to help patients decide which plan is best — a Medicare Advantage plan or traditional Medicare. And those brokers get paid a higher fee, she says, for enrolling you in a Medicare Advantage plan.

In summary, Adler’s recommendation is to carefully compare options before deciding.

For help making that decision in Philadelphia, call PA MEDI at 215-456-7600.