1. Basic benefits

These are the hospital and medical services Original Medicare covers under Part A and Part B. The plan must cover them. It cannot drop them. Hospice is the exception. Hospice stays with Original Medicare, even if you are in a Medicare Advantage plan.

The copay can differ from Original Medicare. A plan may charge a set dollar amount for a doctor visit instead of a percentage. The visit is still covered. The dollar amount is on that plan’s Summary of Benefits, not on this page.

The yearly limit

Each plan has a yearly limit on what you pay for covered in-network Part A and Part B services. Medicare sets the highest limit a plan may use. The plan can set a lower one. After you reach that plan’s limit, the plan pays the rest of those covered in-network services for the rest of the year. The Part B premium, the plan premium, and most prescription costs do not count toward it.

Services to look up on the Summary of Benefits

The cost is not the same on every plan. Confirm the copay, and confirm that the doctor or hospital is in the network, before you rely on it.

  • Inpatient hospitalOften a daily copay, or one copay for the whole stay. The amount is on that plan’s Summary of Benefits.
  • Skilled nursingCare in a nursing facility after a hospital stay. Original Medicare usually requires a three-day inpatient stay first. A Medicare Advantage plan may use a different rule. Read the three-day stay and the Evidence of Coverage.
  • Home healthSkilled care at home when a doctor orders it and it is medically necessary. Many plans charge no copay. Confirm that.
  • Inpatient mental healthA hospital stay for mental health. Often a daily copay. Confirm how many days that copay covers.
  • Outpatient mental healthA visit with a therapist or psychiatrist. Often a copay for each visit.
  • Primary careA visit with your main doctor. Often a set copay. Confirm that doctor is in the network.
  • SpecialistA visit with a specialist. An HMO may require a referral first. See Medicare HMO vs PPO.
  • Preventive careMany screening and preventive services have no copay when you use an in-network provider. The Summary of Benefits lists which ones.
  • Durable medical equipmentItems such as a walker or oxygen equipment. A doctor must order them. The plan may charge a percentage or a set copay.
  • Lab testsBlood work and similar tests. Often a low copay, or no copay, when you use an in-network lab.
  • Outpatient surgerySurgery you do not stay overnight for. Often one copay for the procedure. The plan may have to approve it first.
  • Emergency careCovered in or out of network. On many plans the copay is waived if you are admitted. Confirm that rule.
  • Urgent care away from homeCare you need while you are temporarily outside the plan’s area. Often a set copay.
  • Part B drugs given in a clinicInjections and similar drugs given in a doctor’s office or clinic. These are not the prescriptions you pick up at a pharmacy.

2. Required extras

A required extra is something Original Medicare does not cover, but this plan includes for every member. You do not opt in. You also do not get it free. The cost is in the premium or the copays. It is the same for everyone in that plan.

  • Lower copaysThe plan charges less than the basic Medicare cost for some services. That lower copay is still part of what you pay.
  • Flex cardA set dollar allowance for the plan year. Unused amounts do not become cash.
  • Routine dentalCleanings and other routine dental care, up to the dollar limit in the Summary of Benefits. Two plans can both say dental and cover different services.
  • Routine visionAn eye exam, a glasses allowance, or both. Read the dollar limit and how often you can use it.
  • Routine hearingA hearing exam, a hearing-aid allowance, or both. Read what the allowance will and will not buy.
  • Fitness programA gym or fitness benefit included for every member. Confirm which gyms are included this year.

What a flex card does not do

Read the list of what the card can buy. Write “included for everyone,” then write the dollar limit.

  • It is not cashUnused amounts do not carry over as money you can spend anywhere.
  • It does not pay Part D drugsThis kind of extra cannot pay prescription copays at the pharmacy. Drug costs follow the plan’s drug benefit.
  • It lasts one plan yearThe allowance is for that year. A new year can change the amount or the list of allowed items.

3. Optional extras

An optional extra is offered to everyone, but you do not have to take it. If you take it, you usually pay an added premium or added cost sharing. Ask whether it is already included, and what it costs for the year.

  • More dentalDental beyond the required package, such as fillings or dentures. Ask the yearly cost and the dollar limit.
  • A larger vision allowanceMore than the glasses or exam benefit already included. You pay extra only if you add it.
  • FitnessA gym benefit you can decline when it is not already included for everyone.
  • Rides to appointmentsTransportation you add and pay for. This is different from a ride offer that is not in the Summary of Benefits.
  • Over-the-counter allowanceA set amount for approved drugstore items, when that allowance is not already included for everyone.

4. Not a plan benefit

A plan may also offer something that is not in the benefit package. These items are not in the Summary of Benefits. They are not benefits Medicare approved for the plan. They can be changed or stopped. Medicare marketing rules generally keep them small, often no more than about $75 for one item and about $150 in a year. Do not join a plan to get one.

  • Meals after a hospital stayA short run of meals after discharge. If it is not in the Summary of Benefits, do not count on it next year.
  • A ride that is not a listed benefitA ride program offered outside the plan documents. A transportation benefit in the Summary of Benefits is different.
  • A nurse phone lineA nurse advice line that is separate from the plan’s telehealth benefit. Ask to see it in the Summary of Benefits.
  • A small wellness itemA low-cost item such as a thermometer. It is not a reason to join.
  • A community referralA pointer to a food program or similar local help. Useful, but not a covered benefit.

How to compare

Check the doctor, the medical group, and the hospital on Medicare.gov. Your plan and your medical group explains the California group that often controls referrals. The Medicare Advantage list shows 2027 benefits filed for a California ZIP. It does not name a best plan. Each fall, the Annual Notice of Change says what is different on January 1. How to read that notice is the checklist. My Medicare Checkup is the place to write the answers.

  • A $0 premiumDoes not mean the hospital copay is low, and does not mean your doctor is included.
  • A dental allowanceDoes not mean the plan includes your specialist.
  • A flex cardDoes not pay the prescriptions you pick up at the pharmacy.
  • A giftIs not a benefit you can count on next year.
  • Write the medical costs firstWrite the yearly medical limit and the copays for the hospital and the doctors you use.
  • Mark included extrasThese are the extras every member gets. Note the dollar limit.
  • Mark extras that cost moreThese are the add-ons. Write the extra premium before you count them.
  • Leave out anything not in the Summary of BenefitsIf a gift, a meal, or a phone line is not listed there, do not use it to compare plans.