Essential Medicare Benefits for All Medicare Plans

Reviewed and Updated by Troy Frink,

Prior to 1965 when Medicare was created, people over the age of 65 found it almost impossible to be covered by private health insurance companies after retirement. Original Medicare is the program the government created to cover essential medical needs like hospital stays and doctor visits. There are two parts: A and B.

The term Medicare has expanded since the 1960s to include other important services and programs in order to help people be as healthy as possible. Now, private health insurance companies can sell “Medicare Advantage” plans, often known as Part C. “Extra” Services such as vision insurance, hearing coverage and physical fitness programs typically fall under Part C.

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Does Medicare Count for Minimum Essential Benefits?

The Affordable Care Act originally required that everyone have a health plan with the minimum essential benefits, which included:

  • Ambulatory outpatient services
  • Emergency services
  • Hospitalization
  • Pregnancy/maternity/newborn care
  • Mental health and substance abuse services
  • Prescription drugs
  • Rehabilitative services/devices
  • Lab services
  • Preventive/wellness services
  • Pediatrics (including dental and vision for kids)

If you had Medicare, you would have met the minimum essential benefits requirement. The federal government dropped the requirement that you have a minimum coverage level under the Affordable Care Act (also known as ACA or Obamacare) in 2019. However, certain states still impose penalties.

You meet minimum coverage requirements if you have coverage under Part A, Parts A and B together, or a Medicare Advantage plan (Part C). If you’re covered by any one of those plans, you will not have to pay the penalty for not having health insurance. If you were only enrolled in Part B, you would not meet the government-mandated minimum requirements.

Free Prescription Discount Card
Free Prescription Discount Card

What Does Medicare Cover?

When people talk about Medicare benefits, they are referring to Original Medicare plans. However, specific plans cover different things, and not all plans have the same coverage. Here’s what Original Medicare plans cover:

  • Preventive care
  • Annual wellness appointments
  • Doctor visits
  • Telehealth
  • Mental health
  • Ambulance transportation
  • Home health (limited)

Original Medicare plans do not cover prescription drugs – except in limited cases, such as for oral cancer medications. Most prescription drugs require a Medicare Part D coverage or certain Medicare Advantage plans.

Difference Between Part A and Part B

Medicare Parts A and B fall under Original Medicare. Part A is Medicare hospital insurance, and it covers hospital visits and stays. It does not cover ambulance transportation. (That’s included in Part B.) Part B covers doctor’s appointments, telehealth, mental health, preventive care, annual wellness visits, ambulance transportation, and limited home health.

Medicare Health Benefits

If you need more coverage than what Part A and Part B provide, you’ll want to look towards a Medicare Supplement plan or Medicare Part C. Part C plans can include:

  • Dental
  • Vision
  • Hearing
  • Fitness classes and gym memberships
  • Non-emergency transportation, such as trips to the doctor’s office
  • Meal delivery
  • And more!

Many people will find that Original Medicare benefits cover most of their needs as they age, but it’s important to consider the quality of life that can be obtained when you have access to a gym or have taxi fare to get to the doctor. We can’t think of anything more important than your health and well-being, and a Part C plan can provide the additional benefits you need to be healthy and happy.

Meeting with a licensed agent for Medicare
Meeting with a licensed agent for Medicare

Medicare Advantage

While you aren’t required to enroll in Medicare Part C, it is a valuable asset for most people. Medicare Parts A and B cover only the most basic needs for health care. There are thousands of Medicare Advantage plans to choose from, and a qualified professional can help you sort through them and find one that suits your needs.

Medicare Advantage plans are private health insurance plans that cover every service Original Medicare covers. Advantage plans are often used along with government-run plans to ensure the patient has coverage for what he or she needs, which can include dental, vision, and even meal delivery.


Medigap policies cannot be used in conjunction with Medicare Advantage. Medicare supplements pick up where Original Medicare falls off. Medigap plans can help with coinsurance, co-payments, and deductibles. These plans are strictly for financial coverage, and not health coverage.

How to Get More Benefits

If you need coverage for things that don’t fall under the Original Medicare umbrella, you need to know a few things before you enroll. Medicare Advantage (Part C) and Medicare Supplements (also called Medigap) can serve different needs, and either can be beneficial depending on your circumstances.

The Initial Enrollment Period (IEP) consists of the six months surrounding your 65th birthday and your birthday month. This is important to know because you must select a policy in that timeframe in order to be covered. If you do not enroll in Medicare Advantage during that time, the only other time you can do that is during the Annual Enrollment Period (AEP), which is every year from October 15 through December 7.

While most people who wish to make changes to their health insurance or get new coverage must enroll during the AEP, the Special Enrollment Period (SEP) allows people – even those younger than 65 – to enroll if they are diagnosed with specific, chronic health conditions. If you qualify for the SEP, you can add or change coverage once per quarter during the first three quarters of the year. Some people may have limited special enrollment periods that surround qualifying events. For example, if you move to a new service area where different plans are available, you may be granted a temporary (typically 60 day) special enrollment period.

Get Essential Medicare Health Benefits

A comprehensive Medicare plan can help you live your best life. If you’re ready to enroll in Medicare benefits and need assistance in selecting the right plan for you, we can help you find a plan that fits your budget and lifestyle. Call us at 844-431-1832 or contact us here today.

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