What’s the Difference Between Medicare Advantage and Original Medicare? – Frequently Asked Questions

Steven Mott by Steven Mott | Licensed since 2012
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This article was updated on: 10/29/2018

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Are you new to Medicare and not sure whether to get your coverage through Original Medicare or a Medicare Advantage plan? This article breaks down key differences between Original Medicare and Medicare Advantage so you can make an informed decision.

What is Original Medicare?

Original Medicare is the government health-care program for seniors and certain disabled individuals. It comes in two parts. Medicare Part A covers inpatient hospital services, skilled nursing care, hospice, and certain home health care services. Medicare Part B covers outpatient services, such as doctor visits, preventive care, lab tests, and durable medical equipment.

Prescription drug benefits are limited in Original Medicare, and you’ll need to enroll in a stand-alone Medicare Prescription Drug Plan for this coverage.

What is Medicare Advantage?

The Medicare Advantage (Part C) program is another way to get your Medicare benefits. You’re still in the Medicare program if you have Medicare Advantage. However, instead of getting your Part A and Part B coverage directly through the federal program, your benefits are administered by Medicare-contracted private insurance companies.

Medicare Advantage plans must cover at least the same level of coverage as Original Medicare (except for hospice, which is still covered through Part A). However, many Medicare Advantage plans also cover extra benefits not covered by Original Medicare, such as routine vision and dental, hearing, and wellness programs. In addition, many Medicare Advantage plans include prescription drug benefits wrapped into the plan.

Keep in mind that you’ll need to keep paying your Part B premium, in addition to any premium your Medicare Advantage plan requires. After you’re first eligible for Medicare, you can enroll in a Medicare Advantage during certain times of the year, such as the Annual Election Period and in special situations that may qualify you for a Special Election Period.

How costs compare in Medicare Advantage vs. Original Medicare

There are many factors that affect your Medicare costs, including the medications you take, the type of services you need, and whether you get state assistance.

If you have Original Medicare, your costs will be lowest if you see providers that “accept assignment,” meaning they agree not to charge you more than the Medicare-approved amount for a service or medical equipment.

Medicare Advantage plans, on the other hand, are offered by Medicare-approved private insurance companies. This means that costs like premiums, deductibles, copayments, and coinsurance may vary. Check your Medicare Advantage plan’s “Evidence of Coverage” document for cost information.

Keep in mind that Original Medicare doesn’t have an out-of-pocket limit, meaning there’s no cap on how high your health-care costs could go in a given year. In contrast, all Medicare Advantage plans have a yearly maximum limit, which may vary by plan. If you reach the limit, the Medicare Advantage plan pays for covered costs for the rest of the year.

How providers work with Medicare Advantage vs. Original Medicare

Whether you’re enrolled in Medicare Advantage or Original Medicare may affect the doctors and providers you can use. Original Medicare generally lets you see any doctor, hospital, or provider that is enrolled in the Medicare program and accepting Medicare patients. You don’t usually need a referral to see a specialist.

In contrast, some Medicare Advantage plans, such as Medicare Advantage HMOs, may require you to use provider networks to be covered (except in emergencies). With other type of plans, such as Medicare Advantage PPOs, you have the choice to use in-network or out-of-network providers, but your costs will be lower if you use doctors and hospitals in your Medicare Advantage plan’s preferred network.

Ultimately, only you can decide whether Original Medicare or Medicare Advantage may work best for you, based on your health needs, budget, and preferences. If you like, I can go over plan options with you and answer any questions you may have. We can schedule a phone appointment at your convenience, or I can email you some plan information; find both those links below. Prefer to start browsing on your own? The Compare Plans button will show you coverage options in your zip code.

Medicare has neither reviewed nor endorsed this information

Out-of-network/non-contracted providers are under no obligation to treat <Plan/Part D Sponsor> members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

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