What are the benefits of Medicare Advantage over Original Medicare?
Last Updated : 09/06/20195min read
According to the Center for Medicare and Medicaid Services (CMS), as of 2019, more than a third of all Medicare beneficiaries (36.7%) are projected to be enrolled in Medicare Advantage plans.
What is the difference between Original Medicare and Medicare Advantage?
Medicare Advantage, also known as Medicare Part C, was first offered over 30 years ago as part of the Tax Equity and Fiscal Responsibility Act (TEFRA).
The Medicare Advantage program gave Medicare beneficiaries more coverage options. According to the Kaiser Family Foundation, “Since the 1970s, Medicare beneficiaries have had the option to receive their Medicare benefits through private health plans, mainly Health Maintenance Organizations (HMOs), as an alternative to the federally administered traditional Medicare program. The Balanced Budget Act (BBA) of 1997 named Medicare’s managed care program “Medicare+Choice” and the Medicare Modernization Act (MMA) of 2003 renamed it “Medicare Advantage.”
Federal law requires that all Medicare Advantage plans offer the same coverage, at a minimum, as Original Medicare (except for hospice care, which is still covered by Part A), and these plans are available through private insurance companies approved by Medicare. Because they are privately managed, they can negotiate directly with doctors, hospitals, and health networks to better control health-care costs.
Medicare Advantage plans take several different forms. Depending on where you live and your specific situation, you may be able to choose from a Health Maintenance Organization (HMO) plan, a Preferred Provider Organization (PPO*) plan, a Private Fee-For-Service (PFFS) plan, or a Special Needs Plan (SNP). Each of these types of plans has different guidelines and benefits that may vary depending on the company offering it. For example, some Medicare Advantage plans may require you to choose a primary care physician and/or get your routine and non-emergency care from providers in the plan’s network.
Another key difference between Original Medicare and Medicare Advantage plans is that Medicare Advantage plans are able to offer additional benefits not available to people enrolled in Original Medicare. For example, many Medicare Advantage plans include coverage for:
- Prescription drugs under Medicare Part D
- Routine vision care, in some cases including benefits for eyeglasses or contact lenses
- Routine dental care, including routine cleaning and cavity treatment
- Routine hearing care, in some cases including benefits for hearing aids
- Discounted gym memberships and other wellness benefits
It’s important to keep in mind that not all plan types and benefit options may be available in your location.
Can I have Medicare Supplement with Medicare Advantage?
Keep in mind that if you have a Medicare Advantage plan, you can’t use a Medicare Supplement insurance plan to help pay for your Medicare Advantage plan’s out-of-pocket costs, such as copayments. Medicare Supplement, which may pay some of Medicare’s coinsurance, copayments and deductibles, is only designed to work with Original Medicare (Part A and Part B). In fact, it’s illegal for you to be sold a Medicare Supplement insurance plan if you are enrolled in Medicare Advantage. If you already have a Medicare Supplement insurance plan when you enroll in Medicare Advantage you can keep it, but you can’t use it to pay any of Medicare’s coinsurance, copayments, or deductibles.
What else should I know about Original Medicare vs. Medicare Advantage?
First of all, even if you choose a Medicare Advantage plan, you are still enrolled in the Medicare program and covered by all its rights and protections, such as:
- The right to be treated with respect and dignity and protected against discrimination
- The right to appeal any decisions made by your plan
- The right to file a grievance or complaint about the care you received from a health-care provider or facility
Although some Medicare Advantage plans are called “$0 premium” plans, what this actually means is that you will not be charged an additional premium on top of your normal Part B premium. Everyone enrolled in a Medicare Advantage plan must continue to pay the Part B premium each month. You may also pay an additional premium required by the plan. Medicare Advantage plan premiums may vary depending on the plan you choose and where you live.
If you’re thinking about signing up for a Medicare Advantage plan, and you want to keep the same doctors and specialists you’ve had for a long time, you may want to make sure they’re included in the Medicare Advantage plan’s provider network, if the plan has one.
Finally, Medicare Advantage plans place an annual cap on your out-of-pocket expenses. Once you reach this limit, you generally pay nothing for covered services for the rest of the year. This annual limit may vary by plan and it can change from year to year, but you always have the guarantee that your health expenses can never exceed the annual limit.
Still have questions about Original Medicare vs. Medicare Advantage?
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**Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan 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 your plan’s 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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