Original Medicare vs. Medicare Advantage – What’s the Difference?
People with Medicare can get their health coverage through either Original Medicare or a Medicare Advantage Plan (also known as a Medicare private health plan or Part C). Consider the following key differences between these two options when deciding how you want to receive your Medicare benefits.
Original Medicare
The traditional program offered directly through the federal government
- Includes Part A (inpatient/hospital coverage) and Part B (outpatient/medical coverage)
- Most doctors in the country take this insurance
- Medicare limits how much an individual can be charged when they visit participating or non-participating providers
- Beneficiary receives a red, white and blue card to show to providers when receiving care
Medicare Advantage
Private plans that contract with the federal government to provide Medicare benefits
- Must provide the same benefits offered by Original Medicare, but may apply different rules, costs and restrictions
- May also offer certain benefits that Original Medicare does not cover
- Some of the most common types of plans are Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Private Fee-For-Service (PFFS) plans
- Beneficiary shows the membership card from their plan when receiving care
Medicare Enrollment Periods
If you sign up for Original Medicare and later decide you would like to try a Medicare Advantage Plan—or vice versa—be aware that there are only certain enrollment periods when you are allowed to make changes.
Below is a summary of the key differences between Original Medicare and Medicare Advantage.
Costs
Costs
Supplemental Insurance
Supplemental Insurance
Provider Access
Provider Access
Referrals
Referrals
Prescription Drug Coverage
Prescription Drug Coverage
Money-saving Extra Benefits
Money-saving Extra Benefits
Maximum Out-of-Pocket Limit
Maximum Out-of-Pocket Limit
Original Medicare
Costs
• You will be charged for standardized Part A and Part B costs, including a monthly Part B premium.
• You’re responsible for paying a 20% co-insurance for Medicare-covered services if you see a participating provider even after meeting your deductible.
Supplemental Insurance
Have the option to pay an additional premium for a Medigap policy to help cover Medicare cost-sharing for benefits not covered by Original Medicare.
Provider Access
Can see any provider and use any facility that accepts Medicare (participating and non-participating).
Referrals
No referrals needed for specialists.
Prescription Drug Coverage
Prescription drugs are not covered under Original Medicare. Beneficiaries must sign up for a stand-alone prescription drug plan.
Money-saving Extra Benefits
Original Medicare does not cover vision, hearing, dental or other “extra” benefits/coverage.
Maximum Out-of-Pocket Limit
There are no annual maximum out-of-pocket limits with Original Medicare coverage.
Medicare Advantage
Costs
• Your cost-sharing varies depending on your plan. Usually you’ll pay a copayment for in-network care.
• Depending on a Medicare Advantage plan’s benefits, some Medicare Advantage plans offer $0 premium plan options, while others may charge a monthly premium. In addition to any Medicare Advantage plan premium, you must continue to pay your Part B premium no matter which Medicare Advantage plan you select unless your Part B premium is paid for you by Medicaid or another third party.
Supplemental Insurance
While Medicare Advantage beneficiaries cannot purchase Medicare Supplement (or Medigap) plans, members do not have a need to do so given the expanded coverage of a Medicare Advantage plan which may include Prescription Drug Coverage and other money-saving extra benefits such as vision, dental, hearing, health club memberships, etc.
Provider Access
Typically can only see in-network providers, which differ by plan. PPO plan members may see out-of-network providers without prior approval.
Referrals
Some Medicare Advantage plans do not require referrals for specialists, while others do.
Prescription Drug Coverage
Most Medicare Advantage plans provide prescription drug coverage with predetermined, fixed drug copays based on tiers.
Money-saving Extra Benefits
Medicare Advantage plans are known for their money-saving extra benefits, including OTC allowances, vision, hearing and dental coverage as well as others that differ by plan (health club memberships, chiropractic care, etc.).
Maximum Out-of-Pocket Limit
• Medicare Advantage plans come with an annual maximum out-of-pocket limit.
• This means your plan pays the full cost of your care after you reach your max out-of-pocket (sometimes referred to as “MOOP”) limit.
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