Choosing between Original Medicare and 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 Medicare Part C).
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'd like to try a Medicare Advantage Plan—or vice versa—be aware that there are only certain enrollment periods when you're allowed to make changes.
Key Differences Between Original Medicare and Medicare Advantage
Costs
Supplemental Insurance
Provider Access
Referrals
Prescription Drug Coverage
Money-Saving Extra Benefits
Maximum Out-of-Pocket Limit
• You'll be charged for standardized Part A and Part B costs, including a monthly Part B premium.
• You’re responsible for paying a 20% coinsurance for Medicare-covered services if you see a participating provider even after meeting your deductible.
You 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.
You can see any provider and use any facility that accepts Medicare (participating and non-participating).
You don't need a referral to see specialists.
Prescription drugs aren't covered under Original Medicare. Beneficiaries must sign up for a stand-alone prescription drug plan.
Original Medicare doesn't cover routine vision, hearing, dental, or other “extra” benefits/coverage.
There are no annual maximum out-of-pocket limits with Original Medicare coverage.
• Your cost-sharing varies depending on your plan. Usually you’ll pay a copayment for in-network and out-of-network care.
• 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.
While Medicare Advantage beneficiaries can't purchase Medicare Supplement (or Medigap) plans, members don't have a need to do so given the expanded coverage of a Medicare Advantage plan. Medicare Advantage plans may include prescription drug coverage and other money-saving extra benefits such as vision, dental, hearing, health club memberships, etc.
For HMO plans, you typically have a network of providers you can see. For PPO plans, in addition to having a network of providers, you can also see out-of-network providers.
Some Medicare Advantage plans do not require referrals for specialists, while others do.
Most Medicare Advantage plans provide prescription drug coverage with predetermined, fixed drug copays based on tiers.
Medicare Advantage plans are known for their money-saving extra benefits, including over-the-counter allowances, vision, hearing, and dental coverage, as well as others that differ by plan (health club memberships, transportation, etc.).
• Medicare Advantage plans come with an annual maximum out-of-pocket limit.
• This means your plan pays the full cost of your medical care after you reach your maximum out-of-pocket (MOOP) limit.
Want to learn more about your options?
Request FREE Information
Make an Appointment
Attend a Medicare seminar
