While most Americans have heard of Medicare as one of many health care coverage options, they may not know how it differs from other privately offered options, such as Medicare Advantage. This article explains the differences of Original Medicare vs. Medicare Advantage, including the various doctors one can seek care from, the differences in cost and the range of coverage between plans. While this article provides a useful comparison when choosing a health care plan, each person should ultimately choose a plan that best fits their individual health care needs.
Doctor and Hospital Choice
The first difference of Original Medicare vs. Medicare Advantage is the doctors and hospitals that each plan covers. Original Medicare allows patients to visit any provider in the U.S. that accepts Medicare. Alternatively, Medicare Advantage is only accepted by providers that are within the plan’s network. Further, if a patient needs to see a specialist, a referral is generally not needed with Original Medicare, whereas Medicare Advantage may require one.
Another key difference of Original Medicare vs. Medicare Advantage is the cost. The following costs are associated with Original Medicare:
- For services such as doctor visits, flu shots, health screenings and medical supplies—otherwise known as Part B services—the patient will pay coinsurance, which is 20% of the Medicare approved amount after the deductible is met.
- There will be a monthly premium for Part B services. Further, there will be an additional Part D premium if the patient enrolls in Part D—otherwise known as Medicare drug coverage.
- Unless the beneficiary is enrolled in supplemental coverage, such as Medicare Supplement Insurance (Medigap), there is no yearly limit on out-of-pocket costs.
Medigap or coverage from a former employer can help pay remaining out-of-pocket costs, such as the 20% coinsurance.
For information on costs under Medicare Advantage, consider the following:
- The out-of-pocket cost will vary by the services received.
- Similar to Original Medicare, the patient will have to pay a monthly premium for Part B services. Patients will also have to pay the plan’s premium. However, this premium may help pay all or a portion of the Part B premium and most plans also include Part D coverage.
- There is a yearly limit on what a patient pays for out-of-pocket services for Part A—hospital stays, nursing services, lab tests, etc.— and Part B services. Once this limit is reached, all further Part A and B services are covered for the remainder of the year.
- Unlike Original Medicare, Medigap is neither a necessity nor an available option.
With respect to coverage, Medicare Advantage generally covers a little bit more than Original Medicare. Original Medicare covers most medically necessary services, such as those that are considered Part A and Part B services, but does not include other benefits like vision and dental care. Alternatively, Medicare Advantage covers all of the medically necessary services that Original Medicare covers, and it often also includes additional benefits, such as eye exams and dental services.
Another key difference in coverage relates to Medicare drug plan—Part D. While Part D is included in most Medicare Advantage plans and patients with those plans cannot join a separate Medicare drug plan, patients with Original Medicare do not automatically get Part D coverage. Those with Original Medicare must join a separate Medicare drug plan.
Further, Original Medicare usually does not require that patients get a service or supply request approved in advance in order for it to be covered. On the other hand, Medicare Advantage generally requires that services and supply requests are approved ahead of time for them to be covered.
Lastly, both Original Medicare and Medicare Advantage generally do not provide medical care outside of the U.S. For those with Original Medicare, there may be an option to purchase Medigap that covers foreign emergency care. For Medicare Advantage policyholders, certain plans may provide a supplemental benefit that extends to foreign emergency services.
Ultimately, the choice of Original Medicare vs. Medicare Advantage will depend on each individual’s medical needs and priorities. Generally, Medicare Advantage covers most of what Original Medicare covers and also provides some supplemental benefits. Beyond coverage, the cost of each option and the providers that accept each option will differ.
If you have more questions about the differences between Original Medicare and Medicare Advantage, please make an appointment with HR.
This Know Your Benefits article is provided by Benefit Analysts, Inc. and is to be used for informational purposes only and is not intended to replace the advice of an insurance professional. © 2022 Zywave, Inc. All rights reserved.
The content herein is provided for general information purposes only, and does not constitute legal, tax, or other advice or opinions on any matters. This information has been taken from sources which we believe to be reliable, but there is no guarantee as to its accuracy.