Medicare Advantage vs. Original Medicare: What You Need to Know

Navigating Medicare can be overwhelming, given its wide array of plan choices. Medicare is like a safety net. It provides insurance for people 65 and older and younger individuals with disabilities and chronic health issues.

Deciding between Original Medicare and Medicare Advantage (MA or Medicare Part C) is crucial. This article explains the benefits, drawbacks, and characteristics of each option. It will help you choose wisely.

Already know the basics? View our comparison chart below. 

What is Original Medicare?

The U.S. federal government offers Original Medicare, a traditional program. Original Medicare consists of two parts. Part A provides hospital insurance. Part B provides medical insurance, which includes doctor's visits and outpatient care. You'll be automatically enrolled in Parts A and B if you get Social Security benefits at age 65.

What is Medicare Advantage?

Approved private insurance companies offer Medicare Advantage, or Medicare Part C. These plans include all the services covered under Original Medicare but can also include additional benefits such as dental, vision and wellness programs. Medicare Part D covers prescription drugs. According to a J.D. Power report, many people with Medicare Advantage plans are happy with them. They appreciate the savings and good health care.

Related Reading: Understanding Medicare: An Introductory Guide

Medicare Advantage Plans

To sign up for a Medicare Advantage plan, people 65 or older must be part of Original Medicare Part A and Part B first. Medicare Advantage plans, also called MA plans, have different coverage. Each plan gives different choices and covers different health needs. These include:

• Health Maintenance Organizations (HMOs): To see certain doctors and providers, you need a referral from your main doctor. If you go out of this network, the costs could be significantly higher.

• Preferred Provider Organizations (PPOs): Lets you choose your doctors, but it can be more expensive.

• Medicare Savings Accounts (MSA): You can pick your own provider and use money from your Medicare Savings Account for health care or expenses.

• Private Fee-for-Service (PFFS) Plans: The plan determines how much you pay for services but allows you to go to any Medicare provider or facility that accepts the plan and agrees to treat you.

• Special Needs Plans (SNPs): Helps people with specific diseases or characteristics, such as chronic illnesses, financial limitations, or institutional living. These plans provide specialized care to ensure patients get the right treatment for their situation.

Additional Coverage in Medicare Advantage

Medicare Advantage offers extra services such as dental, vision, and wellness programs. Some Medicare Advantage plans also offer coverage for hearing aids, which can benefit people age 65 and older.

Another advantage is the limit on out-of-pocket expenses for health care services. This limit determines the maximum amount you will have to pay each year. Medicare Advantage may be a better option for individuals requiring extensive medical assistance. This is because Original Medicare does not have an annual out-of-pocket limit.

Coverage Zones

Medicare is available everywhere in the US, but there are some differences:

• Original Medicare: Good for people who travel a lot or live in different states. You can see any doctor who takes Medicare.
• Medicare Advantage (MA) Plans: These have certain rules about where you can get care. They cover emergency care anywhere in the US. But, if you need to see a doctor for something less urgent and you're not in your home state, the plan might not cover it.

Premium Differences

When it comes to premiums, the costs can vary widely. The government determines the Part B premium in Original Medicare annually. Your income may affect your premium. The price of Medicare Advantage can change depending on the plan and provider. It usually covers the Part B premium. When deciding between Medicare Advantage and Original Medicare, it is important to compare all the costs. This includes premiums, copays, out-of-pocket limits, and prescription costs.

Prescription Drug Coverage

To get prescription drug coverage, you need to enroll in a separate Part D plan. Original Medicare doesn't include it. Medicare Advantage plans often have drug coverage, making life easier and cheaper. It depends on your medication needs.

Preventive Services

Preventive services are important for both Original Medicare and Medicare Advantage. But, the services can differ. Medicare covers preventive services like screenings and flu shots. Annual wellness visits are included too. They usually don't cost extra if the health care provider accepts Medicare.

Medicare Advantage plans cover the same preventive services as Original Medicare. They also offer extra services, such as vision and dental screenings. Some people choose Medicare Advantage over Original Medicare because of the extra services it offers.

Network Restrictions and Referral Requirements

Another difference lies in network restrictions. With Original Medicare, you can choose any doctor or health care provider that accepts Medicare. This gives you a wide range of options. Medicare Advantage plans often have network restrictions, especially in HMOs. In HMOs, you need to pick a primary care doctor. Usually, you have to get a referral from your doctor to see a specialist with Medicare Advantage. But, in Original Medicare, a referral is not necessary.

Annual Enrollment Period

Both Original Medicare and Medicare Advantage have annual enrollment periods. These periods are important for making changes to your plans. For Original Medicare, the general enrollment is from January 1 to March 31. You can switch or sign up for Medicare Advantage every year between October 15 and December 7. This is your chance to assess your health care needs and make any necessary changes.

Enrollment Penalties

Many people don't realize that Medicare enrollment penalties can affect their finances in the long run. If you don't join Medicare Part B or a drug plan (Part D) on time, and you don't have other drug coverage, you might have to pay a late fee. This penalty will continue as long as you have Medicare. The penalties are a percentage. It can raise your monthly premium, which affects your health care cost. To avoid penalties, enroll during your initial enrollment period.

Appeals and Grievances 

Both Original Medicare and Medicare Advantage have processes for filing appeals and grievances. If you disagree with your Medicare plan's payment or service decision, you have the right to an appeal. There are different levels in the appeals process. If you don't agree with a decision, you can go to the next level.

Grievances are different from appeals. They are complaints you make about your plan or the quality of care you receive. Understanding how your plan deals with these processes is important. Each plan has its own timelines and procedures for filing. Before going to Medicare's system, you must go through the appeals and grievance processes of Medicare Advantage plans.

Final Thoughts

If you want to pick any doctor and don't need dental or vision coverage, Original Medicare may work for you. If you need prescription drugs, dental, vision, and more, Medicare Advantage could be better for you.

No matter what you choose, it's important to match it with your health, money, and lifestyle. Keep this guide close as you navigate through the complexities of Medicare.

Whatever your health care needs, CareAllies-aligned doctors deliver personalized care centered around you. Use our Find a Doctor tool to find a CareAllies-supported provider near you.

Medicare Advantage vs. Original Medicare: At-a-Glance Comparision