Original Medicare and Medicare Advantage are two different types of medical insurance offered by the federal government for those who are 65 or older. They are also available for some people with disabilities.
Both options provide coverage for doctor visits, hospital stays, and other medical expenses. But they differ in terms of plan network, monthly premiums, and out-of-pocket costs.
Key Takeaways:
- Original Medicare is a government-sponsored health insurance program for individuals who are 65 years or older, or have certain disabilities.
- Medicare Advantage (MA) is an alternative to Original Medicare, offered by private insurance companies and approved by Medicare.
- Original Medicare is comprised of Part A (Hospital Insurance) and Part B (Medical Insurance), while Medicare Advantage plans often include both A and B, as well as prescription drug coverage (Part D).
- Original Medicare typically has higher out-of-pocket costs for beneficiaries, including deductibles and coinsurance, compared to Medicare Advantage plans.
- Medicare Advantage plans often offer additional benefits not included in Original Medicare, such as dental, vision and hearing coverage.
- Beneficiaries must weigh the costs, coverage and network restrictions when choosing between Original Medicare and Medicare Advantage.
What is Original Medicare?
Original Medicare includes Part A and Part B. Part A covers hospital stays, hospice care, and some home health care. Part B covers doctor visits, lab tests, and other medical services. Together, these two parts provide a comprehensive package of medical insurance.
The cost of Original Medicare is determined by the federal government and is based on your income and other factors. The Part B premium, for example, is typically higher for those with higher incomes.
What is Medicare Advantage?
Medicare Advantage, also known as Medicare Part C, is a type of medical insurance offered by private insurance companies. These plans provide all of the coverage that Original Medicare does, but they may also include additional benefits such as vision, hearing, and dental coverage. Medicare Advantage plans also have a network of providers that you must use in order to receive coverage.
Original Medicare vs. Medicare Advantage
When it comes to Medicare coverage, individuals have the option to choose between Original Medicare or a Medicare Advantage Plan (also known as a Medicare Part C). It’s important to be aware of the key differences between these two options in order to make an informed decision on how to receive your Medicare benefits.
Original Medicare is the original and traditional program offered by the federal government.
- It comprises two parts, Part A which covers inpatient or hospital care, and Part B which covers outpatient medical care.
- It is accepted by most doctors across the country and it has limits on the charges that beneficiaries can incur when visiting participating or non-participating providers.
- Beneficiaries will be provided with a red, white, and blue card that they can show to providers when receiving care.
Medicare Advantage is an alternative to Original Medicare,
- It’s provided by private insurance companies that contract with the federal government to offer Medicare benefits.
- These plans must provide the same benefits as Original Medicare but may have different rules, costs, and restrictions.
- Additionally, Medicare Advantage plans may provide additional benefits that Original Medicare does not offer. Some of the most common types of plans are Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Private Fee-For-Service (PFFS) plans.
- When receiving care, beneficiaries will show the membership card from their plan instead of the red, white, and blue card.
The table below compares Original Medicare and Medicare Advantage.
Original Medicare (Part A and B) | Medicare Advantage Plans (Part C) | |
Main difference | Medicare pays providers the Medicare-approved rates for covered services per Medicare rules and regulations. Your providers bill Medicare. | Medicare pays private health plans that have contracts with Medicare to provide all medically-necessary health care that Original Medicare (Parts A and B) cover. Your providers bill your Medicare Advantage plan. |
Costs | You pay Medicare Parts A and B premiums, deductibles and coinsurances. Part A is free if you or your spouse have paid taxes while working a minimum of 10 years (if not, you may pay a premium). For most people, the Part B cost is $164.90 in 2023. After deductibles are met, you pay 20% co-insurance on all Medicare services. There is no limit to the amount of money you will be responsible for paying. Whatever the costs are, you will pay 20%. | You pay Medicare Parts A and B premiums, and your Medicare Advantage Plans premium, if it charges one, and possible deductibles and coinsurances. Part A is free if you or your spouse have paid taxes while working a minimum of 10 years (if not, you may pay a premium). For most people, the Part B cost is $164.90 in 2023. Advantage plans may have deductibles, co-pays and co-insurance but in general are less expensive than Original Medicare. There is also an Out of Pocket Maximum on Advantage plans. Once you reach the maximum out of pocket costs you pay nothing for health care services for the rest of the year. |
Supplemental insurance | You may be able to buy a Medigap policy. Other insurance, such as retiree, employer or union plans may supplement Medicare. | You can’t buy a Medigap policy to help pay your out-of-pocket costs in a Medicare Advantage plan. |
Covers extra services like vision and dental? | No. Covers medically-necessary inpatient and outpatient health care. Doesn’t cover certain services such as routine vision, hearing or dental care. | Maybe. May cover some services Original Medicare doesn’t cover such as routine vision, hearing and dental care. All plans must cover the same inpatient and outpatient services Original Medicare covers. |
Allows me to see providers nationwide? | Yes. You can go to any doctor or hospital in the U.S. that accepts Medicare. | Usually not. Most people have HMOs, which typically have local networks of providers you must use for the plan to cover your care. PPOs plans should cover care you get outside the network, but you will pay more. |
Need referrals to see a specialist? | No. You don’t need a referral. | Maybe. You may need to get a referral from your primary care doctor if you want to see a specialist. |
Covers drugs? | No, but if you want Medicare prescription drug coverage, you can buy a separate Part D plan. | Usually. Most plans include Part D drug coverage. |
Out-of-pocket limits? | No. There’s no cap on what you spend on health care. | Yes. Plans must have an annual out-of-pocket limit, which can be high, but protect you if you need expensive care. The plan pays the full cost of your care after you reach the limit. |
How do I know if I have Original Medicare or a Medicare Advantage?
To determine if you have Original Medicare or a Medicare Advantage plan, check your enrollment status. This will reveal the name of your plan, the coverage it provides, and how long you have been enrolled in it. You can check your enrollment status by calling 1-800-MEDICARE or at Medicare.gov if you have an account.
Do Medicare Advantage Plans Replace Original Medicare?
It’s important to note that Medicare Advantage plans can serve as a replacement for Original Medicare and also provide additional coverage, depending on the plan you choose. These plans are provided by private insurers. They offer the same coverage as Part A and Part B plus additional benefits that Original Medicare does not cover. Therefore, Medicare Advantage plans can be seen as a comprehensive option for your healthcare needs.
You must have both parts A and B (and pay your part B premium) to be enrolled in a Medicare Advantage (Part C) Plan.
Which one is better for me?
Original Medicare is better if you:
- value provider flexibility – the ability to see any medical provider or visit any facility in the country that accepts Medicare;
- are a frequent healthcare/hospital user – if you have ,multiple complex health conditions and need to access numerous specialists you have more choices for care under Original Medicare (Advantage plans are required to have all types of providers in network);
- Are able to afford the 20% co-insurance or can afford a Medicare Supplement Insurance plan,
- plan to travel during your retirement, and prefer to minimize risk.
- You also have the option to purchase a Medigap plan. It can cover certain deductibles, copays, and coinsurance for treatment under Medicare Part A and Part B.
Consider Medicare Advantage Plan if you:
- Live in an area with a wide range of providers and top-notch hospitals.
- Are comfortable deductibles, copays, and coinsurance, and would like the financial protection of an out of pocket maximum;
- Can’t afford a Medicare Supplement Insurance plan.
- Are willing to work within a network of providers and perhaps need referrals for specialty care (Advantage PPO plans do allow you to see out of network providers at a higher cost);
- Want additional benefits such as dental, vision, hearing gym memberships and Over the Counter benefits (additional benefits vary between insurers and plans);
- Would like to have your care and billing managed by one entity rather than working with each individual provider and Medicare directly.
FAQS:
Q: What are the key differences between Original Medicare and Medicare Advantage? A: The key differences between Original Medicare and Medicare Advantage are in the costs, benefits, and provider networks. Medicare Advantage plans may have lower out-of-pocket costs and include additional benefits not covered by Original Medicare, but may have more restrictions on which doctors and hospitals you can visit. Original Medicare offers more flexibility in choosing your healthcare providers, but may have higher out-of-pocket costs for certain services.
Q: Can I have both Original Medicare and Medicare Advantage at the same time? A: No, you cannot have both Original Medicare and Medicare Advantage at the same time. If you enroll in a Medicare Advantage plan, you will be disenrolled from Original Medicare and will receive all of your healthcare coverage through the Medicare Advantage plan.
Q: How do I choose between Original Medicare and Medicare Advantage? A: The choice between Original Medicare and Medicare Advantage depends on your individual health needs and personal preferences. Consider factors such as your healthcare needs, preferred doctors and hospitals, cost, and additional benefits when making your decision.
Final Word:
Identifying which Medicare coverage you have, Original Medicare or Medicare Advantage, is important to ensure you receive the healthcare benefits you need.To determine which coverage you have, you can review your Medicare card or contact Medicare directly. Understanding which coverage you have can help you make informed decisions about your healthcare options and enable you to take full advantage of the benefits available to you. Remember, you may have the option to switch between Original Medicare and Medicare Advantage during certain enrollment periods, such as the Annual Enrollment Period (AEP) or a Special Enrollment Period (SEP), if your healthcare needs change over time.
Need help? Call Health Plans in Oregon: 503-928-6918. Our assistance is at no cost to you.
*By completing this form, you agree that an authorized representative or licensed insurance agent may contact you by phone,email,text, mail or face to face to answer your questions or provide additional information about your Medicare plan options. Not affiliated or endorsed by Medicare or any state or federal governmental agency.
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