It’s important to understand your Medicare coverage choices and to pick your coverage carefully. Today we’ll discuss one important choice—Original Medicare versus a Medicare Advantage plan. 

First, let’s go over the basics of Original Medicare.

Original Medicare is the traditional program offered directly through the federal government. It’s sometimes called Traditional Medicare or Fee-for-Service Medicare.

• With Original Medicare, you can go to any doctor or hospital that takes Medicare, anywhere in the country.
• You can go directly to the doctor or hospital when you need care. This means you don’t need to get permission from Medicare or a referral from your primary care doctor.
• With Original Medicare, you’re responsible for a monthly premium for Part B, and in some cases, a monthly premium for Part A.
• You typically pay a coinsurance, or percentage of the full cost, for each service you receive.
• Those with Original Medicare may have the option to buy a Medigap to help cover out-of-pocket costs like Part A or Part B coinsurance.
• If you want prescription drug coverage with Original Medicare, you’ll need to choose and join a stand-alone Medicare private drug plan, also called a Part D plan.

Unless you choose otherwise, you will have Original Medicare when you first enroll in Medicare. 

Second, let’s review the basics of Medicare Advantage.

Medicare Advantage plans are sold by private insurance companies. The companies contract with and receive payment from Medicare to offer you plans. They’re also called Part C or MA plans.

• In Medicare Advantage plans, you generally need to see doctors who are in your plan’s network to get care and pay the lowest cost for care.
• In many Medicare Advantage plans, you must get permission from the plan or a referral for specialty care or procedures.
• You might owe a premium for the Medicare Advantage plan. If so, this is in addition to the premium for Part B, and in some cases a monthly premium for Part A.
• You’ll often pay fixed copayments per service or item you receive. These costs vary from plan to plan. Plans can’t charge higher copayments or coinsurances than Original Medicare for certain services, like chemotherapy and dialysis. They can charge higher cost-sharing for other services, though. 
• Medicare Advantage plans must cover all the same services as Original Medicare, and they usually include prescription drug coverage.
• All Medicare Advantage plans offer a limit, or cap, on out-of-pocket expenses for Part A and B services. These limits do not exist in Original Medicare. The limits tend to be high but can protect you from unlimited costs if you need a lot of care or expensive treatments.
• Some Medicare Advantage plans may offer certain benefits that Medicare doesn’t cover, such as dental and vision care or certain in-home supports.

Contact a Medicare Advantage plan directly to learn about its costs, coverage, and any additional benefits it may provide.

What to consider when choosing between Original Medicare and Medicare Advantage.

Some of the important factors to consider are: 

• Costs: What premiums and out-of-pocket costs will I owe? 
• Supplemental insurance: Can I buy a Medigap policy? If I have other coverage, like a retiree plan, how will it work with my Medicare coverage? 
• Provider access: What kind of providers can I see? Do I need to see in-network providers or get referrals? If so, are the doctors I see in the plan’s network?
• Drug coverage: Is prescription drug coverage included, or can I choose a separate plan? Does the plan cover the drugs I take? If I have other coverage, like a retiree plan, how will it work with my Medicare coverage? 
• Supplemental benefits: Are extra services covered, like vision, hearing, or dental in the Medicare Advantage plan? If so, what is the cost?
• Out-of-pocket limit: Is there an annual limit on out-of-pocket costs in the Medicare Advantage plan? What is the limit and what counts toward it? 

Your State Health Insurance Assistance Program (SHIP) can help you compare your Medicare coverage options. SHIP counselors are government funded to provide trusted, unbiased Medicare counseling at no cost to you. (Depending on your state, your SHIP may go by another name.) Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted) to find your local SHIP.

You can also use Medicare’s Plan Finder tool to compare Medicare Advantage plans, Part D plans, and Medigap plans in your area.

Once you’ve chosen a plan, you can call 1-800-MEDICARE (633-4227) or go to www.medicare.gov to change your coverage.

Finally, as you compare coverage options, beware of misleading marketing.

Before you enroll in a plan, make sure you understand its benefits and rules. Contact a plan directly to confirm if it will cover certain services for you, and make sure that you get everything in writing.

Remember that an agent or broker should never pressure or mislead you into joining a plan. They should also never offer gifts to sign up or say they were sent by Medicare or Social Security. If you feel an agent has pressured or misled you, save all the information such as an agent's business card, messages, marketing handouts, or other contact information.

You should report this to your local Senior Medicare Patrol (SMP) or SHIP. Your SMP or SHIP can help you review the concern and report it to CMS as a potential marketing violation.      

Still have questions? 

Your SHIP is here for you! You can contact your SHIP for any Medicare-related questions or concerns you have. SHIP counselors are government funded to provide trusted, unbiased Medicare counseling at no cost to you. (Depending on your state, your SHIP may go by another name.) SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted) to find your local SHIP.

If you think you have experienced potential Medicare fraud, errors, or abuse, contact your local Senior Medicare Patrol using the online SMP Locator or by calling 877-808-2468.

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