It is important to understand your Medicare coverage choices and to pick your coverage carefully. Today we’ll look at one important choice—choosing between Original Medicare and a Medicare Advantage Plan.
First, let’s understand the basics of Original Medicare.
Original Medicare is the traditional fee-for-services program offered directly through the federal government. It is sometimes called Traditional Medicare or Fee-for-Service Medicare. Under Original Medicare, you can go to any doctor and hospital that takes Medicare, anywhere in the country. You can go directly to the doctor or hospital when you need care, meaning you do not need to get authorization from Medicare or a referral from your primary care doctor for most services.
In Original Medicare, you are responsible for a monthly premium for Part B, and in some cases, a premium for Part A. You typically pay a coinsurance, or percentage of the full cost, for each service you receive, but those with Original Medicare do have the option to purchase a Medigap to help cover their out-of-pocket costs.
If you want prescription drug coverage with Original Medicare, in most cases you will need to actively 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.
Next, let’s look at the basics of Medicare Advantage.
Medicare Advantage Plans, also known as Part C or MA plans, are plans that contract with the federal government to provide Medicare benefits. Remember, you still have Medicare if you enroll in an MA Plan. This means that you will still owe a premium for Part B and maybe Part A, as well as potentially another premium for the MA Plan. MA Plans must cover all the same services as Original Medicare, and they usually include prescription drug coverage. In MA Plans, you usually need to see providers who are in your plan’s network and service area to pay the lowest cost for services. In many plans, you must get prior authorization or a referral from your primary care provider for specialty services, procedures, and durable medical equipment.
You will often pay fixed copayments per service or item you receive. These costs vary from plan to plan. Plans cannot charge higher copayments or coinsurances than Original Medicare for certain services, like chemotherapy and dialysis, but they can charge higher cost-sharing for other services. All MA Plans must include a limit on your out-of-pocket expenses for Part A and B services, although these limits tend to be high.
Some MA Plans may offer certain benefits that Medicare does not cover, such as dental and vision care or certain in-home supports.
Contact a plan directly to learn about its costs, coverage, and any additional benefits it may provide. You can also use Medicare.gov’s Plan Finder tool to compare Medicare Advantage Plans in your area. Your local State Health Insurance Assistance Program (SHIP) can assist you in comparing your coverage options. Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted) to find your local SHIP.
Now here are some important factors to consider when choosing between Original Medicare and Medicare Advantage.
Costs: What premiums and out-of-pocket costs will I be responsible for?
Supplemental insurance: Will I have the choice to purchase a Medigap policy? If I have other coverage, like a retiree plan, how will it work with my Medicare coverage choice?
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 there prescription drug coverage included or will I need to purchase a Part D plan? Does the drug coverage cover the medications I take?
Additional/supplemental benefits: Are additional services, like vision, hearing, or dental covered?
Out-of-pocket limit: Is there an annual limit on out-of-pocket costs?
If you would like to discuss these factors more and receive assistance comparing your options, you should contact your local State Health Insurance Assistance Program (SHIP). Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted) to find your local SHIP.
Finally, be aware of marketing violations as you compare plans.
Medicare Advantage Plan and Part D plan representatives, agents, and brokers must follow federal guidelines when marketing to you. These guidelines protect you from manipulative and deceptive sales and enrollment tactics. A fundamental principle is that marketing cannot be conducted under the guise of education. Here are some red flags to look for:
You signed up for a plan after being told by a company that certain services or prescriptions are covered, but after enrolling, you discover they were not covered by the plan.
A company represented itself as coming from Medicare, Social Security, or Medicaid.
You received an unsolicited phone call or text from a plan with which you have no prior relationship or have asked not to contact you.
An agent began discussing other insurance products, such as life insurance, during a visit or meeting that was scheduled to only discuss a Part D or Medicare Advantage product.
A plan agent returned uninvited to your residence after missing an earlier appointment.
You signed up for a plan after being told by a company that certain prescriptions or services were covered, but after reviewing your Explanation of Benefits (EOB), you found they were not covered by the plan and you received a bill instead.
Call your local Senior Medicare Patrol (SMP) to report any manipulative or deceptive sales tactics you experience. If you enrolled in a plan because of misleading information, you may be able to change your plan by calling 1-800-MEDICARE. Your SMP or State Health Insurance Assistance Program (SHIP) can also help.
Still have questions?
Your SHIP is here for you! You can contact your SHIP for any other 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.) Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted) to find your local SHIP.