Original Medicare vs. Medicare Advantage

Medicare 101

By Nancy B. O’Connor

Each year, millions of people become eligible for Medicare, most because they turn 65, and some because of disability or certain medical conditions. However, Medicare is not a one-size-fits-all program. That means there are decisions to be made in determining the right type of Medicare coverage that meets your needs at a cost you can afford.

You can choose to get your Medicare coverage through Original Medicare or through a Medicare Advantage Plan.

Original Medicare 

Original Medicare is a fee-for-service plan that is managed by the Federal government. You can go to any doctor, non-physician health care provider, hospital or supplier that is enrolled in and accepts Medicare. Original Medicare has two parts:

  1. Part A (Hospital Insurance): helps cover inpatient care in hospitals, skilled nursing facilities, hospice and home health care.
  2. Part B (Medical Insurance): helps cover services from doctors and other providers, outpatient care, home health care, durable medical equipment and some preventive services.

Under Original Medicare, after you meet your deductible, Medicare covers 80 percent of the approved charges and you are responsible for the remaining 20 percent. In addition, you pay a monthly premium for Part B. Part A is premium-free if you or your spouse paid taxes while working for at least 40 calendar quarters (10 years). If you are not eligible for Part A premium-free, you may get it by paying a monthly premium, the amount of which will depend on the number of quarters you worked.

In Original Medicare, you have the option to add prescription drug coverage by joining a Medicare Prescription Drug Plan, offered by a private insurance company under Medicare Part D. You can also purchase Medicare Supplement Insurance, known as a Medigap Policy, sold by private health insurance companies, to fill “gaps” in Original Medicare Plan coverage, such as the out-of-pocket costs you have with Original Medicare.

You will be enrolled in the Original Medicare plan unless you choose a Medicare Advantage Plan. Most people get their Medicare coverage through Original Medicare.

Medicare Advantage plans

The other option is to receive your Medicare benefits through a Medicare Advantage Plan. These are plans offered and operated by Medicare-approved private insurers under Medicare Part C. They are required to cover all benefits and services covered under Parts A and B, and offer the same rights and protections as Original Medicare. In addition, most include Medicare Part D prescription drug coverage, as well as extra benefits not covered under Original Medicare, usually at additional costs. Theses extra benefits can include vision and dental coverage, eyeglasses, wellness programs, gym membership, and other benefits. Again, the types of extra benefits will vary by plan.

In most Medicare Advantage plans, you need to use doctors, hospitals and other providers who are part of the plan’s network for your services to be covered. If you go outside the plan’s network, except for emergency and urgent care, you are responsible for paying more or all of the cost of the services provided.

Costs for Medicare Advantage plans vary by plan. In addition to the Part B premium, which you are still responsible for paying, there is usually a monthly premium for the plan, co-payments and deductibles. Medicare supplement plans will not pay the cost sharing in a Medicare Advantage plan.

There are also different types of Medicare Advantage Plans, and it’s important to understand how the different types of plans work. Detailed information is available in the “Medicare & You” handbook, and on the Medicare website www.medicare.gov . Not all types of plans are available in all areas.

You can compare Medicare Advantage Plans and Medicare Part D plans available in your area on the Plan Finder section of the Medicare website. There, you can compare the plans’ costs; find out the providers in their networks; see what extra benefits they provide, and learn how well plans have performed on a number of quality and customer service measures, captured in 1-to-5 star rating system.

There is a lot to know and think about when it comes to signing-up for Medicare and choosing your coverage. Fortunately, there is a lot of information and help available, at your fingertips and in your community. Resources include the Medicare website (medicare.gov); 800-MEDICARE (800-633-4227); the Social Security website (socialsecurity.gov) and toll-free number (800-772-1213). VICAP, the State Health Insurance Program in Virginia, can provide personalized help at 800-552-3402.

Nancy B. O’Connor is the Medicare regional administrator for Delaware, Maryland, Pennsylvania, Virginia, West Virginia and the District of Columbia. For answers to all your Medicare questions, call 800-MEDICARE (800-633-4227).

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