Medicare Advantage vs Original Medicare: What Are the Pros and Cons?
Medicare Advantage vs. Original Medicare. That’s a decision that around 10,000 people could face every day. The Centers for Medicare & Medicaid Services (CMS) reported in 2015 that about 10,000 people became eligible for Medicare each day.
Medicare Advantage vs. Original Medicare: what’s the difference?
Original Medicare, Part A and Part B, is the government health insurance program for those 65 and older, and for people who qualify by disability.
Some quick Medicare Part A facts:
- Part A is hospital insurance – it covers your care as hospital inpatient.
- You may not need to pay a monthly premium if you’ve worked at least 10 years while paying Medicare taxes.
- A deductible applies.
- You also have to pay coinsurance or copayments once you have paid the deductible.
Some quick Medicare Part B facts:
- Part B is medical insurance – it may cover preventive services, doctor visits, lab tests, medical equipment and supplies and other medically necessary services.
- You typically have to pay a monthly premium.
- An annual deductible applies to many services.
- You typically pay a 20% coinsurance for most services, although some services are free.
Original Medicare comes directly from the government. But you can choose to get your Part A and Part B benefits through the Medicare Advantage program instead.
The Medicare Advantage program (also called Medicare Part C) gives you a way to get these benefits through a private insurance company. These insurance companies contract with Medicare to deliver your Part A and Part B benefits.
Here’s a table to help you see – at a glance – the main differences between Original Medicare and Medicare Advantage.
|Medicare Advantage vs. Original Medicare|
|Benefit or feature||Medicare Advantage||Original Medicare|
|Medicare Part A and Part B benefits||Yes||Yes|
|Prescription drug coverage||Yes, with many plans (but not all)||Includes only limited prescription drug coverage. Original Medicare doesn’t cover most medications you take at home.|
|Additional benefits beyond Part A and Part B, such as routine vision or hearing care||Yes, with many plans (but not all). Extra benefits may vary among plans.||Generally, no|
|Choice of any doctor who accepts Medicare assignment||Not with every plan. Many plans require you to stay within the plan’s provider network.||Yes|
|Generally covers non-emergency care anywhere in the United States||Usually, no. You must live within the plan’s service area, although plans typically cover emergency care when you’re away from home in the U.S.||Generally, yes|
|Maximum out-of-pocket spending limit.||Yes. Once you’ve reached this limit within a calendar year, the plan may cover your medical costs for the rest of the year. This limit varies among plans and may change year to year.||No|
If you have a Medicare Advantage plan, you’re still in the Medicare program. You still need to pay your monthly Part B premium – plus the Medicare Advantage premium.
Medicare Advantage vs. Original Medicare: when do you have to choose?
There’s no hurry if you can’t make up your mind about Medicare Advantage vs. Original Medicare. In most cases, you’re automatically enrolled in Original Medicare as soon as you’re eligible, if you’re receiving Social Security benefits. If you want a Medicare Advantage plan, you have to take steps to sign up. And you can’t just sign up anytime – it’s important to be aware of your Medicare Advantage enrollment periods.
If you know from the get-go that you want a Medicare Advantage plan, you can sign up when you’re first eligible for Medicare. Your Medicare Initial Enrollment Period goes for 7 months for most people.
If you don’t enroll in Medicare Advantage during the Initial Enrollment Period, you may have other opportunities.
- The Annual Election Period (AEP), also called Fall Open Enrollment, happens every year from October 16 to December 7. You can sign up for a Medicare Advantage during this period – or, you can switch back to Original Medicare if you have a Medicare Advantage plan. You can also switch from one Medicare Advantage plan to another, or make certain other coverage changes.
- In some cases, you might qualify for a Special Enrollment Period (SEP) to sign up for a Medicare Advantage plan. There are a number of different circumstances that may qualify you for an SEP. Many of these involve losing your coverage, like losing employment-based health insurance. If you’re wondering if you could be eligible for an SEP, you can call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. Medicare representatives are available 24 hours a day, seven days a week.
You can usually sign up for a Medicare Advantage plan if you’re enrolled in Medicare Part A and Part B, and live in the plan’s service area. If you have end-stage renal disease (permanent kidney failure), you might not qualify for most types of Medicare Advantage plans – call the plan you want to enroll in, and ask. You can generally enroll in a Special Needs Plan, which is a specific type of Medicare Advantage plan.
To enroll in a Medicare Advantage plan, you can contact the plan, or click Browse Plans on this page to display plans in your area. From there, you can enroll online.
Medicare Advantage vs. Original Medicare – do you still have questions? For personalized assistance, call eHealth to speak with a licensed insurance agent.