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Is Medicare Advantage Better or Worse Than Original Medicare?

Medicare is a federal health insurance program that provides health coverage for Americans aged 65 and older and younger people with disabilities. When you first become eligible for Medicare, you can choose between Original Medicare or a Medicare Advantage Plan. But is Medicare Advantage better or worse than sticking with Original Medicare? There are pros and cons to both options.

What is Original Medicare?

Original Medicare consists of Medicare Part A and Medicare Part B premium. Medicare Part A covers hospital insurance, including inpatient care, skilled nursing facilities, hospice, and some home health care services. Medicare Part B covers doctor visits, preventive services, durable medical equipment, and other outpatient care.

With Original Medicare, you can see any doctor or hospital that accepts Medicare nationwide. You do not need a referral to see a specialist. Original Medicare pays its share of the Medicare-approved amount for covered health care costs to providers after you meet the deductible. But Original Medicare does not cover all health care costs, so you may need to get a Medicare Supplement (Medigap) plan and a Medicare Prescription Drug Plan (Part D) from a private insurance company.

What is Medicare Advantage?

Medicare Advantage, sometimes called Medicare Part C, is an alternative to Original Medicare offered by private insurance companies approved by Medicare. Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care. But they often cover extra benefits that Original Medicare does not cover like vision, hearing, dental, and wellness programs.

With Medicare Advantage Plans, you usually have to see doctors and hospitals in the plan’s network except in emergencies. Medicare Advantage Plans often include integrated prescription drug coverage (Part D). Some Medicare Advantage Plans may also have low monthly premiums or even $0 premiums in exchange for paying higher out-of-pocket costs for services.

There are different types of Medicare Advantage Plans including:

  • HMO: Health Maintenance Organizations provide coordinated care through a network of contracted providers. HMOs require you to choose a primary care physician who oversees your care and refers you to specialists when needed.
  • PPO: Preferred Provider Organizations allow you to see out-of-network providers usually at a higher cost. You pay less if you use providers in the plan’s network.
  • PFFS: Private Fee-for-Service plans allow you to see any Medicare-approved doctor or hospital that accepts the plan’s terms of payment. The provider sets the rate they will be reimbursed at.
  • SNP: Special Needs Plans provide focused and specialized care to people with specific diseases or dual eligible.

Pros of Medicare Advantage over Original Medicare

There are several potential advantages to enrolling in a Medicare Advantage Plan rather than sticking with Original Medicare:

Lower out-of-pocket costs than Original Medicare- Medicare Advantage Plans typically have an annual limit on your out-of-pocket spending for covered medical services. With Original Medicare, there is no limit on out-of-pocket expenses unless you have supplemental coverage.

Extra benefits – Most Medicare Advantage Plans include some health and wellness benefits not covered by Original Medicare like vision, dental, hearing aids, gym memberships, transportation to doctor visits, and over-the-counter allowances.

Prescription drug coverage – Prescription drug coverage is included with most Medicare Advantage Plans whereas you have to purchase a separate Part D Plan with Original Medicare.

Coordinated care – Medicare Advantage Plans usually provide more coordinated care management services to help take care of your health holistically.

All-in-one option – Medicare Advantage enrollees receive medical and drug coverage in one simple plan instead of having different parts like Original Medicare.

Premiums may be $0 – Some Medicare Advantage Plans don’t have a monthly premium beyond the Part B premium.

Cons of Medicare Advantage compared to Original Medicare

However, there are also some potential drawbacks of Medicare Advantage to consider:

Network restrictions – Most Medicare Advantage Plans have provider networks so your choice of doctors and hospitals is limited. With Original Medicare you can see any doctor nationwide that accepts Medicare.

Referrals required for specialists – In a Medicare Advantage HMO, you usually need a referral from your primary care doctor before you can see a specialist. Original Medicare does not require referrals.

Pre-approval needed for procedures – Medicare Advantage Plans often require you to get pre-approval for major procedures and hospital stays. Original Medicare generally does not require this.

Drug formularies – Medicare Advantage prescription drug coverage has a formulary that may not cover all medications. Original Medicare Part D Plans also have formularies.

Less plan flexibility – You can only make changes to your Medicare Advantage Plan during certain times of the year. With Original Medicare you can change plans monthly.

Travel limitations – Medicare Advantage Plans generally only cover emergency and urgent care outside of the plan’s service area. Original Medicare covers you nationwide.

Should I Choose Medicare Advantage or Original Medicare?

So should you enroll in a Medicare Advantage Plan or stick with Original Medicare? Here are some things to consider when deciding:

  • Your health – If you have complex health needs and see several specialists, it may be better to sign up for Medicare Original plan. Medicare Advantage Plans typically require seeing in-network providers.
  • Covered benefits – Look at what benefits beyond medical coverage are important to you. Do you want vision and dental? Some Medicare Advantage Plans also include extra benefits.
  • Costs – Compare premiums, deductibles, copays, and maximum out-of-pocket costs. Medicare Advantage may offer lower costs.
  • Travel habits – If you travel frequently outside your plan’s service area, Original Medicare provides better coverage.
  • Provider choice – With Original Medicare you can see any doctor nationwide that accepts Medicare. Medicare Advantage has network restrictions.
  • Prescriptions – Do you want integrated prescription drug coverage? Medicare Advantage typically includes Part D.
  • Convenience – Do you prefer having medical and drug coverage combined in one plan? Medicare Advantage offers a simpler all-in-one option.

When Can I Enroll in Medicare Advantage?

You have the opportunity to enroll in a Medicare Advantage Plan during your Initial Enrollment Period when you are first eligible for Medicare:

  • Initial Enrollment Period – When you are first eligible for Medicare, you have a 7-month window to enroll that includes the 3 months before you turn 65, the month you turn 65, and 3 months after your birthday month.

You also have opportunities to switch between Original Medicare and Medicare Advantage during Medicare Open Enrollment Periods:

  • Medicare Advantage Open Enrollment Period – From January 1 to March 31, you can leave your Medicare Advantage Plan and switch back to Original Medicare or enroll in a different Medicare Advantage Plan.
  • Medicare Annual Enrollment Period – From October 15 to December 7, you can make changes to your Medicare Advantage or Part D coverage for the following year.

There are also Special Enrollment Periods that allow you to sign up for a Medicare Advantage Plan outside the normal enrollment windows if certain events occur like moving or losing other coverage.

Tips for Choosing Between Medicare Advantage and Original Medicare

  • Use the Medicare Plan Finder tool on Medicare.gov to compare Medicare Advantage Plans and stand-alone Part D Plans with Original Medicare in your area.
  • Look up whether your doctors and preferred hospitals are in the Medicare Advantage Plan’s network before enrolling.
  • Consider Medicare Advantage if you want extra benefits like dental and vision coverage.
  • Enroll in Original Medicare if you want to see specialist doctors without referrals or pre-approvals.
  • Ask how the plans handle authorizations and appeals for services if you have complex health needs.
  • Compare out-of-pocket costs like deductibles, copays or coinsurance, and maximum limits.
  • Make sure to understand the provider network rules if you travel out of town frequently.
  • Shop for Part D prescription drug plans separately if enrolling in Original Medicare.
  • Check to see if you qualify for financial assistance programs to help pay Medicare costs.
  • Read plan materials closely and ask for clarification from a Medicare counselor if needed.

Conclusion

In summary, there are good reasons why some eligible Medicare beneficiaries prefer Medicare Advantage over Original Medicare or vice versa. There is no one-size-fits-all solution. Medicare Advantage offers some appealing benefits like lower costs, extra coverage, and convenience that Original Medicare does not provide. But Original Medicare offers more provider choice and flexibility. Understanding your health needs and priorities will help you determine if Medicare Advantage or Original Medicare is the better choice for you. Whichever option you select, make sure to review your coverage every year during open enrollment and switch plans if your needs change.

We’re Here to Help

You do not have to spend hours reading articles on the internet to get answers to your Medicare questions. Give Scott Sims at Sims Insurance Medicare Plans a Call at (541) 915-0939. You will get the answers you seek in a matter of minutes, with no pressure and no sales pitch. We are truly here to help.

FAQs

Is Medicare Advantage better or worse?

The answer to this question depends on your individual circumstances and healthcare needs. Medicare Advantage Plans, also known as Part C, offer an alternative way to receive your Medicare benefits. These plans are offered by private insurance companies, and they typically combine the coverage of Medicare Parts A and B, along with additional benefits such as prescription drug coverage and dental care. Some people may find that Medicare Advantage Plans better suit their needs, while others may prefer the flexibility and freedom of traditional Medicare.

What is a Medicare Advantage Plan?

A Medicare Advantage Plan is an alternative to traditional Medicare. With a Medicare Advantage Plan, you receive your Medicare Part A and Part B coverage, as well as additional benefits, through a private insurance company approved by Medicare. These plans often include prescription drug coverage and may offer other benefits such as dental and vision care.

What is the difference between Traditional Medicare and Medicare Advantage?

The main difference between Medicare and Medicare Advantage is how the benefits are administered. Traditional Medicare is the original government-run program that provides hospital insurance (Part A) and medical insurance (Part B). Medicare Advantage Plans, on the other hand, are offered by private insurance companies and provide all the benefits of traditional Medicare, along with additional coverage options and benefits.

Are there any disadvantages of Medicare Advantage Plans?

While Medicare Advantage Plans offer additional benefits and coverage options, there can be some disadvantages. One disadvantage is that you may be restricted to using healthcare providers within the plan’s network. Additionally, Medicare Advantage Plans often require you to pay copayments or coinsurance for certain services. It’s important to carefully review the details of any Medicare Advantage Plan to understand its specific disadvantages.

What is Medicare Supplement insurance?

Medicare Supplement insurance, also known as Medigap, is additional insurance that can help cover some of the out-of-pocket costs associated with traditional Medicare. These costs may include copayments, coinsurance, and deductibles. Medicare Supplement Plans are sold by private insurance companies and work alongside your Original Medicare coverage.

Do Medicare Advantage Plans cover prescription drugs?

Many plans include prescription drug coverage. These plans are known as Medicare Advantage Prescription Drug plans (MAPD). However, not all Medicare Advantage Plans offer prescription drug coverage, so it’s important to check the details of each plan to see if prescription drugs are included.

How do I enroll in a Medicare Advantage Plan?

To enroll in a Medicare Advantage Plan, you must be eligible for Medicare Part A and Part B. You can typically enroll during your Initial Enrollment Period, which is a seven-month period that begins three months before your 65th birthday. You may also have the opportunity to enroll during the Annual Enrollment Period, which occurs each year from October 15th to December 7th.

Should I choose Medicare or Medicare Advantage?

The decision between Medicare and Medicare Advantage depends on your individual healthcare needs and preferences. Medicare offers more freedom to choose your healthcare providers, while Medicare Advantage Plans often offer additional benefits such as prescription drug coverage and dental care. It’s important to consider your specific needs and compare the pros and cons of each option before making a decision.

What are the pros and cons of Medicare Advantage?

Some of the pros of Medicare Advantage Plans include additional benefits such as prescription drug coverage, dental care, and vision care. These plans often have a cap on out-of-pocket expenses, providing financial protection. However, there can be some cons to Medicare Advantage, such as limited provider networks and the potential for higher out-of-pocket costs for certain services. It’s important to carefully consider the pros and cons before choosing a Medicare Advantage Plan.

How many Medicare Advantage Plans are available?

The number of Medicare Advantage Plans available varies depending on your location. Different insurance companies offer different plans in different areas, so the number of plans can vary significantly. It’s best to use the Medicare.gov website or consult with a licensed insurance agent to find out how many Medicare Advantage Plans are available in your specific area.