young asian doctor discussing test result and diagnosis with senior couple patients using digital tablet in hospital hallway
Once a person turns 65 years old, they are most likely eligible for Medicare. This means they can receive health through Original Medicare or alternatively, a Medicare Advantage Plan which is also known as Medicare Part C. Original Medicare is the original program offered by the federal government, but Medicare Advantage is a private plan that is contracted with the federal government. When making this critical decision about whether Medicare Advantage or Original Medicare is a better option for you, consider the following differences that can be found when comparing the two.
Provider and Hospital Choice
When covered by Original Medicare, you can visit a hospital or medical professional in the United States that accepts Medicare. You will also not generally need a referral to speak with or be seen by a specialist, such as a cardiologist, gastroenterologist, or dermatologist.
With a Medicare Advantage Plan, you must visit doctors and hospitals in your plan’s network and also get a referral before seeing a specialist.
Under Original Medicare, you will typically be paying 20% of Medicare’s approved amount for services covered under Medicare Part B – once you have met your deductible. Your service costs will be in addition to a monthly fee for Medicare Part B coverage. Additionally, if you join the Medicare drug plan (Medicare Part D), you’ll need to pay an additional monthly fee for drug coverage. There is no yearly out-of-pocket limit for Original Medicare unless you have supplemental coverage. Supplemental coverage could include coverage from a former employer or union, Medicaid, or Medigap.
If you choose a Medicare Advantage Plan, you will pay the Medicare Part B fee each month, and you will pay your plan’s premium. However, your plan could come with a premium that costs $0 and may pay part, or all, of your Part B cost. Most Medicare Advantage Plans include a drug plan (Part D). These Medicare Advantage plans also sometimes do have a yearly out-of-pocket limit which depends upon the plan you choose. Once you reach the yearly limit for the services covered under Medicare Part A and Part B, you will not have to pay anything for any services that would be covered under Parts A or B.
Original Medicare benefits will include coverage of any services or supplies that are deemed medically required in doctor’s offices, hospitals, and other healthcare providers. In most cases, you will not have to get prior authorization for Original Medicare to cover these services or supplies. However, Original Medicare does not cover services such as routine exams, dental, or most eye exams. When covered by Original Medicare, you can purchase a separate drug plan (Part D) to cover your prescriptions.
Medicare Advantage Plans are obliged to cover all the medically required services and supplies covered under Original Medicare. However, the majority of plans offer additional benefits and coverage not available under Original Medicare, such as routine exams, hearing, vision, and dental. However, sometimes, you may need prior authorization before these services and supplies are covered. Also, under a Medicare Advantage Plan, Medicare drug coverage (Part D) is generally included.
Healthcare outside the United States is generally not covered with Medicare Original or Medicare Advantage. However, when covered by Original Medicare, you might be able to purchase a Medicare Supplemental Insurance plan that will cover emergency services outside of the United States. Similarly, with Medicare Advantage, some plans can also offer supplemental benefits to cover emergency and urgent services outside of the United States.
Is Medicare Advantage better than Medicare?
The benefits of Original Medicare versus Medicare Advantage are highly individualized. Your specific medical needs, retiree coverage, and income level must all be considered when choosing which healthcare plan will be the best fit for you. The correct decision for you may not be the same as someone else.
Ensure to take adequate time to consider all of these factors and the differences between Original Medicare and Medicare Advantage mentioned in this article before making a decision. Also, compare multiple plans between Original Medicare and Medicare Advantage, taking note of premium costs, deductibles, out-of-pocket, and services covered. Consider how the different offerings will benefit your health needs and fit your personal budget.
Should you enroll in Medicare Part D?
The first thing to consider when deciding about Part D drug coverage is your medical coverage in addition to Medicare. If you have a retiree medical plan, it could provide prescription drug coverage that is just as good, or better, than Medicare Part D. In this case, you would not need to enroll in Part D. If, however, you do not have such additional coverage, you may want to enroll in Medicare Part D to make sure your prescription drugs are covered. If you fail to get any prescription drug coverage, you will receive no financial help when filling prescriptions, potentially costing you thousands of dollars in prescription costs.
Am I eligible for programs that help lower Medicare costs?
Several programs can help people with low-income pay for Medicare costs, such as premiums and co-pays. Some programs are offered by the federal government, and others are offered by local state governments. These programs include:
- Medicaid: If your monthly income is on the lower bracket, and you don’t have any major assets, then you might be able to receive assistance through Medicaid. Medicaid can help with costs such as co-pays, deductibles, and services that would not normally be covered by Medicare. These would be services such as transportation to medical appointments and dental care.
- Medicare Savings Program (MSPs): MSP is a federal program for people who are not able to qualify for Medicaid, but still have trouble paying Medicare costs. Their MSP comes in three varieties, and all of them pay the Part B premium each month.
- Part D Low-Income Subsidy (LIS): LIS is a program where the federal government helps pay all, or most, costs associated with Part D drug coverage.
- State Pharmaceutical Assistance Program: Some states offer help with prescription drug costs through SPAPs. Most have income guidelines that require you to enroll in Medicare Part D and also apply for LIS. Check with your individual state for more information.
What additional resources are available to help navigate Medicare?
- 1-800-MEDICARE – this is the phone number for federal government assistance for Original Medicare.
- Social Security Administration – a federal government-run site that provides information about Original Medicare.
- State Health Insurance Assistance Program (SHIP) – SHIP provides you with objective outreach, counseling, and training to help you make the most informed decision regarding your health insurance coverage.
- Medicare Rights Center – the largest and a reliable source of information about Medicaid.
Once you have decided about the right Medicare coverage for you, the next important step is choosing the right health care provider. The TopLine MD Alliance was created just for this purpose. It was built around the idea of physicians coming together to make healthcare easier for patients by connecting you with top-of-the-line practices, diagnostic centers, healthcare providers, and imaging centers. These affiliated doctors are then able to seamlessly communicate with one another, and your insurance, for a flawless patient experience. Find your TopLine MD affiliated provider today!