Original Medicare vs Medicare Advantage

Our patients have expressed a lot of confusion and frustration around Original Medicare vs Medicare Advantage Plans. Often times, we see procedures not being covered by Medicare Advantage Plans that would be covered by Original Medicare. Or, procedures may be covered but the prior-authorization period instituted by Medicare Advantage plans can take several weeks and may sometimes not be approved or may even have to go through the appeals process, delaying treatment.  Some  providers may not even discuss all available treatments options, because plans might be limited to certain treatments or procedures.  Major healthcare decisions can be limited or restricted by your insurance policy, how much you pay for coverage, what doctors you can see, and your quality of care. It is important that you know and understand your healthcare policy and find a policy that will meet your needs. We have put together a Q&A of some our most frequently asked questions as they pertain to Original Medicare and Medicare Advantage.

Is Original Medicare the same as Medicare Advantage?

A: No. Original Medicare is managed by the federal government; whereas Medicare Advantage Plans are administered by private companies. Original Medicare includes Medicare Part A (Hospital Insurance) and Part B (Medical Insurance). If you want drug coverage, you can join a separate Medicare drug plan (Part D). To help pay your out-of-pocket costs in Original Medicare (like your 20% coinsurance, or your share of medical costs), you can also shop for and buy supplemental coverage, sometimes referred to as a Medigap policy. You can use any doctor or hospital that takes Medicare, anywhere in the U.S. 

Medicare Advantage (also known as Part C) is an “all in one” alternative to Original Medicare. These “bundled” plans include Part A, Part B, and usually Part D. Plans may have lower out-of- pocket costs than Original Medicare, but may have less coverage. In many cases, you’ll need to use doctors who are in the plan’s network. Most plans offer benefits that Original Medicare doesn’t cover— like vision, hearing, dental, and more. Medicare Advantage Plans are offered by Medicare-approved private companies that must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to doctors, facilities, or suppliers that belong to the plan’s network for non-emergency or non-urgent care).

Q: Do I have the same choice of doctors regardless of my plan?

A: No. With Original Medicare, you can go to any doctor or hospital that takes Medicare. With Medicare Advantage, you’ll need to use doctors and other providers who are in the plan’s network and service area for the lowest costs. Some plans won’t cover services from providers outside the plan’s network and service area.

Q: Do I need a referral to see a specialist for these plans?

A: In most cases, you do not need a referral for Original Medicare, but you may need a referral for Medicare Advantage.

Q: When is open enrollment?

A: The open enrollment period is October 15—December 7. Anyone with Medicare can join, switch, or drop a Medicare Advantage Plan. Your coverage will begin on January 1 (as long as the plan gets your request by December 7).

Q: Can I make changes to my coverage after December 7?

A: Between January 1 and March 31 each year, you can make these changes during the Medicare Advantage Open Enrollment Period. If you’re in a Medicare Advantage Plan (with or without drug coverage), you can switch to another Medicare Advantage Plan (with or without drug coverage). You can drop your Medicare Advantage Plan and return to Original Medicare. You’ll also be able to join a Medicare drug plan. During this period, you can’t: switch from Original Medicare to a Medicare Advantage Plan; join a Medicare Prescription Drug Plan if you’re in Original Medicare; or switch from one Medicare drug plan to another if you’re in Original Medicare.

If you join a Medicare Advantage Plan for the first time and you aren’t happy with the plan, you’ll have special rights under federal law to buy a Medigap policy and a Medicare drug plan if you return to Original Medicare within 12 months of joining the Medicare Advantage Plan. Medigap refers to various private health insurance plans sold to supplement Original Medicare. Medigap insurance provides coverage for many of the co-pays and some of the coinsurance related to Medicare-covered hospital, skilled nursing facility, home health care, ambulance, durable medical equipment, and doctor charges.

For more information, visit www.medicare.gov.