What to Consider When Choosing Your Coverage

When you enroll in Medicare, one of the most important decisions you will make is whether to stay with Original Medicare or enroll in a Medicare Advantage Plan. Both provide Medicare coverage, but they differ significantly in how care is accessed, how costs work, and how much flexibility you have.

Doctor and Hospital Choice

Original Medicare	Medicare Advantage
You can go to any doctor or hospital that takes Medicare, anywhere in the U.S. Coverage includes the 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa. You may pay more if your provider doesn’t accept Medicare assignment.	You may need to use doctors and other providers in the plan’s network and service area for non-emergency care. Some plans offer out-of-network coverage, typically at a higher cost.
In most cases you don’t need a referral to see a specialist.	You may need to get a referral to see a specialist, depending on the plan.

Cost

Original Medicare	Medicare Advantage
For Part B-covered services, you usually pay 20% of the Medicare-approved amount after you meet your deductible. This amount is your coinsurance.	Out-of-pocket costs vary. Plans may have different out-of-pocket costs for certain services.
You pay the monthly premium for Part B. If you choose to join a Medicare drug plan, you’ll pay a separate premium for Part D.	You pay the monthly Part B premium and may also have to pay the plan’s premium. Some plans may have a $0 premium and may help pay all or part of your Part B premium. Most plans include Part D, so you typically don’t have a separate Part D premium.
There’s no yearly limit on what you pay out-of-pocket unless you have supplemental coverage like Medigap, Medicaid, or employer, retiree, or union coverage.	Plans have a yearly limit on what you pay for covered Medicare services. Some plans may have different limits for in-network and out-of-network services. Once you reach the plan’s limit, you pay nothing for covered services for the rest of the year.
You can choose to buy Medigap to help pay out-of-pocket costs that Medicare doesn’t cover, like the 20% coinsurance. Or you can use coverage from a current or former employer or union, or Medicaid if you qualify.	You can’t buy Medigap to cover out-of-pocket costs. However, you may be able to use coverage from a current or former employer or union, or Medicaid if you qualify.

Coverage

Original Medicare	Medicare Advantage
Original Medicare covers most medically necessary services and supplies in hospitals, doctors’ offices, and other health care facilities. Original Medicare doesn’t cover some services, like routine physical exams, eye exams, and most dental care.	Plans must cover all medically necessary services that Original Medicare covers. Plans may also offer extra benefits that Original Medicare doesn’t.
In most cases you don’t need approval (prior authorization) for Original Medicare to cover your services or supplies.	You may need to get approval (prior authorization) from your plan before it covers certain services or supplies.
You can join a separate Medicare drug plan to get Medicare drug coverage (Part D).	Most Medicare Advantage Plans include Part D and you don’t need to join a separate Medicare drug plan.

Foreign Travel

Original Medicare	Medicare Advantage
Original Medicare generally doesn’t cover medical care outside the U.S. You may be able to buy a Medigap policy that covers emergency care outside the U.S.	Plans generally don’t cover medical care outside the U.S. Some plans may offer an extra benefit that covers emergency and urgently needed services when traveling outside the U.S.

Final Thoughts

Original Medicare and Medicare Advantage both provide Medicare coverage, but they work differently. When comparing options, pay attention to provider flexibility, how costs are structured, whether there is an out-of-pocket maximum, and how referrals and prior authorizations work.

Here is an interesting John Oliver video on Medicare Advantage. Take from it what you will.

Blog Disclaimer :This article is provided for general informational and educational purposes only and is not intended to provide investment, tax, legal, insurance, or other professional advice. Nothing contained in this article should be relied upon as a substitute for personalized advice. The information presented may not be applicable to every individual situation and should not be used as the sole basis for making financial or other decisions. Laws, regulations, and interpretations are subject to change, and individual circumstances vary. Readers should consult with qualified professionals regarding their specific situation before taking any action based on the content of this article.

Original Medicare vs Medicare Advantage