Medicare Differences

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Differences Between
Original Medicare And
Medicare Advantage Plans

People with Medicare can get their health coverage either through Original Medicare or a Medicare Advantage Plan. Here’s a look at the differences between these two options.

Original Medicare

  • The traditional program administered directly through the federal government.
  • Includes Part A (hospital) and Part B (medical) coverage if you enroll in both.
  • You pay a deductible and/or coinsurance when you get health care (usually 20% of the Medicare-approved cost for outpatient care).
  • Most people pay a monthly premium for Part B. There’s no Part A premium if you have at least 10 years of United States work history.
  • You can go to any doctor or hospital in the country that accepts Medicare.
  • No referrals needed to see specialists; no prior authorization for services.
  • You can buy a Medigap plan as supplemental coverage.
  • If you want Medicare drug coverage, you must buy a separate Prescription Drug Plan (PDP) from a private insurance company. Medicare Advantage Plans

Medicare Advantage Plans

  • Plans sold by private insurance companies that provide Medicare benefits.
  • Must cover the same Part A and Part B benefits as Original Medicare. Some also cover extra benefits such as vision and dental care.
  • The most common types are HMOs (Health Maintenance Organizations), PPOs (Preferred Provider Organizations) and PFFS (Private-Fee-for-Service) plans.
  • You still have Medicare but you’re no longer in Original Medicare—you’re in a private plan that typically has different costs and restrictions.
  • You pay a deductible and/or copay for services (usually a fixed copay, like $15 per office visit).
  • You still pay Medicare premiums, and your plan may charge an extra premium.
  • You typically are required to use doctors and hospitals in the plan’s network.
  • You may have to choose a Primary Care Physician, get referrals to see specialists, and/or get prior authorization for certain services.
  • You can’t buy Medigap supplemental insurance to help pay your out-of-pocket costs.
  • Plans must have yearly limits on your out-of-pocket health care costs (an out-of-pocket maximum), after which you pay nothing for the rest of the year.
  • If you want Medicare drug coverage, sign up for a plan that includes both health and drug coverage, called a Medicare Advantage Prescription Drug Plan (MA-PD). You usually can’t have a separate Part D plan, unless you’re in a Medicare Medical Savings Account (MSA) or a PFFS plan

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Differences Between Original Medicare
and Medicare Advantage Plans

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