Differences Between Original Medicare and Medicare Advantage

Medicare is a federal health insurance program that provides coverage for Americans 65 years old or older and those with certain disabilities or chronic conditions. There are two main types of Medicare plans: Original Medicare, which includes Part A (hospital insurance) and Part B (medical insurance), and Medicare Advantage, which is also known as Part C. While both types of plans offer healthcare coverage, they have some significant differences in terms of costs, benefits, and provider networks. Understanding these differences can help individuals choose the best plan for their healthcare needs and budget. You can learn more about Medicare on a website like ClearmatchMedicare.com.

1. Cost

Source: forbes.com

Original Medicare has two main parts, Part A and Part B, and individuals typically pay a premium for Part B. In addition to the premium, beneficiaries may have to pay deductibles, coinsurance, and copayments. On the other hand, Medicare Advantage plans typically have lower premiums and out-of-pocket costs but often have more restrictions on providers and services.

Medicare Advantage plans may also have additional costs for prescription drug coverage, which is not included in Original Medicare. Ultimately, the cost difference between the two types of plans depends on an individual’s specific healthcare needs and budget.

2. Benefits

Original Medicare covers medically necessary services and supplies, including hospital stays, doctor visits, and preventive services. On the other hand, Medicare Advantage plans offer the same benefits as Original Medicare but can also include additional benefits like prescription drug coverage, vision, dental, hearing services, wellness programs, and even fitness memberships.

Original Medicare does not offer these added benefits but varies by plan and location. It’s important to carefully review the benefits of both options to determine which plan offers the coverage that best meets an individual’s healthcare needs.

3. Provider Networks

Medicare Advantage plans offer additional benefits, such as dental or vision care, not covered under Original Medicare. It is crucial to consider one’s healthcare needs and preferences when choosing between Original Medicare and Medicare Advantage and to ensure that the plan’s provider network includes the desired healthcare providers.

However, some Original Medicare allows beneficiaries to choose any healthcare provider that accepts Medicare, which includes most doctors and hospitals in the United States. In contrast, Medicare Advantage plans often have a restricted provider network, and beneficiaries may have to pay higher out-of-pocket costs or obtain prior authorization to see out-of-network providers.

4. Prescription Drug Coverage

Source: healthcarefinancenews.com

Unless given during a hospital stay or at a doctor’s office, prescription drugs are often not covered by Original Medicare. Beneficiaries can sign up for a stand-alone Part D plan if they require additional prescription medication coverage. Contrarily, prescription drug coverage is typically included as part of the benefits package for Medicare Advantage plans.

Beneficiaries may find it more convenient to have all their healthcare requirements fulfilled by a single plan. However, to ensure they address a person’s individual needs for prescription drugs, it’s crucial to examine the costs and coverage of various Medicare Advantage plans thoroughly.

5. Referrals and Prior Authorization

Under Original Medicare, patients generally do not need a referral from their primary care physician to see a specialist. However, some services require prior authorization before the plan covers them. In contrast, Medicare Advantage plans typically require patients to obtain referrals from their primary care physicians before seeing specialists.

Many Medicare Advantage plans require prior authorization for certain services, medications, or procedures. These requirements may vary depending on the specific plan, so it is important for patients to carefully review the details of their coverage and consult with their healthcare providers to ensure they receive the care they need.

6. Out-Of-Pocket Spending

Source: healthaffairs.org

Due to the conventional fee-for-service nature of Original Medicare, beneficiaries frequently have to pay coinsurance, copayments, and deductibles to access medical care. Original Medicare has no annual cap on out-of-pocket expenses. In contrast, Medicare Advantage plans feature an out-of-pocket expenditure cap that places a cap on the amount of money users can spend annually on approved treatments.

Regardless of the plan, the cap for in-network services must be at least $7,550. The plan pays all expenses for covered services for the remainder of the year when the cap is reached. In Medicare Advantage plans, however, out-of-pocket expenses for out-of-network services may be much greater.

7. Geographic Restrictions

Original Medicare is a fee-for-service program allowing beneficiaries to see any healthcare provider who accepts Medicare, regardless of location. In contrast, Medicare Advantage plans typically have a network of healthcare providers contracted to provide services to plan members in a specific geographic area.

However, some Medicare Advantage plans may offer out-of-network benefits, providing more flexibility in choosing healthcare providers. Individuals must consider their healthcare needs and location when choosing between Original Medicare and Medicare Advantage.

Numerous factors can impact the costs and benefits of Original Medicare versus a Medicare Advantage plan. Determining which plan best meets an individual’s healthcare needs requires careful research. It’s crucial to understand how each plan works and to review the coverage offered by each option carefully. This includes weighing the costs of out-of-pocket expenses, as well as the benefits and limitations of provider networks.