Medicare vs. Medicare Advantage Plans - Which One Do You Need?

Sep 21, 2023

When it comes to healthcare coverage for seniors in the United States, Medicare has been at the center of the discussion. Medicare was established in 1965 and offers critical healthcare coverage to people aged 65 and older, as well as those with certain disabilities.

However, in recent years, Medicare Advantage plans have grown in popularity.

What is the difference between the two? Which one is better suited for you? Your medical needs, price, and other personal lifestyle variables play a significant role in deciding which coverage is best suited for you.

Understanding Original Medicare

Medicare is a government healthcare program that predominantly serves seniors. Individuals over the age of 65 are automatically enrolled in Medicare. It is also offered to qualified individuals with certain disabilities. Medicare is intended to cover basic medical expenses such as hospitalization, medical services, and prescription medicines.

It is divided into four major sections:

  • Medicare Part A - This covers inpatient hospital care, skilled nursing facility care, hospice care, and certain home healthcare services.
  • Medicare Part B  - It entails all the necessary medical services such as doctor’s visits, outpatient care, and preventive services. Beneficiaries are required to pay a monthly premium for Part B,  which is determined by their income.
  • Medicare Part C (Medicare Advantage Plans) - This is an alternative to traditional Medicare and allows private insurance companies to offer Medicare-approved plans.
  • Medicare Part D: This covers all prescription drugs and is offered through private insurance companies that are approved by Medicare.

What is a Medicare Advantage Plan?

What is a Medicare Advantage Plan?

Medicare Advantage plans, often known as Part C, are private health insurance plans that appear as an alternative method of receiving Medicare benefits. Private insurance companies that have contracts with the federal government to provide healthcare coverage to Medicare recipients offer these plans. It’s important to be aware of these plans in order to make the most of your health insurance benefits.

The following are some essential characteristics of Medicare Advantage plans:

1. Comprehensive Coverage

Medicare Advantage plans often include all of the Original Medicare benefits (Parts A and B) into a single plan. This means that beneficiaries are covered for hospital and medical expenses under a single insurance policy.

2. Additional Benefits

One of the key advantages of Medicare Advantage plans is the possibility of receiving healthcare benefits in addition to those provided by Original Medicare.

Prescription medicine coverage, dental care, vision care, hearing aids, exercise programs, and other services could all be included. However, the particular benefits differ depending on the plan and location.

3. Network Restrictions

Medicare Advantage plans frequently feature provider networks, which means that beneficiaries must select healthcare providers from the plan's network in order to obtain full coverage. Some plans may include out-of-network benefits; however, they might turn out more expensive.

4. Premiums and Costs

While many Medicare Advantage plans charge little or no extra premium over the usual Medicare Part B premium, beneficiaries are still responsible for copayments, deductibles, and other out-of-pocket expenses. Costs can vary greatly between programs.

5. Prescription Drug Coverage

Most Medicare Advantage plans include prescription drug coverage (Part D), however, the formulary (list of eligible pharmaceuticals) and medication cost-sharing varies with each plan.

Benefits of Original Medicare

Benefits of Original Medicare

There are certain things you need to keep in mind before you sign up for Medicare.

1. Nationwide Coverage

Original Medicare provides beneficiaries with extensive access to healthcare providers across the United States, allowing them to see specialists and receive care in other states without any limitations.

2. Standardized Benefits

Original Medicare benefits are standardized, which means that no matter where you live, you will receive the same basic coverage under Part A and Part B.

3. No Network Restrictions

There are no network restrictions with Original Medicare. Beneficiaries can use any healthcare provider who accepts Medicare, offering them more options for doctors and hospitals.

4. Guaranteed Issue

Medicare is a guaranteed issue, which means you will not be denied coverage or charged higher rates if you enlist within your Initial Enrollment Period (IEP).

Cons of Original Medicare

1. Lack of Comprehensive Coverage

Original Medicare does not cover all medical expenses. It does not cover prescription drugs, dental care, vision care, hearing aids, and other important services that many seniors require.

2. High Out-of-Pocket Costs

While Medicare Part A is often premium-free, Part B requires a monthly premium. There are copayments, deductibles, and coinsurance for various services. These costs can add up quickly, especially for those with specific medical needs.

3. No Out-of-Pocket Maximum

Unlike many Medicare Advantage plans, Original Medicare does not have an out-of-pocket maximum, meaning there is no cap on how much you could end up spending on healthcare in a given year.

Which Option Is Right for You?

Before signing up for Medicare, it is important to figure out which is best suited for you. The decision between Original Medicare and a Medicare Advantage plan is based on your specific healthcare needs and preferences.

Here are some things to think about when making your decision:

Choose Original Medicare If:

1. You value nationwide coverage

2. You prefer flexibility in your provider choice

3. You want standardized benefits

4. You have Medigap insurance to help cover out-of-pocket costs.

Choose Medicare Advantage If:

1. You desire a comprehensive coverage plan

2. You want extra benefits to be included such as dental, vision, hearing, and wellness services.

3. You prefer predictable costs

4. You are comfortable with network restrictions

If you're willing to choose healthcare providers from a plan's network, Medicare Advantage can offer cost-effective coverage.

Enrollment Periods

It's important to understand the various enrollment periods for Medicare and Medicare Advantage plans to know when and how to sign up for Medicare.

Enrollment Periods

1. Initial Enrollment Period (IEP)

Your IEP starts three months before your 65th birthday month, includes your birthday month, and lasts three months after that. This is an excellent opportunity to enlist in Original Medicare as well as a Medicare Advantage plan, if desired.

2. Annual Enrollment Period (AEP)

The Annual Enrollment Period takes place every year from October 15th to December 7th. You can make changes to your Medicare Advantage plan or switch from Original Medicare to Medicare Advantage during this time.

3. Special Enrollment Period (SEP)

SEPs are triggered by major life events such as relocating to a new region, terminating work coverage, or becoming Medicaid-eligible. These circumstances give you the ability to make adjustments to your Medicare coverage outside of the regular enrollment periods.

4. Open Enrollment Period for Medicare Advantage (OEP-MA)

From January 1st to March 31st, the Open Enrollment Period permits Medicare Advantage enrollees to make a one-time transition to a different Medicare Advantage plan or return to Original Medicare.

Making an Informed Decision

Here are some steps to help you navigate the decision-making process:

1. Evaluate your individual healthcare needs

2. Compare different healthcare plan options

3. Review the different costs that come with Medicare

4. Check network coverage

5. Understand annual changes that can impact your plan

6. Seek assistance from a Medicare counselor, insurance agent, or financial advisor who specializes in Medicare. 

The choice between Medicare and Medicare Advantage should not be taken lightly because it affects your healthcare coverage and expenditures significantly. Consider your healthcare needs, finances, preferred doctors and hospitals, and the specific benefits offered by the plans available in your area to make an informed decision.

Access Health Care Physicians helps you understand the complexities that come with healthcare insurance and make informed decisions.

Frequently Asked Questions

Prescription medication coverage, dental, hearing, and vision coverage are some extra benefits available with Medicare Advantage plans which may be preferred by some.

The most significant downside of Medicare Advantage plans is that they have closed provider networks, limiting your choice of doctors and medical facilities. Medicare Advantage prices are also primarily determined by the amount of medical care you require, making it more difficult to budget for healthcare expenses.

You can switch to another Medicare Advantage Plan or return to Original Medicare during the Annual Enrollment Period.

A Medicare supplement plan cannot be terminated and is guaranteed to renew indefinitely as long as you pay your premium. Medicare Advantage plans, on the other hand, can change their benefits and networks, or even be canceled.

Medicare is for every individual over the age of 65 and those with certain disabilities.