Choosing between Original Medicare (Parts A and B) and a Medicare Advantage Plan (Part C) forms the bedrock of your Medicare coverage. This decision encompasses a range of healthcare options, from basic medical and hospitalization coverage to selecting a provider network for specialized care.
With numerous Medicare parts and benefit options available, the decision-making process can be overwhelming. Fortunately, the Wandacare Team is dedicated to supporting you every step of the way, ensuring you choose the ideal plan that matches your specific healthcare requirements.
In this article, we’ll examine the distinctions, weigh the pros and cons, and explore the factors to consider when deciding between Original Medicare and a Medicare Advantage Plan. Our goal is to empower and help you make an informed decision about the coverage that best suits your needs.
Comparing Original Medicare and Medicare Advantage Plans
Basic or Original Medicare is the government-funded and managed insurance that includes two parts: Part A covering hospital insurance and Part B covering medical insurance.
Similar to private health insurance, you receive a Medicare card to present at your doctor’s visit. Medicare will pay a set amount for covered services, and you will be responsible for any deductibles, copayments, or coinsurance in a cost-sharing. With Original Medicare, Part A carries a deductible of $1,600.00 each time you go into the hospital, while Part B operates on an 80/20 cost-sharing structure after an annual deductible of $226.00, with Medicare covering 80% and you are responsible for the remaining 20%.
Medicare Advantage Plans, also known as Medicare Part C, are private insurance plans approved by Medicare. Essentially Medicare pays the insurance company to cover your Medicare benefits offered and managed through the Medicare Advantage Plan.
As Medicare Advantage Plans are offered through private insurance companies, they are structured similar to private health insurance plans. There are Medicare Advantage HMOs, PPOs, or even those similar to Original Medicare with a “fee-for-service” structure. These plans often have a set network of providers you choose from, whereas with Original Medicare you can go to any hospital, doctor, or provider within the U.S. who accepts Medicare.
Medicare Advantage Plans provide Part A and B coverage, and most plans also include prescription drug coverage (Medicare Part D), as well as additional benefits like dental and vision plans, and wellness and fitness programs.
Key Distinctions Between Medicare Advantage and Original Medicare
| Original Medicare | Medicare Advantage |
| Government-funded and managed. | Offered and managed through private insurance companies supplemented by federal Medicare. |
| Covers hospitalization (Part A) and medical insurance (Part B). | All-in-one plan providing Part A, Part B, Part D prescription drug coverage, and other benefits like dental, vision, and fitness programs. |
| Can see any healthcare provider within the U.S. who accepts Medicare. | Plans have a set network of providers you choose from. Seeing out-of-network providers can cost more. |
In deciding between Original Medicare or a Medicare Advantage Plan, it’s essential to consider the type of coverage you want, the costs and your budget, and the level of flexibility and benefit choices. The Wandacare Team is here to assist you in this decision-making process, ensuring you select the Medicare option that best meets your healthcare needs.
The Pros and Cons of Medicare Advantage vs. Original Medicare
To help you decide, let’s look at the pros and cons of Original Medicare and Medicare Advantage Plans.
Original Medicare: The Pros
Original Medicare provides the guaranteed, quality, hospitalization and medical coverage that you need. Part A inpatient hospitalization care is premium-free for qualified beneficiaries, but it does include an inpatient hospital deductible you are responsible for of $1600. Medicare Part B has a monthly premium, an annual deductible, and coinsurance or copayments, with Medicare paying 80% of healthcare costs and you paying the remaining 20% once the annual deductible has been met. These rates are set annually, based on income according to the Social Security Act.
Eligibility for Medigap
You can opt for a Medicare Supplement plan (or Medigap), a private insurance plan designed to work with Original Medicare. A Medigap plan fills in the “gaps” or costs that Medicare Parts A and B do not cover (e.g. deductibles, copayments, and coinsurance).
Flexible Choice of Doctors and Providers
With Original Medicare, you can see any healthcare provider in the country who accepts Medicare. There are no “in-network” provider lists or “out-of-network” costs to navigate. You never need a referral or permission from a primary care physician to see a certain doctor or use a certain facility. You can receive care from any provider or specialist in the country, as long as they accept Medicare.
Original Medicare: The Cons
No Prescription Drug Coverage
Original Medicare only includes Parts A and B and does not include Part D prescription drug coverage. To ensure you avoid a late enrollment penalty, it’s important to choose a standalone Part D plan, which is available through private insurance companies and comes with an extra monthly premium. This is necessary even if you currently don’t require prescription medications.
No Additional Benefits
Again, Parts A and B are all you get with Original Medicare. It does not provide, cover, or include options for additional benefits like dental, vision, or hearing. Original Medicare only covers hospitalization and medical services.
Medicare Advantage: The Pros
Prescription Drug Coverage Included
One of the main draws of private Medicare Advantage Plans is that most plans include Medicare Part D Prescription Drug Coverage. Since all Medicare Part D plans are offered by private insurance companies, you won’t need to secure a separate Part D plan, as it will be “packaged” as part of your Advantage Plan from the insurer issuing and managing the plan.
More Benefits and Plan Choices
Besides the inclusion of prescription drug coverage, Medicare Advantage Plans offer additional benefits. Most Medicare Advantage Plans provide Part A, Part B, and Part D prescription drug coverage, with additional benefits like dental, vision, and/or hearing coverage. Many offer perks like wellness services and fitness programs.
Comprehensive Plans with Coordinated Care
A Medicare Advantage Plan combines all the “parts” of Medicare you want into an all-in-one plan. Instead of feeling like you’re piecing together the needed “parts” à la carte, you have a plan with a coordinated approach to your care. All healthcare services are offered through the plan’s network of providers, and, depending on your health needs, many plans offer managed treatment programs and wellness services.
Medicare Advantage: The Cons
In-Network Restrictions
Your “coordinated” care only applies to the “in-network” providers—the set list of preferred healthcare providers (doctors, hospitals, medical facilities) offered by your plan. Going out-of-network for your care means you won’t be fully covered, and can result in higher copayments and out-of-pocket costs. Each plan will also outline specific copayments, coinsurance, and out-of-pocket costs, which can vary based on the plan and its structure (e.g., HMO vs. PPO). It’s important to note that with HMO plans, going outside the plan’s preferred provider network results in NO coverage, meaning you will have to self-pay for any services received out of network.
Required Referrals
While not true of every plan, most Medicare Advantage Plans require you to select a primary care physician (PCP), who then refers you for any needed care or to see a specialist. In these plans, you can’t simply make an appointment with a specialist or treatment facility. A PCP referral is required for care, or it may not be covered by your plan.
Factors to Consider in Choosing Between Medicare Options
In deciding between Original Medicare or a Medicare Advantage Plan, consider the following factors with the assistance of the Wandacare Team:
The level of flexibility: The sheer number and types of Medicare Advantage Plans give you lots of options, but these often come with a set network of providers, with higher costs for going out of network. Whereas, Original Medicare allows you to see any provider in the U.S. who accepts Medicare. Additional benefits to Medicare Advantage plans can include (prescription drug, vision, dental, or hearing). That being said, the dental, vision, and hearing benefits provided by Medicare Advantage Plans are not all-encompassing, and the extent of coverage varies depending on the specific plan you choose. One notable limitation is the network of dentists you are required to see in order to access these services, such as Greenberg Dental and similar providers. These plans often offer enticing benefits to encourage enrollment, but it’s important to be aware of their limitations.
Making an Informed Choice
The Wandacare Team will help you choose the right Medicare plan for you by understanding your healthcare needs, your healthcare budget, and the different plans available.
With over a decade of experience, the Wandacare Team will share the details of all the Medicare plans available to you in Central Florida and Polk County. We’ll do the research of plan comparison, so you can be confident you’ll have the best plan, based on your needs, and within your budget. Our licensed Florida agents are ready to pair you with your perfect plan.
