Hours of Operations Monday to Friday from 8:00am to 7:00pm (EST)
Call Section
Speak to a licensed agent:
+1 (866) 685-0856 (TTY 711)
Get Started

c and Medicare Advantage: 9 Features Compared

Original Medicare and Medicare Advantage differ in costs, provider networks, and extra benefits. Get the major comparisons in this guide.

Medicare is an important aspect of health care coverage for people aged 65 years and older or younger persons living with disabilities. However, the coverage of Medicare is not uniform. Generally, beneficiaries can opt for two primary plans, namely Original Medicare and Medicare Advantage (Part C). While both options provide basic healthcare services, there are some differences in areas of service, administration, and scope of coverage. Medicare Advantage often includes coordinated care for chronic conditions, while Original Medicare requires beneficiaries to manage their care.

This guide analyzes the differences between Medicare and Medicare Advantage, enabling users to select the option that aligns best with their health and financial requirements.

Original Medicare

Original Medicare is the government-based program where the traditional fee-for-service is provided directly by the federal government. It consists of:

  • Medicare Part A (Hospital Insurance): It includes inpatient care in hospitals, skilled nursing facility care, hospice care, and some home health care.
  • Medicare Part B (Medical Insurance): Covers outpatient services including doctor visits, preventive services, durable medical equipment, and some home health care.

The Original Medicare is managed as well as paid by the Centers for Medicare & Medicaid Services (CMS). Beneficiaries can visit any doctor or health care provider in America who is falling under the Medicare network. 

What Is Medicare Advantage?

An alternative to Original Medicare is Medicare Advantage (Part C). These plans are provided by private insurance organizations that are authorized, controlled, and approved by CMS. The federal government provides these companies a set amount per beneficiary per month, which aids in managing care and offering Medicare Part A and B services.

Besides covering everything that original medicare covers, medicare advantage plans have additional benefits such as:

  • Prescription drug coverage (Medicare Part D)
  • Dental, vision, and hearing benefits
  • SilverSneakers Fitness programs
  • Wellness and preventive services

Key Differences Between Original Medicare and Medicare Advantage

Administration and Monitoring

The federal government directly administers Original Medicare through CMS (Centers for Medicare and Medicaid Services). While for Medicare Advantage plans, private insurance companies contract with CMS and manage and administer them. These plans are required to undergo rigorous federal review and receive oversight from CMS, which includes annual evaluations and performance ratings.

Access to Providers and Flexibility.

In Original Medicare plans, beneficiaries can visit any healthcare professional or specialist who accepts Medicare across the country without a referral to see specialists. Original Medicare plans have unlimited flexibility.

Medicare Advantage plans tend to have networks and operate under a Health Maintenance Organization (HMO) or a Preferred Provider Organization (PPO) system.

  • Members of HMO plans are typically required to visit their in-network providers, and referrals are necessary to see specialists.
  • PPOs have a higher level of flexibility than HMOs because they can visit out-of-network providers, usually for additional fees.

Spending and Cost Out of Pocket

For Original Medicare, the beneficiary is required to pay for:

  • Monthly Part B premiums
  • Base B and A deductibles
  • Portion of the coinsurance fee (Usually 20% of commonly used medicare services)
  • Coinsurance (generally 20% for a given service’s Medicare-approved amount)
  • There is no out-of-pocket maximum, which may result in high Medicare spending in the case of extensive care.

Medicare Advantage plans may offer:

  • Negligible or $0 supplemental premiums (besides the Medicare Part B premium)
  • Fixed copayments instead of coinsurance
  • Annual out-of-pocket limits, which cap total expenditure on covered services, including spending on necessary services.

Options for Supplemental Coverage

Original Medicare permits enrollment into Medigap (Medicare Supplement Insurance), which assists in covering the deductibles, copayments, and coinsurance gaps. Private insurance companies sell Medigap plans and offer predictable out-of-pocket costs set in advance.

Enrollees in Medicare Advantage Plans do not have access to Medigap policies and will have to self-manage costs through the structure of the plan.

Other Benefits

Routine dental, vision, and hearing care are considered additional benefits that are not included in Original Medicare and must be paid for directly or enrolled in a separate insurance plan.

Medicare Advantage, along with other services, may provide:

  • Over-the-counter medications
  • Transportation to medical appointments
  • Meal delivery services
  • Hearing aids
  • Routine vision and dental examinations

Areas Serviced and Services Provided

Original Medicare is universally accepted, with standardized benefits throughout the country.

But Medicare Advantage plans have coverage restrictions determined by state, region, or even county zip code. These plans also have annual availability and cost changes.

Care Coordination and Management

Medicare does not facilitate care coordination for its beneficiaries, meaning Original Medicare has no management and requires self-coordination.

Most Medicare Advantage plans have some level of care coordination, particularly for chronic conditions. Many of these plans also provide support through specialized care teams.

Star Ratings and Quality Measures

CMS assesses and annually grades Medicare Advantage plans according to the following criteria, with a star rating of 1-5:

  • (Member) satisfaction
  • Preventative measures
  • Management of chronic care
  • Customer service

Plans with 4 stars or more receive additional payments from CMS, which can improve member benefits. Original Medicare itself does not have star ratings.

Switching and Enrollment

The Original Medicare plan requires enrollment during IEP, with the option of switching during the General Enrollment Period or Open Enrollment (October 15 – December 7) for Medicare Part D.

There is also an Annual Enrollment window (from October 15th to December 7th ) for the Medicare Advantage Plan, along with a specific Open Enrollment phase (from January 1st to March 31st ) where you can adjust or make changes.

What is the Best Choice for You?

Original Medicare vs Medicare Advantage completely depends on people’s requirements, current health status, finances, and even travel patterns. Some of the factors to consider are:

Original Medicare is ideal for you when you:

  • Put a premium on personalisation and wish to visit any healthcare professional or treatment center without being constrained to a particular region, as this will be available to you regardless of where in the country you are residing.
  • Often visit many different countries or are planning to shift your place of residence frequently.
  • Prefer lower and predictable costs.
  • Would like the option to buy Medigap and prefer Medigap plans.
  • Prefer standard government programs.

Medicare Advantage is ideal when you:

  • Desire a unified treatment that incorporates prescription medication, dental work, and even eye care.
  • Enhanced add-on features bundled with reduced upfront charges are what you seek.
  • Tend to stoop to the level of consigned networks and referrals, as well as become acquainted with network providers.

The Difference are Important to Consider 

Original Medicare and Advantage together make sure that the Medicare receiver has adequate options and flexibility. Every year, private insurance companies are allowed to design their plans within the guidelines set by the government, which are strictly checked by CMS to ensure complete adherence to them and maintain federal criteria. 

FAQ'S

Is it possible to switch back to Original Medicare from a Medicare Advantage plan?

Transitioning from a Medicare Advantage plan to Original Medicare is possible during the Annual Enrollment Period (Oct 15 – Dec 7) and the Medicare Advantage Open Enrollment Period (Jan 1 – Mar 31) every year.

Does Original Medicare cover prescription drugs?

No. Original Medicare does not include drug coverage. To get prescription benefits, you need to enroll in a separate Medicare Part D plan.

Is there nationwide coverage for all Medicare Advantage plans?

Generally, no. Most Medicare Advantage plans have regional or local provider networks, which means your coverage may be restricted to your plan’s service area.

Recent Posts