Which Medicare Plan Is Better For You
For those who rely on prescription drugs, Medicare Advantage is the best plan. Original Medicare does not provide any coverage for prescription drugs whether you have Medigap or not. Although you can add Part D coverage to an Original Medicare plan, its typically a much higher cost to do this. About 82 percent of Medicare Advantage plans already include prescription drug coverage. In addition, Medicare Advantage plans make it so there is a cap on out-of-pocket spending. No matter what, you cant spend more money out-of-pocket after a certain limit. There is no out-of-pocket maximum for Medicare, which means that you can often pay more out-of-pocket.
Medicare Advantage plans also include a cap on out-of-pocket expenses. If you dont want to pay the 20 percent coinsurance with Original Medicare, then you should also pick Medicare Part C. Medicare Advantage plans are structured differently and typically cost less for the value that you receive. You may be able to see more doctors and also pay a less premium per month. You may also only be responsive for co-pays when you visit a doctor or hospital. Under some Medicare Advantage plans, extra services are available. If you are looking for assisted living facilities, nursing home care, vision and dental, its best to pick a Medicare Advantage plan that already has those features built in.
When Medicare Advantage Isnt Always Best
Making the Right Medicare Choice
Is Medicare Advantage Cheaper Than Medicare
Both Medicare Advantage and Medicare can have out-of-pocket costs. With Medicare, Part A coverage is typically premium-free for most people. Medicare Part B coverage has both a premium and a deductible. For 2021, the standard Part B premium is $148.50. What you pay for Medicare Part B premiums can depend on your income and tax filing status.
The standard Medicare Part B deductible is $203 for 2021. For Medicare Part B services, you typically pay 20% of the Medicare-approved amount after meeting the deductible. If youre also enrolled in Medicare Part D with Original Medicare, youll pay a separate premium for that.
With Medicare Advantage plans, the amount you pay for premiums or deductibles can depend on the plan. Some Medicare Advantage plans have a $0 premium, for instance. If the plan does charge a premium, youd pay this in addition to the regular Medicare Part B premium. But you may not be paying extra for Part D prescription drug coverage if thats included in the plan.
Medicare Advantage plans may require copayments or coinsurance. There may be a yearly limit, however, on what youre required to pay out of pocket. You wont need to purchase Medigap insurance either, which is designed to supplement some of the costs that Original Medicare doesnt cover.
So which is cheaper, Medicare Advantage vs. Medicare?
Comparing The Costs Of Original Medicare And Ma Plans
Most Medicare Advantage plans cost the same or much less than Original Medicare with supplemental coverage extras. Then there are some Medicare Advantage plans that offer more services but also have a higher premium. If you have ever bought a private health insurance plan on your own, then you will understand how to purchase Medicare Advantage plans. They are offered separately from other plans and can be compared easily on most sites like Medical.net. Each Medicare Advantage plan will offer a different monthly premium, coinsurance, co-pay and out-of-pocket limit. If you do end up with a lower premium for Medicare Advantage, you may have to pay a higher co-pay when you do visit a doctor or facility. Typically, studies have shown that Medicare Advantage plans cost no more than Original Medicare plans and still offer more freebies and extra services because private companies provide them.
Breaking Down Coverage in Medicare and Medicare Advantage
When considering which plan to purchase, you should learn about the basics of coverage for each type of plan. This is a quick look at all of the differences between the two and how each of them work. As the federal government sponsors them both, there are certain limitations to the coverage.
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Why Medicare Advantage Plans Can Fall Short
For many older Americans, Medicare Advantage plans can work well. A JAMA study found that Advantage enrollees often receive more preventive care than those in traditional Medicare. Advantage plans are competing not just on cost but on delivering quality care, says Kenton Johnston, PhD, associate professor of health management and policy at Saint Louis University, co- author of the study.
But if you have chronic conditions or severe health needs, you may want to think twice about Medicare Advantage because of the requirements for pre-authorization and staying in-network, says Melinda Caughill, co-founder of 65 Incorporated, a firm that provides Medicare enrollment guidance to financial advisers and individuals.
If you need to see multiple specialists, and you have to get referrals for each appointment or fight to overturn denials, it can be really challenging, Caughill says.
Steven Feld, 65, a retiree in South Pasadena, Fla., struggled to get coverage for an injection to treat his arthritic knee. The treatment, a prefilled injection administered in a doctors office, is deemed a medical device by the FDA, so the plan twice denied the coverage. When I was on my employers group plan, there was no problem getting the injection covered, says Feld, who joined his Medicare Advantage plan in May.
How To Choose Between Original Medicare Vs Medicare Advantage
Understanding Original Medicare vs. Medicare Advantage can help you choose coverage that best fits your health and budget needs. Read our guide and learn about these Medicare options.
Each Medicare plan and insurance product we feature has been independently selected and reviewed by our editorial team in conjunction with our partners at Medicare Expert USA. If you make a purchase using the links included, Health.com may be compensated.
Key Takeaways:
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With Original Medicare, health insurance benefits come directly from the federal government.
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Medicare Advantage plans include benefits of Medicare Part A and Part B, but are sold by private health insurance providers.
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If you have Original Medicare, you can add a prescription drug plan or supplement insurance to lower your healthcare costs.
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You can only enroll in Original Medicare and a Medicare Advantage plan during certain enrollment periods.
Original Medicare and Medicare Advantage provide similar benefits, but these plans aren’t the same. Original Medicare is health insurance through the federal government. Medicare Advantage plans, on the other hand, are sold by private Medicare-approved health insurance providers.
If you’re eligible for Medicare, it’s important to understand your options to ensure getting the coverage you need.
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Having Medicaid Or A Medicare Savings Program
Medicare covers many services, but it doesnt cover long-term care benefits and can leave its enrollees with large cost-sharing expenses. Medicaid pays for some services that Medicare doesnt cover for enrollees whose incomes and assets make them eligible. If you have Medicaid or a Medicare Savings Program a program where Medicaid pays for Medicare premiums and cost-sharing then your enrollment options are different than if you only had Medicare.
Some Medicare Advantage plans specialize in covering low-income Medicare beneficiaries. These are known as Dual Eligible Special Needs Plans , and are available in every state. If you have Medicare and Medicaid, you should have few out-of-pocket expenses if you see providers enrolled in both programs regardless of whether you enroll in a D-SNP. Receiving coverage through a D-SNP requires you to see only providers who participate with the D-SNP insurer.
Some D-SNPs offer additional services, such as home care, dental or vision benefits. D-SNPs can also help coordinate all of the health services you receive. But low-income Medicare beneficiaries are better off with Original Medicare paired with regular Medicaid as secondary coverage if their providers accept those programs, but not D-SNP plans. In many states, the fee-for-service Medicaid benefit also covers dental or vision care.
Here is more information about programs available to Medicare beneficiaries with limited incomes and assets.
Can You Have A Medicare Advantage Plan And A Medicare Supplement Plan
Medicare Advantage and Medicare Supplement are different types of Medicare coverage. You cannot have both at the same time. Medicare Advantage bundles Part A and B often with Part D and other types of coverage. Medicare Supplement is additional coverage you can buy if you have Original Medicare Part A and B.
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Medicare Plus Medigap Supplemental Insurance Policies
About two-thirds of the 61 million seniors and disabled Medicare beneficiaries choose Original Medicare, Parts A and B, which cover hospitals, doctors, and medical procedures. About 81% of these beneficiaries supplement their insurance with Medigap , Medicaid, or employer-sponsored insurance, and more than 25 million also pay for a stand-alone Medicare Part D prescription drug policy.
Medicare Supplement Insurance, or Medigap plans, are not connected with or endorsed by the U.S. government or the federal Medicare program.
While this may be the more expensive option, it has a few advantages. Both Medicare and Medigap insurance plans cover you for any hospital or doctor in the U.S. that accepts Medicare, and the great majority do. There is no need for prior authorization or a referral from a primary care doctor. Coverage includes the entire U.S., which may be important for anyone who travels frequently or spends part of the year in a different locale. This option is also attractive to those who have particular physicians and hospitals they want to use.
Understanding Your Medicare Choices
If you’re nearing age 65 or have already reached that milestone, you’ve undoubtedly heard about Original Medicare and Medicare Advantage. Even if you choose Medicare Advantage, remember you’ll need to first enroll in Original Medicare .
To decide which option is best for you, you’ll need to consider your health care needs, budget, and personal preferences. Read on for a summary of facts that will help you weigh the pros and cons of each coverage approach.
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Medicare: More Choices And Better For Psychological Health
The bottom line for most A-Fib patients is that Original Medicare not only gives you more choices but is also better for your psychological health. Also, with Original Medicare if you disagree with a coverage or payment decision, you have the right to appeal.
Under Original Medicare, its tremendously liberating to know you can go to any doctor or facility you want. The last thing you want in your life is some bureaucrat dictating to you what treatments or doctors you can access.
Though obviously many personal and individual factors may influence your choice of Medicare plans, in general, Original Medicare is probably a better choice for many patients with A-Fib.
Medicare coverage options is a complicated business. To learn more, see the downloadable booklet, Your Medicare Benefits.
Is Medicare A State Or Federal Program
Medicare is a federal program, meaning that its eligibility and coverage are mostly the same across the U.S. Its important to remember that this distinction is only the case for Original Medicare, which includes Parts A and B. If you have Original Medicare, there is essentially no difference in coverage depending on where you live.
This is not true of Medicare Advantage plans, which vary significantly by the state in cost and coverage. Medicare Advantage plans, or Medicare Part C, are provided by private insurers and include additional benefits and coverage beyond the scope of Original Medicare.
Medicare Part D, an optional benefit to cover prescription drugs, also varies by state and region.
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Beneficiaries Enrolled In Medicare Advantage And Traditional Medicare Look Similar After Separating Out Snps
After excluding beneficiaries in SNPs, beneficiaries enrolled in traditional Medicare do not differ significantly from Medicare Advantage enrollees on age, income, or receipt of a Part D low-income subsidy , which helps low-income individuals pay for prescription drugs . However, beneficiaries in traditional Medicare are significantly more likely than Medicare Advantage enrollees to reside in a nonmetropolitan area, as well as more likely to live in a long-term-care or residential facility.
Beneficiaries in SNPs are different. Given the eligibility criteria for these plans, it is not surprising that enrollees tend to have significantly lower incomes and a greater likelihood of receiving Medicaid benefits or LIS than other Medicare beneficiaries. Enrollment in SNPs for people who require an institutional level of care has been growing rapidly, leading to a similar share of SNP enrollees and beneficiaries in traditional Medicare living in a long-term-care facility.8
Racial/ethnic distribution of enrollees. The racial and ethnic distribution of beneficiaries in traditional Medicare and Medicare Advantage is similar, after separating SNPs from other Medicare Advantage plans . Most beneficiaries in traditional Medicare and Medicare Advantage plans identify as white. However, SNP enrollees are significantly more likely to identify as Hispanic or Black.
You Can Use The Healthcare Providers Of Your Choice
Patients with Original Medicare can use any healthcare provided thats approved by Medicare to accept Medicare payments. This is both good and bad.
While most primary care physicians and specialists are approved by Medicare, not all accept new Medicare patients. And, not all doctors accept Medicare-assignment, which requires them to take payment Medicare establishes for each healthcare service. Many doctors and specialists who dont accept Medicare-assigned will see patients for an additional 15 percent fee, which is billed to the patient as Part B Excess ChargesA Medicare Part B excess charge is the difference between a health care providers actual charge and Medicares approved amount for payment…..
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Medicare Vs Medicare Advantage: The Basics
If you have original Medicare, the goverment directly pays for your Medicare benefits. In contrast, with Medicare Advantage plans, you receive your benefits from private medical insurance companies that Medicare has approved. There are several types of Medicare Advantage Plans:
The Official U.S. Government Site for Medicare online states that you must live in the service area of you prospective plan and also have Medicare Part A and Part B in order to join a Medicare Advantage Plan.
Both Medicare and Medicare Advantage are also legally required to cover certain basic health services, though the costs you pay and the specific services that are covered vary.
Medicare Advantage began in 1995, though similar programs were available as early as the 1970s. The key distinction between the two programs is that Medicare is government health insurance, while Medicare Advantage is private health insurance that the government helps fund.
Whats Included In Original Medicare Plans
These plans are for Part A and B. They do not include Part C or Part D. Original Medicare is completely offered through the federal government. You can use this type of Medicare everywhere that Medicare payments are accepted.
- Part A and Part B are included if enrolled in both.
- You pay a coinsurance and deductible when you receive healthcare. Medicare typically expects you to pay 20 percent of the cost for outpatient care .
- Most enrollees must pay a premium for Part B. There arent any premiums for Part A if you meet the work requirement . Nearly all of Medicare enrollees meet this requirement. .
- You can receive medical care from any hospital or doctor who accepts Medicare in the United States.
- You dont need a referral to see a specialist.
- No pre-authorization is needed to get services.
- You can buy a Medigap policy if you want supplemental insurance.
- To get prescription drug coverage, you have to buy a separate plan from a private insurance company.
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Local Conditions And Convenience
In some areas where physicians and hospitals are scarce, its important to check out both the networks of available Medicare Advantage plans and the locations of providers who accept regular Medicare. Are the doctors accepting new patients? Will you have to travel far to see a provider or be treated in an emergency room? Advice from local professionals, neighbors, and licensed insurance brokers can help you find Medicare Advantage plans that do business in your area. Compare plans to find one that may suit your needs.
Original Medicare Vs Medicare Advantage Vs Medicare Supplement
by Christian Worstell | Published April 22, 2021 | Reviewed by John Krahnert
Original Medicare is Part A and Part B .
But beneficiaries also have other Medicare coverage options, including Medicare Advantage plans and Medicare Supplement Insurance plans .
Learn more about how these options compare to find out which one might be right for your needs.
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Drug Coverage In Medigap Vs Medicare Advantage Ppo
If you are on a Medicare Advantage PPO, you cannot purchase a stand-alone drug plan. What that means is that if the PPO that works best for your medical needs for you doesnt have the drug coverage youd like, you are out of luck.
If the plan you want doesnt offer prescription coverage, you are out of luck.
Even if you dont take any medications, youll need either a drug plan or creditable coverage to avoid future penalties. With a Medicare Supplement plan, you can purchase the drug plan that saves you the most money. But it will be at an added expense. Heres how to find the prescription drug plan that saves you the most money.
Part B Medications in Medicare Advantage PPO vs Medicare Supplement
Medicare Advantage PPOs handle Part B medications differently than original Medicare and a Medicare Supplement Plan.
For example, if you are diabetic and use a pump, Medicare and Plan F covers your insulin at 100%. With Medicare Advantage PPOs, you could have a co-pay ranging up to 20 50% of the cost of the drug.
The same thing applies to chemotherapy drugs and other doctor provided shots such as Lupron. The Medicare Advantage PPO could require you to pay a co-insurance amount where-as with a Medigap Plan you could have a smaller amount to pay.
Durable Medical Equipment in Medicare Supplement vs Medicare Advantage PPO
Medical Conditions in Medigap vs Medicare Advantage PPO
The good news about Medicare Advantage PPOs is that they MUST accept you into their plan as long as you:
