When you first enroll in Medicare, one of the biggest decisions is whether to stick with Original Medicare or switch to a Medicare Advantage Plan. Medicare Advantage, also called Medicare Part C, offers an alternative way to get your Medicare benefits through private health insurance companies. These plans also provide all of your Part A and Part B coverage and often include prescription drugs and other perks as well. But is joining a Medicare Advantage Plan the right move for you? Here is an in-depth look at the key factors to consider when weighing whether Medicare Advantage is a good choice versus Original Medicare.
Background on Medicare Parts A and B
Before diving into Medicare Advantage specifics, let's review the basic parts of Original Medicare:
- Medicare Part A - Hospital coverage including inpatient stays, skilled nursing facility care, hospice. Most don't pay a premium for Part A.
- Medicare Part B - Outpatient medical coverage for doctor visits, preventive services, lab tests. Part B has a standard monthly premium.
- Medicare Part D - Prescription drug plans purchased separately from private insurers. Monthly premiums apply.
- Medigap - Supplemental plans that help cover Medicare out-of-pocket costs such as deductibles and coinsurance amounts.
With traditional Medicare Parts A and B, you can visit any doctor or facility in the country that accepts Medicare. You can add a Medigap Plan to cap your total out-of-pocket spending for the year, plus enroll in a stand-alone Part D prescription plan.
What is Medicare Advantage?
Medicare Advantage, sometimes called Medicare Part C, allows private insurers to provide your Medicare benefits through managed care plans. These plans include:
- Health Maintenance Organizations (HMOs)
- Preferred Provider Organizations (PPOs)
- Private Fee-for-Service Plans (PFFS)
- Special Needs Plans (SNPs)
Insurers must cover all of the same services as Original Medicare. MA plans often bundle in prescription drug coverage as well. Some key highlights:
- $0 premium plans may be available
- Networks are smaller than Original Medicare
- Maximum annual out-of-pocket spending caps
- Extra benefits like dental or gym membership
You still pay your monthly Part B premium. Medicare pays insurers a fixed monthly amount per enrollee.
Potential Advantages of Medicare Advantage
There are good reasons why over 28 million beneficiaries have chosen MA plans:
Many plans don't charge a premium beyond the Part B premium. Deductibles may be lower and copays are fixed dollar amounts vs. coinsurance. Maximum out-of-pocket limits protect against high healthcare costs.
Prescription Drug Coverage
MA plans combine medical and drug coverage in one plan. No need for a separate Part D purchase.
Popular additional benefits include some dental/vision/hearing coverage, gym memberships, transportation to doctor visits, and over-the-counter allowances.
MA plans focus on preventive care and managing chronic illnesses to help members stay healthier.
Potential Disadvantages of Medicare Advantage
However, there are some key downsides to weigh with MA plans:
Limited Provider Network
You must use doctors and facilities in your plan's network except in emergencies. Many plans require referrals to see specialists. Provider choices are fewer than with Original Medicare coverage.
Healthcare Utilization Management
MA plans implement more controls like prior authorizations for services. This can lead to delays in care. Out-of-network services often not covered.
Insurers change costs, coverage rules, networks frequently from year to year. Your preferred providers or drug coverage may change going forward.
No Medigap Coverage
Can't pair MA plans with a Medigap policy to lower your out-of-pocket costs.
Key Factors to Consider in Your Decision
As you weigh your options, consider:
- Current health status - Do you have complex medical needs or multiple chronic conditions requiring specialists that may require referrals under MA?
- Prescription needs - Review MA plan formularies to ensure your medications are covered.
- Provider preferences - Are your doctors in the MA plan's network? Double check hospital systems as well.
- Travel habits - Frequent long trips are difficult under MA as nationwide coverage is limited.
- Financial situation - Can you afford higher premiums of Original Medicare plus Medigap and Part D?
- Healthcare utilization - If you require frequent medical services, MA costs can add up.
Your personal circumstances should drive whether Medicare Advantage offers the affordability and flexibility you require.
Conclusion: Is Medicare Advantage a Good Option?
In general, healthier individuals who take few prescription medications, see doctors infrequently, and prioritize benefits like dental coverage do well under Medicare Advantage Plans. Plus you may find $0 premium options that provide savings over Original Medicare's Part B premium and deductible.
However, those with more complex healthcare needs and individuals who wish to see specialists freely are often better served under Original Medicare paired with supplemental Medigap coverage and a Part D prescription plan. This combination provides the greatest choice and coverage stability long-term even though premium costs are higher.
Carefully weigh the advantages against potential restrictions when considering Medicare Advantage vs Original Medicare. Review plan details like provider networks, drug formularies, and past benefits/premium changes to avoid surprises. Consult with your State Health Insurance Assistance Program (SHIP) for free unbiased guidance. Make an informed plan choice that best fits your healthcare and financial profile.
We’re Here to Help
You do not have to spend hours reading articles on the internet to get answers to your Medicare questions. Give the licensed insurance agents at Premier 360 Solutions a Call at (714) 248-8255. You will get the answers you seek in a matter of minutes, with no pressure and no sales pitch. We are truly here to help.
What is Original Medicare?
Original Medicare is Medicare Part A and Part B, managed directly by the federal government.
What are Medicare Advantage Plans?
Private insurance plans like HMOs and PPOs approved by Medicare that provide Part A/B benefits.
What services do Medicare Advantage Plans provide?
They provide all Part A and B coverage along with prescription drug coverage in many options.
What are some pros of Medicare Advantage?
Often includes additional benefits and many have lower out-of-pocket costs than traditional Medicare.
What are potential cons of Medicare Advantage?
Medicare Advantage Plans may have limited provider networks and patients pay more for out-of-network care in many options.
What is Medigap supplemental insurance?
Private plans labeled Plans A through N that cover costs Original Medicare does not like copays and deductibles.
Can I switch between Medicare Advantage and Original Medicare?
Open enrollment periods allow beneficiaries to change between the two main Medicare options each year.
When is Medicare Open Enrollment?
It runs annually from October 15th to December 7th for coverage starting the following January.
What are advantages of Original Medicare?
It has no networks so you can see any doctor that accepts Medicare nationwide.
How do Part D drug plans work?
Medicare Advantage often includes drugs but you can also sign up separately for Part D Plan ordrug coverage.
What are pros and cons to consider when choosing a plan?
Weigh network size, costs and coverage details based on your individual health situation and needs.
How can I get more information on Medicare Plans?
Visit Medicare.gov to research plan options and contact a local agent for personalized assistance.