Consider these things when deciding between Original Medicare and a Medicare Advantage Plan for your health coverage:
Original Medicare
You can go to any doctor or hospital that takes Medicare, anywhere in the U.S.
Medicare Advantage
In many cases, you can only use doctors and other providers who are in the plan’s network and service area (for non-emergency care). You may need to get a referral to see a specialist.
Original Medicare
For Part B-covered services, you usually pay 20% of the Medicare-approved amount after you meet your deductible. This amount is called your coinsurance.
You pay the monthly premium for
Part B. If you choose to join a Medicare drug plan, you’ll pay a separate premium for your Medicare drug coverage (Part D).
There’s no yearly limit on what you pay out-of-pocket, unless you have supplemental coverage – like Medicare Supplement Insurance (Medigap), Medicaid, employer, retiree, or union coverage.
Medicare Advantage
Out-of-pocket costs vary. Plans may have different out-of-pocket costs for certain services.
You pay the monthly Part B premium and may also have to pay the plan’s premium. Some plans may have a $0 premium and may help pay all or part of your Part B premium. Most plans include Medicare drug coverage (Part D).
Plans have a yearly limit on what you pay for covered Part A and Part B services (with different limits for in-network and out-of-network services). Once you reach your plan’s limit, you’ll pay nothing for covered services for the rest of the year.
You can’t buy Medigap to cover your out-of-pocket costs.
Original Medicare
Original Medicare covers most medically necessary services and supplies in hospitals, doctors’ offices, and other health care facilities. Original Medicare doesn’t cover some services, like routine physical exams, eye exams, and most dental care.
In most cases, you don’t need approval (prior authorization) for Original Medicare to cover your services or supplies
Medicare Advantage
Plans must cover all medically necessary services that Original Medicare covers. For some services, plans may use their own coverage criteria to determine medical necessity. Plans may also offer some extra benefits that Original Medicare doesn't cover.
In some cases, you may need to get approval (prior authorization) from your plan before it covers certain services or supplies.
Medicare drug coverage (Part D) is included in most plans. In most types of Medicare Advantage Plans, you can't join a separate Medicare drug plan.
Original Medicare
Original Medicare generally doesn’t cover medical care outside the U.S. You may be able to buy a Medicare Supplement Insurance (Medigap) policy that covers emergency care outside the U.S.
Medicare Advantage
Plans generally don’t cover medical care outside the U.S. Some plans may offer an extra benefit that covers emergency and urgently needed services when traveling outside the U.S.
For more information, contact a Health Insurance Professional for guidance as you consider your options.
This article was adapted from an article by CMS.gov
This article is for information only and should not be considered a recommendation. Talk with a licensed Health Insurance Professional about your specific circumstances. For more information you can go to The Texas Department of Insurance.
