Dear Colette,

It’s great that you are taking the time to learn about your options before enrolling in a plan. There are many important choices to make about your health care coverage, and being informed can help you make the best decisions for your own needs.

People with Medicare can get their health coverage through either Original Medicare or a Medicare Advantage Plan (also known as a Medicare private health plan or Part C). While there are many differences between the two, remember that Medicare Advantage Plans must provide the same benefits offered by Original Medicare, but may apply different rules, costs, and restrictions.

Let’s review some of the main differences between these two ways to get your Medicare:

Costs

• Original Medicare: You will be charged for standardized Part A and Part B costs, including a monthly Part B premium. You are responsible for paying a 20% coinsurance for Medicare-covered services if you see a participating provider after meeting your deductible.
• Medicare Advantage: Your cost-sharing varies depending on the plan. You usually pay a copayment for in-network care. Plans may charge a monthly premium in addition to the Part B premium.

Supplemental insurance

• Original Medicare: You have the choice to pay an additional premium for a Medigap policy to cover Medicare cost-sharing.
• Medicare Advantage: You cannot purchase a Medigap policy.

Provider access

• Original Medicare: You can see any provider and use any facility that accepts Medicare (participating and non-participating).
• Medicare Advantage: You can typically only see in-network providers.

Referrals

• Original Medicare: You do not need referrals for specialists.
• Medicare Advantage: You typically need referrals for specialists.

Drug coverage

• Original Medicare: You must sign up for a stand-alone Part D plan if you want prescription drug coverage.
• Medicare Advantage: In most cases, the plan provides prescription drug coverage (you may be required to pay a higher premium).

Other benefits

• Original Medicare: Does not cover vision, hearing, or dental services.
• Medicare Advantage: May cover additional services, including vision, hearing, and/or dental (additional benefits may increase your premium and/or other out-of-pocket costs).

Out-of-pocket limit

• Original Medicare: No out-of-pocket limit.
• Medicare Advantage: Annual out-of-pocket limit. Plan pays the full cost of your care after you reach the limit.

Between the two options, one is not better than the other for everyone. Medicare Advantage and Original Medicare are just different, and you may prefer one over the other depending on your needs and priorities.

Because you have a Medigap, I do want you to note that if you switch from Original Medicare to Medicare Advantage, you will lose your Medigap. Depending on your state’s Medigap enrollment rules, it may be difficult or expensive to purchase a Medigap later. There are only a few specific protected times to purchase a Medigap under federal rules, but your state may offer additional rights.

To receive individualized counseling on your options, I recommend calling your local State Health Insurance Assistance Program (SHIP). I hope this helps!

-Marci