Whats the difference between Original Medicare and Medicare Advantage?

Beneficiaries must be eligible for Original Medicare Parts A and B to enroll in a Medicare Advantage Part C. Enrollment is done through specific enrollment periods, such as the Initial Enrollment Period (when first eligible for Medicare) or the Annual Enrollment Period (October 15 to December 7 each year). The beneficiary has a choice. They can either select Original Medicare Parts A and B or they can enroll in a Medicare Advantage Plan (Part C), which includes Medicare Parts A, B, and D, which includes a prescription drug plan if they enroll in a Medicare Advantage with prescription drug coverage.

Original Medicare and Medicare Advantage Part C are both options for healthcare coverage for those who are eligible for original Medicare. Please note that benefit coverage for either an Advantage PPO or HMO plan is required to be at least as comprehensive on Parts A and B as Original Medicare is for Parts A and B.

Medicare Approved Provider Choice:

1. Original Medicare allows you to choose any healthcare provider that accepts Medicare.
2. Medicare Advantage PPO plans have a network of preferred providers, including doctors, hospitals, and other healthcare professionals or facilities, with whom the plan has negotiated discounted rates. You have the flexibility to choose any healthcare provider within the network without a referral.
3. Medicare Advantage HMO plans have a network of preferred providers, including doctors, specialists, hospitals, and other healthcare professionals or facilities. You typically need to choose a primary care physician (PCP) from within the network who will coordinate your care and provide referrals to specialists within the network. That PCP will refer you to specialists when they feel it is necessary. They help beneficiaries manage their health care needs.

Out-of-network coverage:

1. Original Medicare allows you to choose any healthcare provider that accepts Medicare.
2. Medicare Advantage PPO plans also offer coverage for out-of-network care. You can still receive healthcare services from providers outside the network, but generally at a higher cost than the preferred PPO network. This is due to the negotiated discounts the PPO network has with certain health providers. Out-of-network providers may charge higher deductibles, copayments, and coinsurance.
3. Medicare Advantage HMO plan beneficiaries generally receive coverage for healthcare services ONLY from providers within that particular HMO network. If you go outside the network for non-emergency or non-urgent care, the provider's service or hospital may not be covered, except in certain possible situations, such as when traveling temporarily outside the plan's service area.

Health Care Out-of-pocket costs:

1. Original Medicare has set maximum charges for providers who accept Medicare and the medical services that are provided, hospitals, and equipment. That regulation is true whether it's Original Medicare or either a Medicare Advantage plan (PPO or HMO).
2. Medicare Advantage PPO plans typically have lower out-of-pocket costs within the network because of pre-negotiated costs with their managed network providers. When you receive care from network providers, Medicare Advantage PPO plans may offer more favorable cost-sharing terms than Original Medicare Parts A and B because of PPO-negotiated rates with network providers.
3. Possible PPO benefits may include lower deductibles, copayments, and coinsurance compared to receiving care from out-of-network providers.
4. Medicare Advantage HMO plans may also have lower out-of-pocket costs because of pre-negotiated costs for deductibles, copayments, and coinsurance for healthcare services received from providers within the network. However, costs may be higher or not covered at all for out-of-network care, except for emergencies or certain authorized services.

Primary Care Physician (PCP) requirement:

1. Original Medicare Parts A and B do not require a referral from a primary care physician (PCP) to see a specialist physician.
2. Medicare Advantage PPO plans typically do not require you to select a primary care physician or obtain referrals to see specialists.
3. In most cases, Medicare Advantage HMO plans require you to obtain a referral from your primary care physician (PCP) before seeing a specialist.

Prescription drug coverage:

1. Original Medicare requires the beneficiary to obtain prescription drug coverage from either a stand-alone prescription drug policy or an employer's creditable prescription drug plan.
2. Some Medicare Advantage PPO plans include prescription drug coverage (Medicare Part D) as part of the plan benefits. This is called an MA-PD plan. This plan allows you to receive both medical and prescription drug coverage through a single plan.
3. Many Medicare Advantage HMO plans often provide prescription drug coverage (Medicare Part D) coverage for prescription drugs as part of the plan benefits. This allows you to receive both medical and prescription drug coverage through a single plan.

Coordination of Care:

1. Original Medicare does not provide care coordination or case management services.
2. Most Medicare Advantage PPO and HMO plans provide some degree of health care coordination service to help beneficiaries manage their healthcare needs and may also offer disease management programs for chronic conditions.

Structure:

1. Medicare Advantage plans are offered by private insurance companies who have been approved by CMS-Medicare. These private insurance companies provide at least all of the benefits of Original Medicare (Parts A and B) and may include additional benefits. Specific additional plan benefits offered can vary depending on the plan.

Patient Cost-sharing:

1. Medicare Advantage plans have their own premiums, deductibles, coinsurance, and copayments, which may differ from Original Medicare. The costs can vary among plans and insurance companies.

It's important to carefully consider your healthcare needs and compare the costs and benefits of Original Medicare and Medicare Advantage before making a decision about which option is best for you.