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November 2020

Which Should You Choose, Original Medicare or Medicare Advantage?

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If you are turning 65 this year, chances are you are researching Medicare. Did you know you could choose between Original Medicare and Medicare Advantage? This article will explain both types of Medicare and the differences between them so that you can choose the plan that suits your budget, your health, and where you want to receive care.

What is Medicare?

Medicare is the name of the federal health insurance program for people who are 65 or older. Others can join Medicare as well:

  • Some younger people who have a disability;
  • People with End-Stage Renal Disease, which is also called ESRD and is permanent kidney failure requiring dialysis or a transplant;
  • Those with Amyotrophic Lateral Sclerosis (ALS), also called Lou Gehrig’s Disease.

There are currently four parts to Medicare:

  • Part A provides inpatient/hospital coverage.
  • Part B provides outpatient/medical coverage.
  • Part C offers an alternative to Original Medicare (Parts A and B) called the Medicare Advantage Plan, or the Medicare private health plan.
  • Part D provides prescription drug coverage.

What are the Features of Original Medicare?

If you require medical attention, you go to your primary care doctor or hospital. No prior authorization is required. Most doctors and hospitals accept Medicare.

You will pay a monthly premium for Part B, and some people also pay a premium for Part A. Typically, you will pay a copay for the medical care you receive. Medicare places limits on the amounts that doctors and hospitals can charge for your medical care.

Original Medicare does not cover prescription drugs. You must purchase Part D or choose and purchase a private drug plan (PDP). Original Medicare does not cover dental care or vision.

What are the Features of Medicare Advantage?

Each Medicare Advantage Plan is a private plan that is required to provide all Part A and Part B services covered by Original Medicare. The primary difference is that Medicare Advantage plans have different rules, costs, and restrictions that can affect how, when, and where you receive medical care.

Like Original Medicare, you will usually pay copays for medical services if you have Medicare Advantage. Unlike Original Medicare, you are restricted to health care providers who are in your network and within your geographical service area, and many medical services require preauthorization. Some Medical Advantage plans provide benefits that Original Medicare does not, such as dental care, vision, hearing, and membership in fitness programs or clubs.

Medicare Advantage plans generally have an annual maximum out-of-pocket spending limit. If you reach this limit, your plan pays your medical expenses for the rest of the year.

The Most Important Differences Between Original Medicare and Medicare Advantage

You may save money on premiums and expand coverage to other services like dental care or vision if you don”t mind getting preauthorization for medical care and only visiting providers in your network. If this is you, look into private insurance under Medicare Advantage.

If you prefer to visit your own doctors and to seek medical attention when you want, Original Medicare may suit you, although you will have to purchase additional prescription drug coverage and coverage for other medical care like dental and vision, if needed.

Both forms of Medicare require that you pay the Medicare Part B premium. The standard Part B premium amount in 2020 is $144.60, which most people pay. In 2020, the Part B deductible is $198. After you meet your deductible for the year, you typically have a 20% copay for most doctor services, outpatient therapy, and durable medical equipment (DME).

Can I Change My Medicare to a Different Plan or Add or Drop Coverage?

Yes. If you sign up for one form of Medicare and decide later to switch to another form, or if you want to purchase additional coverage or drop any coverage, there are certain times of the year that you are able to do that.

The Fall Open Enrollment Period, also known as the Annual Coordinated Election Period or ACEP), occurs annually from October 15 through December 7. Any new coverage selected takes effect the following January 1.

During the Fall open enrollment period, you can change your choice of healthcare coverage no matter what you previously chose, and you can add, drop, or change Medicare prescription drug coverage.

The Medicare Advantage Open Enrollment Period, or MA OEP, occurs each year from January 1 through March 31. During this period, you can switch from your Medicare Advantage Plan to another Medicare Advantage Plan or to Original Medicare with or without a stand-alone prescription drug plan (Part D or a private prescription plan). Any changes you make take effect on the first of the month following the month you make the changes. People who have Original Medicare coverage may not make any changes during the MA OEP but must wait until the Fall Enrollment Period.

If Medicare Advantage appeals to you, research the plans offering coverage in your area. You may find a plan that suits you and your medical needs and preferences better than Original Medicare, or, you may not. Do your homework before enrolling in any form of Medicare.  Better yet, reach out to your Federal Retirement Consultant and ask us to compare all plans for you.

About the Author

Veronica Baxter is a legal assistant and blogger living and working in the great city of Philadelphia. She frequently works with David Offen, Esq., a busy Philadelphia bankruptcy lawyer.