Original Medicare vs. Medicare Advantage

(Provided by CMS – @CMSHHSgov)

Overview

Original Medicare includes Part A and Part B.
You can join a separate Medicare drug plan to get Medicare drug coverage (Part D).
You can use any doctor or hospital that takes Medicare, anywhere in the U.S.
To help pay your out-of-pocket costs in Original Medicare (like your 20% coinsurance), you can also buy supplemental coverage, like Medicare Supplement Insurance (Medigap), or have coverage from a former employer or union, or Medicaid.

Medicare Advantage is a Medicare-approved plan from a private company that offers an alternative to Original Medicare for your health and drug coverage. These “bundled” plans include Part A, Part B, and usually Part D.
In most cases, you’ll need to use doctors who are in the plan’s network.
Plans may have lower out-of-pocket costs than Original Medicare.
Plans may offer some extra benefits that Original Medicare doesn’t cover — like vision, hearing, and dental services.

You can go to any doctor or hospital that takes Medicare, anywhere in the U.S.
In most cases you don’t need a referral to see a specialist.

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.

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.
In most cases you don’t need a referral to see a specialist.
There’s no yearly limit on what you pay out-of-pocket, unless you have supplemental coverage – like Medicare Supplement Insurance (Medigap).
You can choose to buy Medigap to help pay your remaining out-of-pocket costs (like your 20% coinsurance). Or, you can use coverage from a former employer or union, or Medicaid.

Out-of-pocket costs vary – plans may have lower or higher out-of-pocket costs for certain services. You may also have an additional premium.
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 out of pocket for services Medicare Part A and Part B cover. Once you reach your plan’s limit, you’ll pay nothing for services Part A and Part B covers for the rest of the year.
You can’t buy and don’t need Medigap.

Original Medicare covers most medically necessary services and supplies in hospitals, doctors’ offices, and other health care facilities. Original Medicare doesn’t cover some benefits like eye exams, most dental care, and routine exams.
You can join a separate Medicare drug plan to get Medicare drug coverage (Part D).
In most cases, you don’t need approval for Original Medicare to cover your services or supplies

Plans must cover all medically necessary services that Original Medicare covers. Plans may also offer some extra benefits that Original Medicare doesn’t cover – like certain vision, hearing, and dental services.
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.
In many cases, you may need to get approval from your plan before it covers certain services or supplies.

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.

Plans generally don’t cover medical care outside the U.S. Some plans may offer a supplemental benefit that covers emergency and urgently needed services when traveling outside the U.S.