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Vol. 13, Issue 20  • October 6, 2014

What is the difference between Original Medicare and Medicare Advantage?

Dear Marci,

I turned 65 last year and signed up for Original Medicare when I was first eligible. My friend told me that I should look at my health care coverage during Fall Open Enrollment in case I want to make any changes. He said that he is enrolled in a Medicare Advantage plan. What is the difference between Original Medicare and Medicare Advantage?

- Ian (Fort Lauderdale, FL)

Dear Ian,

Medicare beneficiaries have two options for receiving their health care coverage: Original Medicare or Medicare Advantage. Each option has different costs and rules about the providers you use, so it is important to understand the basics about both before changing your coverage. Your friend is right, you are able to make changes to your Medicare coverage during Fall Open Enrollment, and it is a good idea to review your options every year to ensure that you have the best coverage possible. Remember, Fall Open Enrollment lasts from October 15- December 7 of each year and the changes you make during this time take effect on January 1.

Original Medicare is the traditional fee-for-service Medicare program administered directly by the federal government. Under Original Medicare, you can see any doctor in the country who participates in the program, and most doctors do. It includes Part A, which covers inpatient hospital costs, and Part B, which covers outpatient medical costs. In order to have prescription drug coverage under Original Medicare, you must actively choose and enroll in a stand-alone Part D prescription drug plan.

With Original Medicare, after you pay your monthly premium, you pay a coinsurance for each service that you receive. If you have Original Medicare, you can purchase Medigap supplemental insurance to assist with Part A and Part B premiums and copays. Note that Medigaps do not assist with Part D prescription drug costs. Some people also have supplemental insurance through retiree insurance or union benefits.

Medicare Advantage plans are plans administered by private insurance companies that provide Medicare benefits. These plans contract with Medicare, and are paid a fixed amount to provide Medicare benefits. You must live in the plan’s service area in order to enroll. Medicare Advantage plans are generally managed care plans, and the most common types are Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Private Fee For Service (PFFS) plans. You still have Medicare if you join a Medicare Advantage plan. In most cases, you must still pay your Part B monthly premium (and a Part A premium, if you have one). Each Medicare Advantage plan must provide all Part A and Part B services, but they can do so with different costs and restrictions than Original Medicare. This can affect how and when you can get care. For example, Medicare Advantage plans require members to use their networks of doctors and hospitals. If you use an out-of-network provider, you may have to pay more for your care.

Medicare Advantage plans must limit the amount you spend out-of-your own pocket for health care. These limits tend to be high but are helpful if you need a lot of care. Plans can also offer additional benefits that Original Medicare does not cover, like routine vision or dental care. Generally, if you want to enroll in a Medicare Advantage plan and also need drug coverage (Part D), you must join a plan that includes drug coverage. If you have a Medicare Advantage plan, you cannot purchase a Medigap policy.

Even if you are satisfied with your current Medicare coverage, it’s important to investigate during Fall Open Enrollment whether other Medicare options may better suit your individual needs in the next calendar year. Research shows that people with Medicare prescription drug coverage (Part D) could lower their costs by shopping among plans each year. Being proactive about your coverage can help to reduce costs and make sure that your health care needs are met.


Health Tip
October is National Breast Cancer Awareness Month. Breast cancer is the second most common cancer in women. Early detection and treatment are essential for women, and many can survive breast cancer if it is found and treated early.

Talk with your doctor about your risk for breast cancer, especially if a close family member has had breast or ovarian cancer. If you are a woman aged 40 to 49, it is important to talk with your doctor about when to start getting mammograms, an x-ray screening to detect signs of breast cancer. If you are a woman age 50 to 74, be sure to get a mammogram every two years. You can discuss with your doctor about getting them more often, especially if you are at a higher risk for breast cancer.

Medicare covers preventive screening mammograms, and you do not pay a deductible or coinsurance for a screening mammogram if you see a provider that accepts Medicare assignment. Click here to read more about Medicare’s coverage of mammograms.

Click here to read more about breast cancer awareness and prevention from the Centers for Disease Control and Prevention. Click here for a toolkit from the U.S. Department of Health and Human Services to plan a National Breast Cancer Awareness Month event.

Need to Know
Fall Open Enrollment is coming!

During Fall Open Enrollment (October 15-December 7), you may make changes to your Medicare health and drug coverage. If you need help deciding your Medicare coverage for 2014, call the Medicare Rights Center’s free, national consumer helpline at 800-333-4114.

Dear Marci is a biweekly e-newsletter designed to keep you — people with Medicare, social workers, health care providers and other professionals — in the loop about health care benefits, rights and options for older Americans and people with disabilities.

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