Medicare 101: What’s the difference between Original Medicare and Medicare Advantage?
Medicare can be a confusing topic, so if you are planning to initially enroll or review your options during the Annual Election Period (AEP) it’s important to explore all your choices.
Susan Schaffrath, a senior services advocate counselor at Advocate Christ Medical Center and Certified Senior Health Insurance Program (SHIP) Counselor trained by the Illinois Department on Aging, offers 5 key points you should know:
1: What is the difference between Original Medicare vs. Medicare Advantage?
Schaffrath says there are two main ways to obtain Medicare coverage: Original Medicare or a Medicare Advantage plan. Use the chart below to help you understand your Medicare coverage choices.
2: What is the Medicare Annual Election Period (AEP)?
The Medicare Annual Election Period (AEP) occurs every year from Oct. 15 to Dec. 7. During this time, individuals can change their Medicare health or Part D prescription drug coverage. This includes returning to Original Medicare or joining or switching to a Medicare Advantage plan. New coverage begins January.
Schaffrath says you should ask yourself three questions when considering your Medicare options:
- Does my current Medicare coverage allow me to see all the providers that are important to me?
- Are my prescription drug costs as reasonable as they can be?
- Do I currently have all the health care benefits that are most essential to me?
If answered no to any of these questions you may want to consider exploring other Medicare options. Some worth looking into may be:
- Medicare Advantage, often referred to as MA plans, bundle your Medicare Part A and B benefits and often include a prescription drug plan. These types of plans often resemble employer HMO and PPO plans.
- Medicare Cost Plans (available in Wisconsin) are similar to MA plans. The difference between these plans is that Original Medicare will pay for Medicare covered services if a cost plan enrollee receives care outside of the cost plan network. This does not happen with MA plans.
Consider the following if you want to select one of these plan types:
- MA plans offer one way to receive Medicare benefits through private insurance companies approved by Medicare.
- MA plans provide the same Medicare Part A and Part B coverage as Original Medicare and most plans bundle in prescription drug coverage.
- MA plans may cover additional benefits that Original Medicare does not cover, for example vision, dental, hearing and transportation.
- You continue to pay your Medicare Part B monthly premiums whether you enroll in a MA plan, Cost plan or Original Medicare.
- Plan premiums vary and most have copays for each medical service received. In addition, they also have a yearly limit on what you pay for medical services.
- In most cases, you will need to use doctor’s and services that are in the MA plan’s network.
- MA plans are not subject to the mandated benefit requirements under Wisconsin insurance law (In Wisconsin, some Medicare Cost Plans and Medicare supplements are required to cover the treatment of certain specific health conditions, and certain types of healthcare providers even when Medicare does not cover these expenses).
When can I enroll in a Medicare Advantage plan?
You can enroll in a MA plan when you first become Medicare eligible during what’s called your Initial Enrollment Period (IEP). The IEP is a 7-month period that begins three months before you turn age 65, the month you turn 65 and ends the third month after your 65th birthday.
You can also enroll during the Annual Election Period and in certain circumstances if you qualify for a Special Enrollment Period.
What if I enroll in a Medicare Advantage plan and I don’t like it?
There are special trial rights available for people who join a MA plan when they are first eligible for Medicare due to age 65. They may drop the MA plan and go back to Original Medicare anytime within the first 12 months of enrolling in a plan.
5: What are available Medicare resources?
Schaffrath knows Medicare enrollment can be complicated, but she reminds individuals help is available to ensure you have the right coverage. Check out these available resources:
- For more information on Medicare resources and related services in your area:
- If you are a resident of Illinois, visit advocatehealth.com/medicare.
- If you are a Wisconsin resident, visit aurora.org/medicare
- To view and compare 2023 available plans in your area, visit the Medicare plan finder at medicare.gov/plan-compare or call 1-800-MEDICARE after October 1.
- State Health Insurance Assistance Program (SHIP) counselors are available to assist you. To contact SHIP, visit www.shiptacenter.org or call 877-839-2675. TTY users can call 1-877-486-2048.
About the Author
Liz Schoenung, health enews contributor, is an integrated marketing manager at Advocate Health Care and Aurora Health Care. She earned her bachelor’s degree in Corporate Communication from Marquette University. Outside of work, Liz has a goal of visiting all U.S. national parks.
Medicare 101 – article really helped me to understand what this Medicare enrollment period is about; and if I need to change coverage. Thanks
With Medicare Advantage you CANNOT see ANY physician; you MUST stay in the plan’s network of doctors. So, if you are critically ill and would like to go to the Cleveland or Mayo Clinic…if they are not in your plan network you are screwed. Who is the primary promoter of Medicare Advantage? INSURANCE COMPANIES. Dear Seniors: do not be duped by paid celebrities who are hawking these plans. Go with traditional Medicare and a Medigap policy.
I have a Medicare Advantage PPO plan and can go to any doctors. I don’t need to stay in the plan’s network. By the way, thanks for this very helpful and clear article.
Next year I turn 65 and I’m about to enroll to have a Medicare, but I’m not retiring yet: if I enroll to have a Medicare, it will kick of at once even though I have still health insurance in my work.???
Please expain the medicare supplement. As i understand it – it is an insurance product for which there is screening and you can be turned down. Currently and since I started with medicare I have medicare and united Health care supplement. I have multiple medical conditions so I have been told that it was best for me to stay with United Health care as another supplement probably would not cover me.