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Medicare vs. Medicare Advantage: Biggest Difference Between Them

February 01, 20244 min read

Understanding the differences between Medicare and the Medicare Advantage Prescription Drug Plan, including coverage details, costs, and enrollment options.

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Understanding the Difference between Medicare and Medicare Advantage

Medicare, often referred to as Original Medicare, includes Part A (hospital insurance) and Part B (medical insurance), providing coverage for hospital care, doctors' services, and medical supplies. It operates on a fee-for-service basis, which is a key difference between original Medicare and other plans, allowing you to visit any doctor or hospital in the U.S. that accepts Medicare. However, it's important to note that Original Medicare does not cover long-term care or most vision, dental, and hearing services. Costs associated with Original Medicare, or Medicare parts A and B, include premiums for Part B, deductibles, and coinsurances, typically requiring beneficiaries to pay 20% of the Medicare-approved amount for most doctor services.

One notable flexibility of Original Medicare is the ability to see any doctor or hospital nationwide that accepts Medicare, offering a broad choice of providers without the need for network restrictions. This aspect is particularly beneficial for those who travel frequently or live in multiple states throughout the year.

Exploring Medicare Advantage

Medicare Advantage Plans cover a range of services, known as Medicare Part C and are an alternative to Original Medicare, offered by private companies. These plans, provided by insurance companies, must cover everything included in Original Medicare but can also offer additional benefits like prescription drugs, and routine dental, vision, and hearing care. A significant difference between Medicare and Medicare Advantage is the network restrictions; Medicare Advantage often requires beneficiaries to use doctors and facilities within the plan's network, potentially limiting choice but also potentially streamlining care.

An example of the additional benefits that can be included in Medicare Advantage Plans is the inclusion of fitness programs and transportation to doctor visits, which are not covered under Original Medicare. With Medicare Advantage Plans, which are part of private insurance, however, these extra benefits such as drug coverage can come with additional premiums on top of the Part B premium, depending on the specific Medicare Plan chosen.

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Comparing Costs and Coverage Between Medicare and Medicare Advantage

When comparing costs and coverage between Original Medicare and Medicare Advantage, it's crucial to consider premiums, copays, deductibles, and out-of-pocket costs. Original Medicare typically involves paying a Part B premium, a deductible for both Part A and Part B and 20% coinsurance for most services. In contrast, Medicare Advantage Plans may have different structures for premiums, copays, and deductibles, and often include an annual out-of-pocket limit, which Original Medicare does not have. This cap can provide some financial protection if you require extensive care.

Medicare Advantage Plans might offer lower costs based on the plan choice and coverage needs, especially for beneficiaries willing to navigate within a network of providers and adhere to the plan's rules for referrals and specialist visits.

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Enrollment and Plan Options

Enrollment periods for both Original Medicare and Medicare Advantage are critical to understand. The Initial Enrollment Period for Medicare, which includes the traditional Medicare coverage, is a 7-month window that starts three months before you turn 65. For Medicare Advantage, enrollment typically occurs during the Annual Election Period from October 15 to December 7 each year, with the possibility of changing or joining plans.

Medicare Advantage Plans offer a variety of options with different network structures, coverage benefits, and costs, making it important to assess your health history, preferred providers, and coverage benefits when choosing a plan. The flexibility to choose among different plan options, including HMOs and PPOs, allows beneficiaries to select a plan that closely matches their healthcare needs and preferences.

Additional Benefits and Considerations

Medicare Advantage Plans often include additional benefits such as wellness programs, over-the-counter drug allowances, and telehealth services, which are not covered by Original Medicare. However, beneficiaries should carefully consider network limitations, the need for referrals to see specialists, and how the plan covers prescription drugs when choosing a Medicare Advantage Plan. Unlike Original Medicare, Medicare Advantage Plans do not allow for the purchase of a Medigap policy, which can help cover out-of-pocket costs in Original Medicare.

Personalized Assistance and Next Steps

Choosing between Traditional Medicare and Medicare Advantage involves considering personal healthcare needs including inpatient and outpatient services, and preferences. Bourgeois Insurance Agency, LLC specializes in helping individuals navigate the complexities of Medicare and Medicare Advantage Plans, offering top-rated plans and facilitating the switch from Original Medicare to Medicare Advantage if required. For personalized assistance and to explore your Medicare options, visit Bourgeois Insurance Agency, LLC, or call Price Bourgeois at (985) 803-8999 for a free consultation.

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Plans are insured or covered by Medicare Advantage (HMO, PPO, and PFFS) organization with a Medicare contract and/or a Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with Medicare. We do not offer every plan in your area. Please contact medicare.gov or 1-800-Medicare to get information on all your options.


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