Two Ways to Get Medicare

At a family reunion, my Aunt Abby and Uncle Glen got into a squabble over the best way to get their Medicare benefits. Uncle Glen is an Original Medicare man, and has been for a decade or so. Aunt Abby prefers Medicare Advantage, which is similar to a health plan she had before enrolling in Medicare.

When they turned to me, asking me to referee and declare which form of Medicare is better, I gave them a big smile and answered, “Well, it depends.”

Original Medicare and Medicare Advantage have different benefits and costs to consider based on personal needs. Medicare open enrollment season runs from Oct. 15 to Dec. 7. It’s a good idea to know how the two types of Medicare work before selecting one.

With Original Medicare, patients can choose any doctor, hospital or other healthcare provider, as long as they accept Medicare. When patients receive medical services or goods, Medicare pays the provider directly. About 70 percent of all people with Medicare have Original Medicare.

The other way to get your benefits is Medicare Advantage, a form of managed care, like an HMO or PPO. Medicare Advantage is provided by private insurance companies approved by Medicare. Patients in Medicare Advantage generally must go to doctors and other providers in the insurance company’s network. Outside the network, they may have to pay more.

On the other hand, Medicare Advantage plans may offer services such as dental, hearing, vision and prescription drug coverage that Original Medicare doesn’t. Most people with Original Medicare pay a monthly premium. With Medicare Advantage, patients may have to pay an additional monthly premium to the private insurer. With Original Medicare, supplemental insurance must pay deductibles, co-pays and coinsurance.

To cover these “gaps” in Medicare, some people buy supplemental insurance called Medigap. With a Medigap policy, Medicare pays its share of the covered costs, and then the Medigap policy pays its share.

Original Medicare doesn’t cover prescription drugs. For drug coverage, a separate Medicare Part D plan is needed. Such plans are sold through private companies approved by Medicare for an additional monthly premium.

Medicare Advantage companies must cover all of the services that Original Medicare covers. Original Medicare covers hospice care, some new Medicare benefits and some costs for clinical research studies, even for patients in a Medicare Advantage plan. In all types of Medicare Advantage plans, emergency and urgent care is always covered.

Medicare Advantage plans are open even with any pre-existing condition except for End-Stage Renal Disease (ESRD). People with ESRD usually are covered through Original Medicare.

Keep in mind that Medicare Advantage plans can charge different out-of-pocket amounts and have different rules for how to get service. Check with the plan before receiving a service to find out whether it’s covered and the costs. If the plan decides to stop participating in Medicare, join another Medicare health plan or return to Original Medicare.

There’s a good comparison of Original Medicare and Medicare Advantage in the Medicare & You handbook. Medicare & You is mailed to all Medicare beneficiaries every fall. Find it online, at www.medicare.gov/pubs/pdf/10050-Medicare-and-You.pdf. 

 

Greg Dill is Medicare’s regional administrator for Arizona, California, Hawaii, Nevada and the Pacific Territories. Get answers to Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).