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Understanding Medicare

What is the difference between Original Medicare and Medicare Advantage?

October 1, 2022
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Medicare is a U.S. federal health insurance program. It is available for people who are 65 or older and certain younger people with disabilities. When you are enrolling in Medicare, you can select from two different types of plans:

In this article, we will explain how both plans work, what the plans cover, and the benefits of Medicare Advantage plans. We hope this information will help you select the plan that is best for you.

What does Original Medicare cover?

Original Medicare has two parts:

With Original Medicare, you are still responsible for your copayments, deductibles, and co-insurance, and there is no out-of-pocket maximum. Original Medicare also doesn’t cover the cost of your prescription drugs, dental, vision, or hearing services.

To learn more, read Your Medicare Questions Answered: Who Is Eligible, How to Apply, and More Medicare Basics.

What are Medicare Advantage plans?

Medicare Advantage plans (also known as Part C) are offered through private insurance companies. A Medicare Advantage plan provides all the benefits of Original Medicare and more in one plan. Many Medicare Advantage plans offer extra benefits such as dental, vision, and hearing.

How do Medicare Advantage plans work?

Once you are eligible for Medicare, you can enroll in a Medicare Advantage plan through a private health insurance company of your choice. That company will then become the official provider of your medical and prescription drug benefits. 

When can I join or switch to a Medicare Advantage plan?

When you first become eligible for Medicare, you can choose a Medicare Advantage plan during your Initial Enrollment Period (IEP). This is the 7-month period surrounding your 65th birthday, which comprises:

If you are currently enrolled in Original Medicare only or a Medicare Advantage plan, you can switch plans during the Annual Enrollment Period (AEP). This period runs from October 15 to December 7. Your new coverage will begin on January 1 of the following year.

If you are enrolled in a Medicare Advantage plan, you may also have a one-time opportunity to switch plans during the Open Enrollment Period (OEP). This period runs from January 1 to March 31. During OEP, you can switch to a different Medicare Advantage plan or switch to Original Medicare and enroll in a Medicare Prescription Drug plan. If you miss this chance, you’ll have to wait until AEP to switch to a Medicare Advantage plan—unless you qualify for a Special Election Period.

A Special Election Period is the time when people who receive Medicare can change their Medicare Advantage or Part D coverage outside the annual AEP and OEP time frames. To qualify for a Special Election, you must be experiencing a major life event such as moving, getting married, or losing your coverage.

Understanding your health plan options

This chart will help you understand your Medicare options. It shows what Original Medicare and Medicare Advantage plans cover, and which costs you are responsible for paying.

Covered by Original Medicare Parts A & BCovered by Medicare Advantage Plans (Part C)
Your monthly plan PremiumYour Part B premium– Your Part B premium
– A low or $0 monthly premium
Prescription drug coverageNot included; you pay an additional premium if you want a Part D prescription drug planIncluded in most plans at no additional costs to you
Dental and vision coverageNot includedIncluded in some plans at no additional cost to you
Transportation servicesNot includedIncluded in some plans
Worldwide emergency careNot includedIncluded in some plans
Provider networkYou may use any provider that accepts MedicareYou may need to use a provider in the plan network
Your out-of-pocket costsYou pay more with no out-of-pocket capYou pay less with an annual out-of-pocket maximum and many plans have set copays for services

We hope this article helped you understand the benefits of selecting a Medicare Advantage plan to help cover the costs that are not covered by Original Medicare alone.

Sources: When you click these links, you will leave the Commonwealth Care Alliance website

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