RESOURCES
Original Medicare vs. Medicare Advantage
- Doctor & hospital choice
| Original Medicare | Medicare Advantage |
|---|---|
|
You can go to any doctor or hospital
that takes Medicare, anywhere in
the U.S. |
In many cases, you’ll need to only use
doctors and other providers who are in
the plan’s network (for non-emergency
care). Some plans offer non-emergency
coverage out of network, but typically
at a higher cost. |
|
In most cases, you don’t need a referral
to see a specialist. |
You may need to get a referral to see
a specialist |
- Cost
| Original Medicare | Medicare Advantage |
|---|---|
|
For Part B-covered services, you usually
pay 20% of the Medicare-approved
amount after you meet your deductible.
This is called your coinsurance. |
Out-of-pocket costs vary—plans
may have different out-of-pocket costs
for certain services. |
|
You pay a premium (monthly payment)
for Part B. If you choose to join a
Medicare drug plan, you’ll pay a separate
premium for your Medicare drug
coverage (Part D). |
You pay the monthly Part B premium
and may also have to pay the plan’s
premium. Plans may have a $0 premium
and may help pay all or part of your
Part B premium. Most plans include
Medicare drug coverage (Part D). |
|
There’s no yearly limit on what you
pay out of pocket, unless you have
supplemental coverage—like Medicare
Supplement Insurance (Medigap). |
Plans have a yearly limit on what you
pay out of pocket for services Medicare
Part A and Part B covers. Once you
reach your plan’s limit, you’ll pay
nothing for services Part A and Part B
covers for the rest of the year. |
|
You can get Medigap to help pay your
remaining out-of-pocket costs (like
your 20% coinsurance). Or, you can use
coverage from a former employer or
union, or Medicaid. |
You can’t buy and don’t need Medigap. |
- Coverage
| Original Medicare | Medicare Advantage |
|---|---|
|
Original Medicare covers most medically
necessary services and supplies in
hospitals, doctors’ offices, and other
health care facilities. Original Medicare
doesn’t cover some benefits like eye
exams, most dental care, and routine
exams. |
Plans must cover all of the medically
necessary services that Original
Medicare covers. Most plans offer some
extra benefits that Original Medicare
doesn’t cover—like some routine exams
and vision, hearing, and dental services. |
|
You can join a separate Medicare drug
plan to get Medicare drug coverage |
Medicare drug coverage (Part D) is
included in most plans. In most types
of Medicare Advantage Plans, you
can’t join a separate Medicare drug
plan. |
|
In most cases, you don’t have to get a
service or supply approved ahead of
time for Original Medicare to cover it. |
In some cases, you have to get a service
or supply approved ahead of time for
the plan to cover it. |
- Foreign travel
| Original Medicare | Medicare Advantage |
|---|---|
|
Original Medicare generally doesn’t
cover care outside the U.S. You may
be able to buy a Medicare Supplement
Insurance (Medigap) policy that covers
emergency care outside the U.S. |
Plans generally don’t cover care
outside the U.S. Some plans may offer
a supplemental benefit that covers
emergency and urgently needed
services when traveling outside the U.S. |
How does my other insurance work with Medicare?
When you have other insurance (like group health plan, retiree health, or Medicaid coverage) and Medicare, there are rules for whether Medicare or your other coverage pays first.
| If you have retiree health coverage (like insurance from your or your spouse’s former employment)… | Table Header |
|---|---|
|
If you have retiree health coverage (like
insurance from your or your spouse’s former
employment)… |
Medicare pays first. |
|
If you’re 65 or older, have group health plan
coverage based on your or your spouse’s
current employment, and the employer has 20
or more employees… |
Your group health plan
pays first. |
|
If you’re 65 or older, have group health plan
coverage based on your or your spouse’s
current employment, and the employer has
fewer than 20 employees… |
Medicare pays first. |
|
If you’re under 65 and have a disability, have
group health plan coverage based on your or a
family member’s current employment, and the
employer has 100 or more employees… |
Your group health plan
pays first. |
|
If you’re under 65 and have a disability, have
group health plan coverage based on your or a
family member’s current employment, and the
employer has fewer than 100 employees… |
Medicare pays first. |
|
If you have group health plan coverage based
on your or a family member’s employment or
former employment, and you’re eligible for
Medicare because of End-Stage Renal Disease
(ESRD)… |
Your group health plan
pays first for the first
30 months after you
become eligible to enroll
in Medicare. Medicare
pays first after this
30-month period. |
|
If you have Medicaid... |
Medicare pays first. |
If you’re still working and have employer coverage through work, contact your employer to find out how your employer’s coverage works with Medicare.