What is the difference in medicare and medicare advantage

Q: What are the negatives of a Medicare Advantage Plan?

Medicare Advantage can become expensive if youre sick, due to uncovered copays. Additionally, a plan may offer only a limited network of doctors, which can interfere with a patients choice. Its not easy to change to another plan. If you decide to switch to a Medigap policy, there often are lifetime penalties.

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Medicare vs. Medicare Advantage: The Basics
Medicare vs. Medicare Advantage: Differences
Why Choose Medicare Advantage?
What is the difference between a Medicare Advantage Plan and regular Medicare?
What are the negatives of a Medicare Advantage Plan?
Does Medicare Advantage replace Medicare?
Is Medicare Advantage the best option?

Key differences between Original Medicare and Medicare Advantage

	Original Medicare (Part A and B)	Medicare Advantage Plans (Part C)
Main difference	Medicare pays providers the Medicare-approved rates for covered services per Medicare rules and regulations. Your providers bill Medicare.	Medicare pays private health plans that have contracts with Medicare to provide all medically-necessary health care that Original Medicare (Parts A and B) cover. Your providers bill your Medicare Advantage plan.
Costs	You pay Medicare Parts A and B premiums, deductibles and coinsurances. Part A is free if you or your spouse have paid taxes while working a minimum of 10 years (if not, you may pay a premium). For most people, the Part B cost is $148.50 in 2021.	You pay Medicare Parts A and B premiums, and your Medicare Advantage Plans premium, if it charges one, and possible deductibles and coinsurances. Part A is free if you or your spouse have paid taxes while working a minimum of 10 years (if not, you may pay a premium). For most people, the Part B cost is $148.50 in 2021.
Supplemental insurance	You may be able to buy a Medigap policy. Other insurance, such as retiree, employer or union plans may supplement Medicare.	You can't buy a Medigap policy to help pay your out-of-pocket costs in a Medicare Advantage plan.
Covers extra services like vision and dental?	No. Covers medically-necessary inpatient and outpatient health care. Doesn't cover certain services such as routine vision, hearing or dental care.	Maybe. May cover some services Original Medicare doesn't cover such as routine vision, hearing and dental care. All plans must cover the same inpatient and outpatient services Original Medicare covers.
Allows me to see providers nationwide?	Yes. You can go to any doctor or hospital in the U.S. that accepts Medicare.	Usually not. Most people have HMOs, which typically have local networks of providers you must use for the plan to cover your care. PPOs plans should cover care you get outside the network, but you will pay more.
Need referrals to see specialist?	No. You don't need a referral.	Maybe. You may need to get a referral from your primary care doctor if you want to see a specialist.
Covers drugs?	No, but if you want Medicare prescription drug coverage, you can buy a separate Part D plan.	Usually. Most plans include Part D drug coverage. In Washington state, if you are enrolled in a Medicare Advantage plan, you cannot buy a standalone Part D plan. If you do, you'll automatically get disenrolled from your Medicare Advantage plan and enrolled in Original Medicare.
Out-of-pocket limits?	No. There's no cap on what you spend on health care.	Yes. Plans must have an annual out-of-pocket limit, which can be high, but protect you if you need expensive care. The plan pays the full cost of your care after you reach the limit.

Definitions:

Premium: The monthly fee you pay to have Medicare or your health plan.
Deductible: What you must pay before Medicare or your health plan starts paying for your care.
Copayment/coinsurance: Your share of the cost you pay for each service.
Part A: Medicare hospital insurance for inpatient care.
Part B: Medicare medical insurance for outpatient care.
Part D: Medicare drug coverage.
Medigap: Supplemental insurance that helps pay your out-of-pocket cost in Original Medicare.

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Original Medicare and Medicare Advantage have identical eligibility requirements. Medicare Advantage, however, is private insurance that offers slightly different benefits.

Since the 1990s, Medicare recipients have been able to choose private health plans as an alternative to original Medicare. These health plans, once called Medicare Part C, are now known as Medicare Advantage.

Most Medicare recipients still choose the original program, but in 2019, 34% of Medicare beneficiaries opted to enroll in Medicare advantage. In 2016, 29% of new Medicare beneficiaries chose an Advantage plan during the first year of enrollment. The two programs offer similar benefits, but there are some important distinctions.

Medicare vs. Medicare Advantage: The Basics

If you have original Medicare, the goverment directly pays for your Medicare benefits. In contrast, with Medicare Advantage plans, you receive your benefits from private medical insurance companies that Medicare has approved. There are several types of Medicare Advantage Plans:

Health Maintenance Organization (HMO) plans. HMO plans limit you to doctors, healthcare providers, and hospitals that fall within the plan's network—except for emergency or urgent care needs. Under these plans, you'll typically have to get a referral from your primary care doctor in order to access certain forms of diagnostic testing or see a specialist.
Preferred Provider Organization (PPO) plans. In a PPO plan, you can choose from a number of doctors, healthcare providers, and hospitals within your plan's network. You pay less to see in-network providers, and pay more if you opt for providers that are not in your plan's network.
Private Fee-for-Service (PFFS) plans. These plans pay for a certain amount to doctors, healthcare providers, and hospitals for your care, while you also pay a certain amount. Some who opt for this plan access care from providers and hospitals in their PFFS plan. For others, these plans define a network within which members can choose their providers. These providers offer lower rates than those outside of the network.
Medical Savings Account (MSA) plans. In these plans, which are similar to non-Medicare Health Savings Account plans, you choose your healthcare services and providers. MSA plans blend a high-deductible insurance plan with a medical savings account. Your high-deductible health plan will only begin to cover your healtcare costs after you meet a high yearly deductible, which each plan determines differently. But you can use money that the plan deposits into your MSA to fund your healthcare costs prior to meeting your deductible.

The Official U.S. Government Site for Medicare online states that you must live in the service area of you prospective plan and also have Medicare Part A and Part B in order to join a Medicare Advantage Plan.

Both Medicare and Medicare Advantage are also legally required to cover certain basic health services, though the costs you pay and the specific services that are covered vary.

Medicare Advantage began in 1995, though similar programs were available as early as the 1970s. The key distinction between the two programs is that Medicare is government health insurance, while Medicare Advantage is private health insurance that the government helps fund.

Medicare vs. Medicare Advantage: Differences

Both Medicare and Medicare Advantage will fund most basic health costs, including doctor's visits and hospital stays. The specific cost of each plan, as well as the out-of-pocket copays and other costs, vary. Some key differences between the two programs include:

Original Medicare includes Medicare Part A (hospital care) and Part B (medical care) only. People who want prescription drug coverage must purchase a Medicare Part D plan. Medicare Advantage often includes Part D, and may offer coverage for services original Medicare will not cover.
You can use original Medicare at any doctor or hospital that accepts the program. Medicare Advantage programs may limit you to specific in-network providers.
Out-of-pocket costs with Medicare Advantage plans are usually lower.
The government sets prices for various services offered under original Medicare plans. With a Medicare Advantage plan, you may pay a different rate based on the rate negotiated by the insurer. This rate may be higher or lower than the original Medicare rate.

Why Choose Medicare Advantage?

Medicare Advantage plans must offer benefits comparable to original Medicare. The government regulates these plans, ensuring that they meet certain basic care requirements. The costs and copays for various services, however, may be different. For some people, Medicare Advantage is a better choice. You might choose Medicare advantage because:

There are more options. In 2018, the average Medicare beneficiary could choose from 21 plans, though some regions offered even more choices.
Premiums may be lower on some plans. Some even offer $0 premiums, though this usually means you'll pay higher copays.
There is usually prescription drug coverage. Original Medicare does not cover prescription drugs unless you enroll in Part D. In 2019, 90% of Medicare Advantage policies offered prescription drug coverage.
You may pay less for expensive services. Medicare Advantage plans are legally required to limit your out-of-pocket maximum costs. With original Medicare, you keep paying costs no matter how much you spend. In 2020, the out-of-pocket maximum for most Medicare Advantage costs was $6,700.
There is often coverage for services original Medicare will not fund. Each plan is different, so it is important to compare and review plan documents. However, many Medicare Advantage plans offer dental or vision coverage. Original Medicare, by contrast, covers only medical and hospital care.

What is the difference between a Medicare Advantage Plan and regular Medicare?

Medicare Advantage is a Medicare-approved plan from a private company that offers an alternative to Original Medicare for your health and drug coverage. These “bundled” plans include Part A, Part B, and usually Part D. In most cases, you can only use doctors who are in the plan's network.

What are the negatives of a Medicare Advantage Plan?

Medicare Advantage can become expensive if you're sick, due to uncovered copays. Additionally, a plan may offer only a limited network of doctors, which can interfere with a patient's choice. It's not easy to change to another plan. If you decide to switch to a Medigap policy, there often are lifetime penalties.

Does Medicare Advantage replace Medicare?

Medicare Advantage does not replace original Medicare. Instead, Medicare Advantage is an alternative to original Medicare. These two choices have differences which may make one a better choice for you.

Is Medicare Advantage the best option?

Is Medicare Advantage or Medigap Coverage Your Best Choice? If you are in good health with few medical expenses, Medicare Advantage can be a suitable and money-saving choice. But if you have serious medical conditions with expensive treatment and care costs, Medigap is generally better.