Original Medicare or Medicare Advantage? - National Multiple Sclerosis Society

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Original Medicare or Medicare Advantage?

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Overview

All Medicare beneficiaries have the option of getting their health care, including their prescription drug coverage, in one of two ways: through Original Medicare or by enrolling in a Medicare Advantage Plan. People with MS should carefully consider the pros and cons of both options before committing to either one, especially since most cannot switch to a different plan until the following year once enrollment into a plan has occurred.

Original Medicare

Original Medicare consists of Part A (hospital coverage) and optional Part B (doctor coverage). To add prescription drug coverage (Part D) to Original Medicare, you would purchase a separate, or "stand alone" prescription drug plan (PDP). If you stay with Original Medicare, you will continue to pay a monthly premium for your Part B benefit, an additional monthly premium for your Part D benefits, and any out-of-pocket costs for your portion of covered services or medications.

Original Medicare gives you the flexibility of choosing doctors, hospitals, neurologists and other specialists, and does not restrict you to the doctors and hospitals in a managed care network. However, there is no limit to your out of pocket medical expenses, and you will always pay 20% of the cost of medical services under Part B making your costs hard to predict. Supplemental plans (called Medigap plans) may be available to beneficiaries who enroll in Original Medicare with prescription drug coverage.

Medicare Advantage

Medicare Advantage Plans are private health plan options approved by Medicare, but run by separate companies. These health plans still remain part of the Medicare program and cover the beneficiaries' hospital and doctors' costs together. Many Medicare Advantage plans include prescription drug coverage as well (MA-PDs). Medicare Advantage Plans may provide you with some additional benefits, such as basic vision, hearing, and/or dental coverage for an additional cost.

There are many different types of Medicare Advantage Programs, although most are health maintenance organizations (HMOs) or preferred provider organizations (PPOs) that limit you to their "in network" doctors and hospitals. Some types of Medicare Advantage plans cover more out-of-network care, but generally have higher out-of-pocket costs. Most Medicare Advantage Plans have limits to what you will pay out of pocket for medical services throughout the year, although these limits do not apply to any prescription drug coverage offered by the plan.

It is important to be careful before enrolling in a Medicare Advantage Plan to ensure that you are able to access your hospitals, doctors, and, if considering a MA plan that includes prescription drugs, includes convenient pharmacies. Make sure that you are not limiting your coverage by getting into a plan that only has a few appropriate doctors who accept the specific plan.

Example: Joe called looking for advice on Medicare Advantage Plan ‘X'. He said he saw a TV commercial about it and it sounded really good. The questions he should be asking are: What makes this plan right for me? What kind of plan is it? How much will I have to pay for medical services? Are my current doctors in the network?  Is there coverage if I need to see a doctor out of the network? Are the pharmacies and hospitals in their network convenient for me? Are all of my medications going to be covered?

Note that all Medicare prescription drug plans, including both stand-alone prescription drug plans and Medicare Advantage Drug Plans, require their members to fill their prescriptions through certain participating local or mail order pharmacies.  When you begin comparing plans, the location and convenience of their participating pharmacies should be considered.

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