If you’re getting close to 65, your mailbox has probably turned into a Medicare catalog. Postcards, brochures, and TV commercials all toss around two terms like you should already know what they mean: Original Medicare and Medicare Advantage.
Here’s the good news. You don’t need to be an expert to understand the basic difference. Once you see how the two fit together, a lot of that mail starts making more sense. (It won’t make the mail stop, unfortunately. I can’t help you there.)
First, a quick Medicare refresher
Medicare is the federal health insurance program for people 65 and older, plus some younger people with certain disabilities or conditions. It’s organized into “parts”:
- Part A (hospital insurance): inpatient hospital stays, skilled nursing facility care, hospice, and some home health care
- Part B (medical insurance): doctor visits, outpatient care, lab work, preventive services, and medical equipment
- Part C (Medicare Advantage): more on this below
- Part D (prescription drug coverage)
Original Medicare and Medicare Advantage are two different ways to receive your Part A and Part B benefits. That’s really the whole idea. Everything else is detail.
What is Original Medicare?
Original Medicare is Part A and Part B, provided directly by the federal government. When you get care, Medicare pays its share of the bill and you pay yours, usually through deductibles and coinsurance.
A few things to know:
- You can see any doctor or hospital in the U.S. that accepts Medicare.
- In most cases, you don’t need a referral to see a specialist.
- It doesn’t include most prescription drug coverage. If you want drug coverage with Original Medicare, you’d typically join a separate Medicare Part D plan.
- Some people add a Medicare Supplement policy. Original Medicare doesn’t cover everything, and you’re responsible for your share of costs like deductibles and coinsurance. A Medicare Supplement Insurance policy, also called Medigap, is sold by private insurance companies and can help pay some of those remaining costs. Medigap policies work alongside Original Medicare, not Medicare Advantage.
What is Medicare Advantage?
Medicare Advantage, also called Part C, is another way to get your Part A and Part B benefits. Instead of the federal government handling your coverage directly, you get it through a private insurance company that Medicare approves.
A few things to know:
- Plans have to follow rules set by Medicare and cover the medically necessary services Original Medicare covers.
- Most plans include prescription drug coverage.
- Many plans use a network of doctors and hospitals, and some require referrals to see a specialist.
- Some plans include benefits Original Medicare doesn’t cover, like certain vision, hearing, or dental services. What’s included varies from plan to plan.
To join a Medicare Advantage plan, you generally need to have both Part A and Part B and live in the plan’s service area.
The part people miss: you’re still in Medicare either way
One of the most common things I hear is, “If I pick Medicare Advantage, am I leaving Medicare?” Nope. You still have Part A and Part B, you still have your Medicare rights and protections, and you generally still pay your Part B premium.
What changes is how your benefits are delivered and who handles your claims. That’s it.
When does this choice come up?
There are a few windows when people make or revisit this decision:
- When you’re first eligible. Your Initial Enrollment Period is a seven-month window around the month you turn 65.
- Your Medigap Open Enrollment Period. If you’re interested in a Medicare Supplement, there’s a one-time, six-month window that starts the month you’re 65 or older and enrolled in Part B. It’s worth knowing about early, since it doesn’t come around again.
- Every fall. During the Annual Enrollment Period, October 15 through December 7, you can move between Original Medicare and Medicare Advantage or change plans, with new coverage starting January 1.
- When life changes. Certain situations, like moving or losing employer coverage, can open a Special Enrollment Period.
What this means for you
Understanding these two paths is the foundation for everything else in Medicare. How they apply to your own doctors, prescriptions, and budget is a personal conversation, and it’s one worth having with someone who’ll listen before they start talking.
If you’re turning 65 soon, helping a parent sort through their mail, or just want to make sure you understand where you stand, I’m happy to answer your questions. There’s no cost to you to talk with us. Agents like me are paid by the insurance companies, not by you.
Call or text me at 281-819-6619, or grab a time that works for you:
No question is too basic. I promise I’ve heard it before.
Caroline Worthen, Worthen Insurance Group, Friendswood, TX
Sources: Medicare.gov – Your Medicare coverage choices; Medicare & You handbook.
We do not offer every plan available in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.