Comparing Original Medicare, Medicare Advantage and Medigap plans

Here at ApexHealth, we think Medicare is a pretty great idea – taking care of people 65 and older and those with certain health conditions. One thing that is great about Medicare is that you’re able to choose the type of coverage that best suits your needs. To help you out when comparing Original Medicare, Medicare Advantage and Medigap Plans, we break everything down by these six important factors:

1. Primary coverage

Original Medicare (Medicare Parts A and B) is the most basic form of Medicare, and it covers hospital stays, doctor visits, specialists and urgent care visits. Original Medicare covers 80 percent of your eligible hospital and medical expenses. This means you’ll pay 20 percent of the cost, known as coinsurance, for common health services including doctor’s office visits or outpatient surgeries.

Medigap plans are offered by private insurance companies and work alongside Original Medicare to cover some of what it doesn’t pay. Policies are labeled Plans A, B, C, D, F, G, K, L, M and N and while their coverage is standardized, their costs are not. Think of Original Medicare as your primary insurance and your Medigap plan as your secondary insurance. It can cover up to 20 percent of Original Medicare expenses.

Medicare Advantage plans are offered by private health insurance companies (like ApexHealth) and cover everything Original Medicare does (medical and hospital costs) and more. Most Medicare Advantage plans include Part D prescription drug coverage and supplemental benefits such as dental, vision and fitness perks. Coverage varies by plan. You can’t enroll in both a Medicare Advantage and Medigap plan.

2. Monthly premiums and additional costs

Most people do not pay a premium for Medicare Part A, but you may have to cover a deductible. The standard Medicare Part B premium is set each year by CMS, and you’ll pay that amount monthly (and it’s usually deducted from your Social Security check). You’ll also have to cover a deductible. Keep in mind that Original Medicare covers 80 percent of eligible doctor and hospital visits which leaves you to pay the remaining 20 percent. You’ll also pay for all prescription medications unless you enroll in a separate Part D plan.

If you purchase a Medigap plan, you’ll have to pay your monthly Part B premium plus an additional premium for your Medigap plan. Often, Medigap monthly premiums are higher than Medicare Advantage monthly premiums. You might also have to pay a deductible and co-pays, depending on the plan. You’ll also pay for all prescription medications unless you enroll in a separate Part D plan.

Monthly premiums vary by Medicare Advantage plan, with some plans offering $0 premiums. You’ll also need to pay your monthly Part B premium. You might also have to pay a deductible, as well as co-pays for some services, depending on the plan. However, using copays instead of coinsurance means you’ll generally pay less for the same benefit or service.

3. Out-of-pocket limits

Remember that there is no out-of-pocket limit for Original Medicare, meaning there’s no limit on the amount you may have to spend on annual medical expenses. Some, but not all, Medigap plans have limits on your out-of-pocket costs. All Medicare Advantage plans have limits on your out-of-pocket costs. CMS sets an out-of-pocket maximum standard for Medicare Advantage plans for combined in and out of network expenses each year; however, some plans may set lower limits. 

4. Provider network

If you have Original Medicare or Original Medicare plus Medigap, you can go to any doctor or facility that accepts Medicare, and you won’t need a referral to see a specialist. Medicare Advantage plans have a fixed provider network of doctors and hospitals with rules about whether or not you’re able to get care outside your network or see a specialist without a referral. Provider networks vary by plan, and you’ll likely end up paying more for out-of-network care. However, having a provider network is beneficial for coordination of care between primary care doctors and specialists.

5. Prescription drug coverage

Both Original Medicare and Medigap do not include Part D prescription drug coverage. Prescription drug coverage is included with most Medicare Advantage plans. Keep in mind if you choose Original Medicare, plus a Medigap plan, plus a separate Part D prescription drug policy, this means three kinds of coverage with a premium for each. Medicare Advantage plans typically have lower (sometimes $0) monthly premiums and also offer the convenience of having one policy, rather than juggling three different types of coverage.

6. Supplemental benefits

Original Medicare does not cover supplemental benefits such as dental, vision and hearing. Also, Medigap policies do not provide extra benefits such as routine dental or vision care. Medicare Advantage plans offer these benefits and additional benefits which may include OTC allowance and gym memberships. Note that coverage and offerings vary by plan.

We hope that this information helps make Medicare simpler for you.  If you have any questions, we’re always here to help!  Starting on Oct. 1, you can call (844) 279-0508 (TTY: 711) to speak with an ApexAssistant. Our hours of operation are Monday through Friday 8 a.m. – 8 p.m. (local time) from Apr. 1 through Sept. 30 and seven days a week 8 a.m. – 8 p.m. (local time) from Oct. 1 through Mar. 31.

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