Medicare or Medicare Advantage, which is right for me?

Each year between October 15 and December 7 you have the opportunity to review your Medicare coverage and make changes to your plan.  During this period you can change from original Medicare to an Advantage Plan, change from an Advantage Plan to original Medicare, switch Medicare Advantage Plans and/or change your Part D prescription Drug Plan.  But what is the right choice for you?

There are several things to consider when choosing a Medicare plan that is right for you:

  • Coverage
  • Out of pocket costs
  • Provider choice and access
  • Referrals and precertification required
  • Prescription drug coverage
  • Other benefits


Medicare covers medical services and supplies in doctors’ offices, hospitals, and other healthcare settings.  Advantage Plans must cover all of the same benefits offered by original Medicare, but they can apply different rules, costs, and restrictions.

Out of Pocket Costs

You will be charged standardized Part A and Part B costs monthly for original Medicare premiums; you may also be responsible for additional coinsurance for Medicare covered services.  Advantage Plan cost sharing varies by plan and you will usually have copays for in-network care.  These Advantage Plans may allow you to use out-of-network providers but typically at a higher out-of-pocket cost.  You do have the option to pay for a Medigap policy to cover coinsurance for original Medicare but you are not able to enroll in a Medigap program while enrolled in an Advantage Plan.

Provider Choice and Access

Enrolled in original Medicare you are able to use any facility and see any provider that accepts Medicare. When enrolled in an Advantage plan you are typically only able to use in-network providers for that plan or may have a much higher copay to see an out of network provider, this makes it very important to choose a plan wisely so you are able to choose the providers you wish to use.

Referrals and precertification’s required for service

Original Medicare does not require referrals to see specialists or precertification to receive services, eligibility for services are determined by you in conjunction with the providers.  Advantage Plans typically require a referral, precertification, or prior authorization for services.  Eligibility for service requiring prior authorization is usually determined by the insurance company and not your provider; which can result in denial of services that would otherwise have been covered by original Medicare.

Prescription Drug Coverage

Original Medicare does not have prescription drug coverage; you must sign up for a stand-alone prescription drug plan or a Medicare Part D Plan.  In most cases Advantage Plans provide prescription drug coverage but you may be required to pay a higher premium.  In either circumstance you are going to want to examine each plan to make sure that your prescription drugs are covered by the individual plan’s formulary.

Other Benefits

Original Medicare does not cover vision, hearing, or dental services; whereas Advantage Plans may cover these, the additional benefits may increase your monthly premium and other out-of-pocket costs.

Make sure you are in control of your healthcare, that you can choose your provider, and have all the benefits you need.  An initial cost savings could cost you more in the end by choosing the wrong