Original Medicare VS Medicare Advantage 2024

Original Medicare VS Medicare Advantage 2024

When you become Medicare eligible you have some options which include taking Original Medicare or a Medicare Advantage plan – Here are some highlights.

Items To Review

  • Choices
  • Enrollment
  • Coverage
  • Network
  • Billing
  • Extras
  • Prescription Coverage
  • 2024 Updates

Choices

Enrollment – Original Medicare

  • 65 or older or under-age 65 with certain disabilities, ALS or end-stage renal disease (ESRD)
  • Initial Enrollment Period
    • 3 months before, the month of, and 3 months after 65th birthday month
  • General Enrollment Period
    • January 1st to March 31st
    • Benefits begin the first of the month following the month you enroll (example: enroll in February, benefits begin March 1st)

Enrollment – Original Medicare

Delayed Enrollment

  • Must be covered by employer or union group health plan based on your or your spouse’s current employment
  • 8-month Special Enrollment Period starts when employment or coverage ends, whichever happens first

Enrollment – Medicare Advantage

  • Must have both Medicare Part A and Part B to join, and continue to pay Part B premium
  • Initial Enrollment Period
    • 3 months before, the month of, and three months after 65th birthday month with A & B entitlement
  • Annual Enrollment Period
    • October 15th through December 7th
    • Benefits begin on January 1st

Enrollment – Medicare Advantage

  • Open Enrollment Period
    • January 1st through March 31st
    • Must be a member of a Medicare Advantage plan to make a change
    • Changes effective 1st of the month following an enrollment
  • Special Enrollment Period
    • Change in residence
    • Loss of group coverage
    • Gain, maintain, or lose Medicaid or Extra Help
    • Enter into, reside in, or leave a nursing facility
    • Many others

Coverage – Original Medicare

Part A – Facility Coverage

  • Deductible: $1,632 per benefit period
  • Days 1-60: $0
  • Days 61-90: $408 per day
  • Days 91 and beyond: $816 per each “lifetime reserve day, up to 60 days per lifetime
  • Beyond lifetime reserve days: no coverage

Coverage – Original Medicare

Part B – Medical Coverage

  • $240 calendar year deductible
  • 20% of the Medicare-approved amount
  • No out-of-pocket limit

Coverage – Medicare Advantage

Copays and coinsurance for services – set by carrier

  • Copay: set amount for specific services
    • $10 for a Primary Care visit
    • $300 per day for inpatient services
  • Coinsurance: percentage for specific services
    • 20% for outpatient surgery
    • Based on carrier’s contracted amounts for services

Coverage – Medicare Advantage

Maximum Out-of-Pocket (MOOP)

  • Limit on out-of-pocket spending
  • All copays and coinsurance for A & B covered services apply
  • $8,850 – highest allowable MOOP
    • Plans can offer a lower maximum

Network – Original Medicare

  • 93% of doctors accept Medicare patient
  • Over 5,300 hospitals accept Medicare
  • Visit www.Medicare.gov to find all participating providers and facilities

Network – Medicare Advantage

Health Maintenance Organization – HMO

  • Must see in-network providers and facilities
  • Responsible for 100% of costs for out-of-network providers (except in emergency or urgent care situations)

Preferred Provider Organization – PPO

  • Lowest costs to utilize in-network providers and facilities
  • Can go outside the network but will usually pay higher copays/coinsurance
    • Out-of-network provider/facility must accept Medicare

Billing – Original Medicare

Participating Provider   – Accepts Medicare Assignment

  • Bills Medicare directly, Medicare pays provider directly

Non Participating Providers

  • Bills Medicare directly, Medicare pays beneficiary, beneficiary pays provider

Exclusionary Providers

  • Bills patient directly, patient responsible for 100% of the billed amount
  • Medicare will not reimburse for expenses incurred at excluded providers/facilities

Billing – Medicare Advantage

  1. Provider/facility bills Medicare Advantage
  • Medicare Advantage pays provider/facility directly
  • Client pays provider/facility any applicable copay/coinsurance

Extras – Original Medicare

  • “Welcome to Medicare” Physical
    • Done within 12 months of Part B start date
  • Annual Wellness visit
  • Preventive Services
    • Bone mass measurements
    • Cardiovascular screenings
    • Cancer screening
    • Colonoscopies
    • Diabetes screenings
    • Many others

Extras – Medicare Advantage

  • Dental
  • Vision
  • Hearing
  • Fitness
  • Transportation
  • Chiropractic
  • Acupuncture
  • Annual Physical
  • Post-discharge meals
  • Telemedicine
  • Over-the-counter supplies
  • More

*Benefits will vary by plan

Prescription Coverage

Original Medicare

  • Must purchase a separate Part D plan

Medicare Advantage

  • Many plans include Part D coverage
  • Can only purchase stand-alone Part D with a PFFS, MSA or Medicare Cost Plan that doesn’t include drug coverage

Recent Changes

  • As of the 2024 plan year, Part D plans will cover 100% of the costs of covered drugs when beneficiaries reach the $8,000 out-of-pocket threshold
  • Individuals at or below 150% of the Federal Poverty Level will quality for 100% premium subsidy through the Extra Help program

Questions?

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