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
- 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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I’m here to help – Contact Me.
- https://www.kff.org/medicare/issue-brief/primary-care- physicians-accepting-medicare-a-snapshot/
- https://data.medicare.gov/Hospital-Compare/Hospital- General-Information/xubh-q36u
- https://www.medicare.gov
- https://www.bettermedicarealliance.org/sites/default/files/2020- 01/BMA_WhitePaper_CaringForESRDBeneficiaries-FIN.pdf