Should you get original Medicare or an Advantage plan? Know this before you enroll

Open enrollment for Medicare starts soon, so it’s time to start thinking about what’s next for your healthcare.

The public insurance is for people 65 and older, although some younger people who have certain disabilities or conditions may also be eligible.

There are two main ways to get coverage, either through original Medicare or Medicare Advantage.

Open enrollment for traditional Medicare is Oct. 15 though Dec. 7. For people who have a Medicare Advantage plan, open enrollment is Jan. 1 through March. 31.

We asked readers to share their questions about Medicare and Medicare Advantage. And then we asked the Centers for Medicare and Medicaid Services, a federal agency, to help answer them.

Here’s what to know:

What’s the difference between original Medicare and Medicare Advantage plans?

Original Medicare:

Traditional Medicare, also known as original Medicare, covers inpatient care in hospitals, skilled nursing facilities care, hospice care and home health care, according to the Centers for Medicare and Medicaid Services. It also covers services from doctors, outpatient care, “durable medical equipment” such as wheelchairs and walkers, as well as preventive services such as screenings, an annual wellness visit and certain vaccines, including for COVID-19.

Medicare has four parts and traditional Medicare is what’s considered to be Part A (hospital insurance) and Part B (Medicare insurance), according to the agency. Part C is Medicare Advantage plans and Part D is drug coverage.

“People with Medicare can go to any doctor or hospital, anywhere in the United States that accepts Medicare. If they have traditional Medicare, they can also buy Medicare Supplement Insurance (Medigap) policy from a private insurance company,” the federal agency told the Miami Herald in an email. “Traditional Medicare pays for much, but not all, of the cost for covered healthcare services and supplies. A Medigap policy can help pay some of the remaining healthcare costs, such as co-payments, coinsurance, and deductibles.”

The federal agency recommends people who get traditional Medicare should also enroll in Part D, which provides prescription drug coverage. This way you’ll get hospital, medical and prescription drug benefits.

Medicare Advantage:

A Medicare Advantage plan typically “bundles” original Medicare — hospital insurance and Medicare insurance — with Medicare prescription drug coverage into “one health insurance plan,” according to the agency.

“If someone selects Medicare Advantage coverage, they join a plan offered by Medicare-approved private companies. Each plan can have different rules for how someone gets services — like referrals to see a specialist,” the agency said. “All plans must cover emergency and urgent care, as well as all medically necessary services covered by traditional Medicare.

However, while most Medicare Advantage plans include hospital, medical and prescription drug coverage, you can’t go to any doctor you want. Medicare Advantage plans usually require you to use doctors and other providers who are in a plan’s network and service area.

“Costs for monthly premiums and services vary depending on which plan you join. Some plans may offer some extra benefits that traditional Medicare doesn’t cover — like vision, hearing and dental services,” the agency said.

What documents do you need to apply for Medicare?

If you want to enroll in Medicare Part A (hospital insurance) and Part B (Medicare insurance), you’ll need to contact the Social Security Administration. This is the information the Centers for Medicare and Medicaid Services says you should have available:

▪ Your Social Security number

▪ Where you were born (city, county, state)

▪ The start and end dates of any group health plans in which you’re enrolled. If you’ve enrolled for a 65-plus group health plan ahead of time, make sure to have the start and end date.

▪ A valid email address and your existing Medicare number, although the federal agency notes this information is only needed for people who want to enroll in Part B (medical insurance.)

Should you stay in your spouse’s private insurance or enroll in Medicare?

This is a personal decision. You’ll have to review the benefits and costs of staying in your spouse’s health insurance versus enrolling in Medicare or a Medicare Advantage plan. You should also consider whether your wife or husband works for a small business or a large company, according to AARP.

The good news: “No matter what the size of the company, you won’t have to pay a late enrollment penalty if you have health coverage through your spouse’s current employer and you enroll in Medicare within eight months of losing that coverage,” AARP explained in a blog post. “But if you get your coverage through a small business, you may face gaps that you’ll have to pay for yourself if you don’t sign up for Medicare at age 65.”

Some people also opt to stay in the employer health insurance and enroll in Medicare Part A once they’re 65 because they don’t have to pay premiums if they or their spouse have paid Medicare taxes for at least 40 quarters, which is about 10 years of work, according to AARP. If you decide to do this, and the company has more than 20 employees, the employer’s insurance will pay medical bills first, with Medicare being the secondary payer. If the company has fewer then 20 employees, Medicare will pay the bills first and the employer insurance will be the secondary payer.

Can you keep my doctors if you enroll in Medicare?

Most likely, you can keep the doctors you see if you enroll in Medicare.

People with traditional Medicare can go to any doctor, hospital, facility or other healthcare provider that accepts Medicare. The good news is that many providers accept Medicare. You also don’t need to choose a primary care doctor, and in most cases, you also don’t need a referral to see a specialist, according to the Centers for Medicare and Medicaid Services.

For people with Medicare Advantage plans, take note: You can only use doctors and other providers who are in your plan’s network. Keep in mind that “costs for monthly premiums and services vary depending on which plan you join” and “some plans may offer some extra benefits that traditional Medicare doesn’t cover — like vision, hearing, and dental services,” according to the federal agency.

If you want to make sure your doctors accept Medicare and Medicare Advantage plans, call and ask. The federal government also has an online Medicare provider database you can use to find and compare providers near you. The website lets you filter by location, provider type (doctors, hospitals, nursing homes). and you can also search for your doctor by name.

For people who have Medicare A and B, how much does it usually cost to add Plan D for drugs?

Medicare Part D, drug coverage, is an optional and recommended Medicare benefit people can enroll in to help cover the cost of prescription drugs.

“In Medicare Part D, prescription drug plans may charge a monthly premium. Premiums vary by plan. People enrolled in a Part D plan may pay this premium in addition to the Part B premium,” according to the Centers for Medicare and Medicaid Services. “If someone is in a Medicare Advantage plan with prescription drug coverage, the monthly premium may include an amount for drug coverage.”

It’s recommended that people with traditional Medicare enroll in Part D to get drug coverage. Most Medicare Advantage plans include prescription drug coverage, but it’s important to make sure your plan of choice has it.

And make sure to shop around this year as there are new changes rolling out under the Inflation Reduction Act to lower how much money people with Plan D coverage will pay out-of-pocket for prescription medication in 2025.

A key change: For 2025, there will be a $2,000 cap on out-of-pocket expenses. While the goal is to make it cheaper for people to buy prescription medication, there’s concern that the change could be more expensive for companies offering the plans, possibly leading to premium increases, according to KFF, a nonprofit that researches and reports on health policy. The law does have a rule that puts a cap on how much premiums can increase.

The cost of Part D plan premiums for 2025 won’t be available until September, according to KFF, but people should expect premium prices to vary by plan, ranging from $0 to $100 per month or more, just like in 2024. Medicare Advantage Plans, on average, will likely also have lower monthly premiums compared to stand-alone drug plans, the nonprofit says.

If you already have Medicare, is it worth switching to a Medicare Advantage plan?

Switching from Medicare to a Medicare Advantage plan depends on what you need. Here are some of the differences:

▪ Doctors and hospital choice:

Original Medicare lets you visit any doctor or hospital in the U.S. that accepts Medicare, and you usually don’t need a referral to see a specialist.

Medicare Advantage requires you to use doctors and other providers who are in the plan’s network and service area. You may also need to get a referral to see a specialist.

▪ Coverage:

Original Medicare covers most medically necessary services and supplies although it doesn’t cover some benefits like eye exams, most dental care and routine exams.

Medicare Advantage plans are required to cover all medically necessary services, just like traditional Medicare, but depending on the plan, may also offer extra benefits including vision, hearing and dental services.

Original Medicare needs you to enroll in Part D to get prescription drug coverage.

Medicare Advantage plans typically include drug coverage, and won’t let you join a separate Medicare drug plan. And while you don’t need approval for original Medicare to cover your services or supplies, you might need approval from your Medicare Advantage plan.

▪ Cost:

Original Medicare patients usually pay 20% of the Medicare-approved amount for Part B (medical) services after meeting their deductible.

Medicare Advantage out-of-pocket costs will vary for certain services depending on the plan.

Original Medicare doesn’t have a yearly limit on out-of-pocket costs for Part A or Part B, unless you have supplemental coverage. However, starting in 2025, there will be a $2,000 out of pocket cap for Part D prescription drugs for everyone with Medicare Part D.

Medicare Advantage plans have a limit for Part A (hospital) and Part B (medical) services. This means that once you hit the plan limits, you don’t have to worry about paying out-of-pocket anymore for hospital and medical services for the rest of the year.

Original Medicare also lets you buy Medigap, a supplemental insurance, to pay for remaining out-of-pocket costs;

Medicare Advantage does not allow Medicap coverage.

To learn more about the differences and to compare plans, visit https://www.medicare.gov/basics/get-started-with-medicare/get-more-coverage/your-coverage-options/compare-original-medicare-medicare-advantage

How to enroll in Medicare, Medicare Advantage? Who can you contact for help?

People who apply for retirement or disability benefits from Social Security or the Railroad Retirement Board and start getting benefits at least four months before turning 65 are automatically enrolled in Original Medicare (Part A and B) once you turn 65, according to the Centers for Medicare and Medicaid Services. People who live in Puerto Rico or outside the U.S. would still need to sign up for Part B.

Everyone else has to enroll in Medicare through Social Security, either at your local Social Security office, calling Social Security at 800-772-1213, or using the online portal, which is the easiest and fastest way to sign up.

If you have questions about Medicare, call 800-MEDICARE (800-633-4227). TTY users can call 877-486-2048.

You can also contact the Florida Department of Elder Affairs SHINE Program, which provides free Medicare and health insurance counseling and information to Medicare beneficiaries, their families and caregivers. Call 800-96-ELDER or email information@elderaffairs.org. For TTY, call 800-955-8770.