Choosing Between Traditional Medicare and Medicare Advantage

If you turn 65 soon, Medicare is probably on your mind. You know you need to enroll. You know there are choices to make. And if you feel confused about what those choices are, you’re not alone.

Traditional Medicare and Medicare Advantage sound similar, but they work in different ways. Understanding those differences can help you choose the best fit for you.

How Traditional Medicare Works

Traditional Medicare is the federal health insurance program that’s been around since 1965. It’s run by the government, which means the rules are the same no matter where you live.

You get two parts:

Part A covers hospital stays, skilled nursing facilities, hospice care and some home health services. You don’t usually pay a premium for Part A if you or your spouse paid Medicare taxes while working.

Part B covers doctor visits, outpatient care, lab tests, medical equipment and preventive care. You pay a monthly premium for Part B, which is usually deducted from your Social Security check.

What That Means in Practice

• You can see any doctor or go to any hospital that accepts Medicare. No network. No referrals. If you need a specialist, you make an appointment. If you want a second opinion, you get one.
• You know the cost structure. For many covered services, Medicare pays 80% after you meet your deductible. You typically pay the other 20%.
• You can add coverage where you need it. Take medications? Add a Part D prescription plan. Want help with that 20% coinsurance? Add a Medigap policy. You build what works for you.

What Traditional Medicare Doesn’t Cover

• Prescription drugs. You need a separate Part D plan for that.
• Dental, vision and hearing. Routine cleanings, eye exams, glasses and hearing aids are out-of-pocket expenses.
• Out-of-pocket costs are unlimited. You’re responsible for 20% of covered services with no annual cap. If you have a serious health issue that requires ongoing care, that 20% can add up. Medigap helps cover it, but that’s another monthly premium.

How Medicare Advantage Works

Medicare Advantage (also called Part C) is run by private insurance companies that contract with the federal government. These plans cover everything Traditional Medicare does, and most include prescription drug coverage. You can also add extras like dental, vision and hearing coverage.

Here’s How it’s Different

• You’re tied to a network. You have to use doctors and hospitals that participate in your plan. If your doctor doesn’t take your plan or drops it, you’ll need to find a new one or pay to stay.
• You may need permission to see specialists. Some plans require referrals and prior authorizations, which means extra steps and possible delays.
• Your costs are capped. Unlike Traditional Medicare, Medicare Advantage plans limit your total out-of-pocket expenses each year. That provides some protection if you need a lot of care.
• Premiums vary widely. Some plans advertise $0 premiums, but they usually come with higher copays, deductibles, drug costs and tighter network restrictions.

What You Give Up with Medicare Advantage

• You can’t just switch doctors or see any specialist you want. You’re working within a network, and if you go outside it, you pay.
• The ability to add Medigap. If you pick Medicare Advantage, you can’t use a Medigap policy. If you decide to switch back to Traditional Medicare and want Medigap, you might face medical underwriting and higher premiums.

Which One Makes Sense for You

This decision comes down to what you value and what you’re willing to trade off.

Traditional Medicare makes sense if you want to choose your own doctors, see specialists without referrals or travel frequently. It also makes sense if you want the flexibility to change providers as your health needs change.

Medicare Advantage makes sense if you’re comfortable staying in a network, don’t mind getting referrals for specialists and want lower monthly premiums. The out-of-pocket cap can also provide peace of mind if you’re worried about high costs.

Neither plan is inherently better. They’re different. And what works for you now might not work for you in five years. That’s okay. You can switch during Open Enrollment (October 15 to December 7 each year) if your needs change.

How This Affects Home Health and Hospice Care

If you’re considering in-home care, both Traditional Medicare and Medicare Advantage cover home health and hospice services when they’re medically necessary.

The difference is in how you access that care. Traditional Medicare lets you choose any Medicare-certified agency. Medicare Advantage plans may require you to use providers within your network.

Ohioans Home Health & Hospice works with both. We’re Medicare-certified and accept Traditional Medicare and many Medicare Advantage plans. If you have questions about what your plan covers or how our services work with your coverage, call us at 855-600-0806 or contact us.