Original Medicare vs. Medicare Advantage: A Practical Open Enrollment Checklist
Choosing Medicare coverage isn’t just about premiums; it involves considering your doctors, prescriptions, and healthcare costs. The main options are Original Medicare, which offers flexibility but no yearly cost limit, and Medicare Advantage, which often includes additional benefits and a yearly cap. Review your plans during Open Enrollment for the best decisions.
Choosing Medicare coverage involves more than comparing monthly premiums. Your doctors, prescriptions, preferred pharmacy, and expected health care costs can all affect which option works for you.
This guide explains the two main ways to get Medicare coverage and gives you a checklist to use during Open Enrollment.
Original Medicare vs. Medicare Advantage: What’s the difference?
Original Medicare includes Part A (hospital insurance) and Part B (medical insurance). You can generally use any doctor or hospital in the United States that accepts Medicare. You can add a separate Part D plan for prescription drug coverage. You may also be able to buy Medicare Supplement Insurance, called Medigap, to help pay your share of certain costs.
Medicare Advantage, also called Part C, provides your Part A and Part B benefits through a private plan approved by Medicare. Most plans include Part D drug coverage. Plans may offer additional benefits, but the details vary. Many plans use provider networks and may require referrals or prior authorization for certain care. You cannot use Medigap to pay costs in a Medicare Advantage plan.
Original Medicare generally has no yearly limit on what you pay out of pocket for covered Part A and Part B services unless you have other coverage. Medicare Advantage plans have a yearly out-of-pocket limit for covered Part A and Part B services, but the limit and your costs along the way vary by plan.
Compare the two coverage paths on Medicare.gov.
How do I check whether my doctors are covered?
If you’re considering Original Medicare, ask each doctor or facility whether it accepts Medicare and whether it accepts new Medicare patients.
If you’re considering a Medicare Advantage plan, check the provider directory for the exact plan, then contact the doctor’s office and the plan to confirm participation. An office may accept one plan from an insurance company but not another. Check your primary care doctor, specialists, hospitals, and any other providers you use regularly. Also ask what you would pay for out-of-network care, if the plan allows it.
Provider networks can change. Confirm the details again before you enroll or renew, particularly if continuing care with a specific doctor is essential to you.
How do I check my prescriptions?
Make a list of each medication’s name, dosage, and how often you take it. Include the pharmacy you prefer to use.
When comparing plans, look for each drug on the plan’s list of covered medications, called a formulary. Check its estimated cost, whether your pharmacy is in the network, and whether the plan applies rules such as prior authorization or step therapy. A preferred pharmacy may cost less than another in-network pharmacy.
You can enter your medications and pharmacies in Medicare’s Plan Finder to compare estimated costs. If a medication is especially important to your treatment, confirm its coverage and rules directly with the plan before making a change.
Does a $0 Medicare Advantage premium mean the plan is free?
No. $0 refers to the plan’s monthly premium, not every cost of having or using the coverage. You generally must continue paying your Medicare Part B premium. Depending on the plan and the care you receive, you may also pay deductibles, copayments, coinsurance, and prescription costs.
Compare the likely total cost for a year, not just the monthly plan premium. Think about your regular appointments, medications, possible specialist or hospital care, and the plan’s yearly out-of-pocket limit.
What should I review during Medicare Open Enrollment?
Medicare Open Enrollment runs from October 15 through December 7 each year. Changes made during this period generally take effect January 1. Before deciding whether to keep or change coverage, review:
- Your current plan’s Annual Notice of Change. It explains changes in coverage, costs, and other terms for the coming year.
- Your doctors and hospitals. Confirm whether they participate in the specific plan for the coming year.
- Your prescriptions and pharmacies. Recheck the formulary, plan rules, and estimated annual drug costs.
- Your full cost picture. Compare premiums, deductibles, copays, coinsurance, and out-of-pocket limits.
- How you receive care. Consider networks, referrals, prior authorization, and any travel or out-of-area needs.
- Other coverage you have. If you have employer, retiree, union, or other insurance, ask its benefits administrator how a Medicare change could affect it before you switch.
You do not have to change plans just because Open Enrollment has arrived. Reviewing your coverage each year helps you decide whether it still fits your needs.
Ready to explore your options? Use Medicare’s Plan Finder for plans available in your area. You can also call Medicare4Me at 1-888-708-8633 to speak with a licensed insurance agent and request a free, no-obligation quote.