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Traditional Medicare verses Medicare Advantage

When you turn 65 and are choosing your health insurance coverage, remember that Traditional Medicare and Medicare Advantage are entirely different programs. Traditional Medicare is a public program that pays the doctors and hospital direct and allows you to choose your doctor and hospital. Medicare Advantage is through different insurance companies and has control over what doctor you see and where you can seek medical help.

From a consumer's point of view, there are three important things to consider between Traditional Medicare and Medicare Advantage.

The first is a difference in coverage
The second is a difference in access
The third would be a difference in the cost as a consumer

Traditional Medicare and Medicare Advantage plans both cover the same benefits package of what's medically necessary, although with traditional Medicare you have a lot more doctors and hospitals to pick from. Medicare Advantage plans to cover the same range of benefits, but the plan decides what is medically necessary, and it may be different.

The second difference is access. With Traditional Medicare, you can go to any doctor or hospital that takes Medicare, which is approximately 93% of doctors, and you don't need a referral. If you want to go to a doctor that's in Medicare's network, you can go to that doctor. With Medicare Advantage, you typically have to get a referral from your primary care physician or from the Medicare Advantage plan. When you are extremely ill, you may need a more specialized doctor, but you suddenly have to start getting authorization and approval. That's taking away your choice.

The third difference is the cost difference. With Traditional Medicare, there are premiums, coinsurance, and deductibles. People who can afford to do so, typically buy a Medigap policy (supplement) to take care of the copays and deductibles. If you do that, you will have good coverage with traditional Medicare. Medicare Advantage is different. You can't buy a supplemental policy to go on top of Medicare Advantage. When Medicare Advantage Plans charge you copays and deductibles, you can't buy Medigap to cover that. If you are sick and want to go to the doctor of your choice and they are not in-network, you will be responsible for more out-of-pocket expenses than with an in-network provider. Medicare Advantage will only pay for doctors and hospitals of their choice. With HMO Medicare Advantage plans, there's a limit to how much you can pay. You can't have more than $7,550 in out-of-pocket expenses.

With Traditional Medicare and a supplement, you have little to no out-of-pocket expenses for healthcare. The main reason a Medicare Advantage plan is picked is due to lower premiums and options for vision/dental coverage. The lower premium is nice but nearly $8,000 in out-of-pocket expenses is excessive. With traditional Medicare, that is not an issue.

Some people may receive a Medicare Advantage plan as their retirement plan. There is not much to be done about this. You may contact your plan and see if something can be done on that end. You will be accepted in most places but out-of-pocket costs will be higher than with Traditional Medicare.

The main thing to remember when choosing between Traditional Medicare and Medicare Advantage is having a choice. Even though Medicare Advantage may appear to be less expensive, most small, rural area health facilities will not be in your network and you will be responsible for a much larger bill in the end. If you have any questions about picking a plan or changing to Traditional Medicare, call one of our "Medicare Specialists" in Social Services at Sabetha Community Hospital at (785) 284-1547. They can help you pick the plan that allows you to get your health care at your local hospital.