Choose Your Coverage

Understanding your Medicare Choices

There are 2 distinct ways to select from on how you are covered with Medicare:

1) Original Medicare

• Includes Part A (hospital) and Part B (doctors).
  • You can use any doctor or hospital that takes Medicare, anywhere in the U.S.
  • Original Medicare does not require referrals. A beneficiary simply goes to the Physician Compare database and finds a list of providers who accept Medicare assignment.(a)
  • Original Medicare does not have prior authorization requirements. Doctors and other healthcare providers have an obligation to know and follow Medicare’s coverage criteria. They determine the appropriate plan for their patients.(a)
• Optional -Part D (Prescription drug coverage)
  • flexibility each year to select a new Plan that best fits your prescription needs & budget.
  • If you don’t opt to get Part D when you’re first eligible, you may have to pay more to get this coverage later. For Part D, this could mean a lifetime premium penalty.
• Optional-Medicare Supplement Insurance (Medigap) policy. To help pay out-of-pocket costs in Original Medicare (like your 20% coinsurance).
  • Available to you on as “Guarantee Issue” during your IEP. Outside of IEP may only be available with Medical underwriting a

2) Medicare Advantage

An “all in one” alternative to Original Medicare.   These “bundled” plans include Part A, Part B, and usually Part D. Most plans offer extra benefits that Original Medicare doesn’t cover – like vision, hearing, dental, and more. Key features:

• In most cases, you’ll need to use doctors who are in the plan’s network.
• Referrals are a staple of Medicare Advantage HMO (health maintenance organization) plans. A new member must pick a primary care physician. That physician must submit a referral before the member can see a specialist or another healthcare provider, or get certain medical services and treatments. The referral can expire and, if that happens, the process starts over.(a)
• Most require Prior Authorization A physician must obtain approval from an insurance plan to prescribe a healthcare service, treatment plan, or a piece of medical equipment. This process allows the insurance company to verify coverage and medical necessity of the proposed care. Authorization can result in a certain number of visits or a specific test or treatment. It’s also possible the plan can choose not to authorize the physician’s request.
• You can only join a plan at certain times during the year. In most cases, you’re enrolled in a plan for a year.
• Following plan rules, like getting a Referral to see a specialist in the plan’s Network can keep your costs lower. Check with the plan.
• Go to a doctor, other health care provider, facility, or supplier that belongs to the plan’s network, so your services are covered and your costs are less. In most cases, this applies to Medicare Advantage HMOs and PPOs.
• Providers can join or leave a plan’s provider network anytime during the year. Your plan can also change the providers in the network anytime during the year. If this happens, you may need to choose a new provider.
• Medicare Advantage Plans have a yearly limit on your out-of-pocket costs for medical services. Once you reach this limit, you’ll pay nothing for covered services. Each plan can have a different limit, and the limit can change each year. You should consider this when choosing a plan.
• If the plan decides to stop participating in Medicare, you’ll have to join another Medicare health plan or return to Original Medicare.

Additional information Advantage Plans:

Advantage Plan Finder Medicare.gov