With so many options and decisions related to Medicare coverage, it's important you feel confident in your choice. Whether you're approaching age 65 or reviewing your coverage during the Annual Enrollment Period (AEP), understanding the key differences between Original Medicare and Medicare Advantage is just one way you can be more informed about the type of Medicare coverage that is available for you.
What is Original Medicare?
Original Medicare, also simply referred to as Medicare, is a government-sponsored health insurance program External Link for individuals age 65 and older and those with certain disabilities. Original Medicare is made up of two parts — Part A and Part B — that cover different health care needs.
Part A covers hospital stays, skilled nursing facility care, hospice and some home health care.
Part B covers doctor visits, durable medical equipment, outpatient services and lab tests.
While Original Medicare reduces health care costs, it doesn't cover everything. Part A and Part B both have deductibles and Original Medicare plan members may have to pay coinsurance for covered services. Original Medicare does not include extras like dental or vision coverage, or prescription drugs except in certain situations External Site. Because Original Medicare doesn't cover everything, most people need additional coverage. In this case, you may want to consider enrolling in a Medicare Advantage plan to help cover your additional health care needs.
What is Medicare Advantage (Part C)?
Medicare Advantage plans are offered by private insurance companies, like Wellmark Advantage Health Plan, and are approved by Medicare. You may hear Medicare Advantage plans referred to as Part C.
Medicare Advantage plans are comprehensive plans that cover all of the benefits of Original Medicare, as well as additional benefits. Additional benefits typically include vision, dental, hearing, and over-the-counter items, like vitamins and toothpaste. Medicare Advantage plans often include coverage for prescription drugs, too, which means you don't have to worry about purchasing an additional prescription drug plan, also referred to as Medicare Part D.
Medicare Advantage plans, especially those from local companies like Wellmark, also provide members access to an extensive network of trusted health care providers and facilities, so you can feel confident that you are receiving great care.
Differences between Medicare and Medicare Advantage plans
Here is a comparison of the differences between Original Medicare and Medicare Advantage plans. It’s important to note that because Medicare Advantage plans are offered by private insurers, plan benefits may differ from one insurer to another.
| Original Medicare | Medicare Advantage | |
|---|---|---|
| Cost | Premiums under Part A are no cost to individuals and their spouses who have paid at least 40 quarters of Medicare tax. Part A has a deductible and you may have a coinsurance, depending on the service. You'll pay a premium and deductible for services covered under Part B. The monthly premium is determined by what's reported on your tax returns External Site from two years ago. Medicare has no yearly limit for out-of-pocket costs for covered services. |
The cost of Medicare Advantage plans varies based on where you live and the insurance company you choose. With Wellmark Advantage Health Plan, monthly premiums start at $0. You will still need to pay the Part B monthly premium. Medicare Advantage plans have a maximum out-of-pocket limit. This means, once you have reached your plan's annual limit for medical out-of-pocket costs, you'll pay nothing for these covered services. |
| Network |
You can go to any hospital or doctor in the United States that accepts Medicare. You don’t need a referral to see a specialist, in most cases. |
Most private insurance companies require you to go to health care providers and facilities within their network. Different Medicare Advantage plans have different network rules. For example, with Blue Medicare AdvantageSM PPO plans, you can go to any doctor or hospital in the Blue Cross Blue Shield network. If you choose the Medicare Advantage HMO plan, nationwide coverage is available only in emergency and urgent situations. |
| Additional coverage |
Original Medicare does not cover vision, dental, hearing or prescription drugs which means you'll have to pay out-of-pocket for those services, in addition to your Part B deductible, premium, and coinsurance. You can purchase a Medicare Supplement plan to help pay for some of those medical costs, as well as a Medicare Part D plan for prescription drug costs. |
Medicare Advantage plans cover everything Original Medicare does and offer additional coverage. Medicare Advantage plans often include benefits for:
|
| Original Medicare | |
|---|---|
| Cost | Premiums under Part A are no cost to individuals and their spouses who have paid at least 40 quarters of Medicare tax. Part A has a deductible and you may have a coinsurance, depending on the service. You'll pay a premium and deductible for services covered under Part B. The monthly premium is determined by what's reported on your tax returns External Site from two years ago. Medicare has no yearly limit for out-of-pocket costs for covered services. |
| Network | You can go to any hospital or doctor in the United States that accepts Medicare. You don’t need a referral to see a specialist, in most cases. |
| Additional coverage | Original Medicare does not cover vision, dental, hearing or prescription drugs which means you'll have to pay out-of-pocket for those services, in addition to your Part B deductible, premium, and coinsurance. You can purchase a Medicare Supplement plan to help pay for some of those medical costs, as well as a Medicare Part D plan for prescription drug costs. |
| Medicare Advantage | |
| Cost | The cost of Medicare Advantage plans varies based on where you live and the insurance company you choose. With Wellmark Advantage Health Plan, monthly premiums start at $0. You will still need to pay the Part B monthly premium. Medicare Advantage plans have a maximum out-of-pocket limit. This means, once you have reached your plan's annual limit for medical out-of-pocket costs, you'll pay nothing for these covered services. |
| Network | Most private insurance companies require you to go to health care providers and facilities within their network. Different Medicare Advantage plans have different network rules. For example, with Blue Medicare AdvantageSM PPO plans, you can go to any doctor or hospital in the Blue Cross Blue Shield network. If you choose the Medicare Advantage HMO plan, nationwide coverage is available only in emergency and urgent situations. |
| Additional coverage | Medicare Advantage plans cover everything Original Medicare does and offer additional coverage. Medicare Advantage plans often include benefits for:
|
Do I really need a Medicare Advantage plan?
Depending on your health needs and budget, Original Medicare may not provide the coverage you need or the security of a maximum out-of-pocket limit. It’s important to consider what your health care costs are now or may be in the future to choose a plan that will provide you with the coverage you need at an affordable price.
When can I enroll in a Medicare Advantage plan?
If you aren't currently enrolled in Medicare, you can first enroll during a seven month period known as your Initial Enrollment Period. This includes the three months leading up to your 65th birthday, the month of your birthday, and three months after your birthday month.
You can also enroll in a Medicare Advantage plan during the Annual Enrollment Period, which occurs every year from Oct. 15 to Dec. 7. During this time, you can switch from Original Medicare to Medicare Advantage or from one Medicare Advantage plan to another.
Find a Medicare Advantage plan made with your needs in mind
Wellmark has more than 85 years of experience in covering Iowans and South Dakotans at all life stages. With combined medical and drug coverage, dental benefits through Delta Dental®, vision, hearing and the SilverSneakers® fitness program, Wellmark Medicare Advantage plans are comprehensive to support our members’ whole health.
Have more questions? We’re here to help
No matter what type of Medicare coverage you decide to enroll in, Wellmark can help you understand the plan options that are available to you. In addition to Medicare Advantage plans, Wellmark has a variety of Medicare Supplement plans to fit your budget, lifestyle and health care needs. To talk to an expert about your Medicare Advantage and Medicare Supplement options, call . We have representatives available to help you Monday–Friday, 8 a.m.–5 p.m. CT.
If you're new to Medicare, request a free Medicare Get-Ready guide Opens New Window and learn more about the basics of Medicare, when you’re eligible to enroll, and your medical, dental and vision coverage options.
If you live outside Iowa or South Dakota, go to Bcbs.com External Site to find a Blue Cross Blue Shield plan near you.
Dental benefits provided by Delta Dental of Iowa and Delta Dental of South Dakota. These are independent companies providing dental services on behalf of Wellmark Advantage Health Plan, Inc.
SilverSneakers is a registered trademark of Tivity Health, Inc. © 2023 Tivity Health, Inc. All rights reserved.
Wellmark Advantage Health Plan is a PPO and an HMO plan with a Medicare contract. Enrollment in Wellmark Advantage Health Plan depends on contract renewal.
Y0156_CompMtoMA24_M CMS Accepted 11202023
