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Access to Care: Medicare Advantage vs Original Medicare

Eligible seniors can choose between Original Medicare and Medicare Advantage for their Medicare benefits. Both options include Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) but Medicare Advantage plans typically also provide additional coverage for services such as prescription drugs, dental, hearing, and vision. If you’re getting ready to transition to Medicare, you may have heard that you’ll have better access to care with Original Medicare or Medicare Advantage. Let’s take a look at some of the differences in how Medicare services are accessed for Original Medicare vs Medicare Advantage plans.

Access to care: Medicare Advantage vs Original Medicare


Original Medicare


Original Medicare is a government health plan run by the Centers for Medicare & Medicaid Services. Kupuna who choose to receive their Medicare coverage through Original Medicare can seek Medicare services through any doctor or hospital who accepts Medicare payments across the United States. In addition, beneficiaries don’t need a referral from a primary care physician to see specialists.


Under Original Medicare, participating Medicare providers, physicians, and suppliers agree to accept the Medicare-approved amount as full payment for covered services. This is a written agreement called “assignment.”


Not all doctors accept Medicare assignment. Non-participating Medicare providers can choose whether or not to accept Medicare assignment for individual services and may be legally allowed to charge more for services than the Medicare-approved amount. If you receive a service from a non-participating Medicare provider, you may be billed for an “excess charge”, up to 15% more than what Medicare allows for certain services.


There are also health care providers who have “opted out” of Medicare. These providers will not bill Medicare for any services, including those that would normally be covered by Medicare. Patients are expected to provide private insurance or to pay cash for the services they receive from these providers.


Medicare Advantage plans


Medicare Advantage plans are offered by private insurance companies contracted with Medicare. If you choose to receive your Medicare coverage through a Medicare Advantage plan, your services will be geared toward a regional service area. As a result, plan members should seek care from “in-network” providers to ensure the best coverage. Some Medicare Advantage plans require a referral to see a specialist. Before choosing a Medicare Advantage plan, speak with an experienced Medicare agent who can help you understand how each plan works.


Some Medicare providers belong to Medicare Advantage plan networks. Medicare Advantage plan networks are required to include all basic health services, such as primary care physicians and specialists, hospitals, dialysis centers, and other health-care professionals and suppliers. Before transitioning to Medicare, it’s a good idea to ask your preferred medical providers if they participate in a Medicare Advantage plan network.


Keep in mind that Medicare Advantage plans are not required to contract with every Medicare provider in their area. A contract is contingent on an agreement between the two parties; among other things, the Medicare provider must accept the Medicare Advantage plan’s reimbursement schedules and administrative rules.


There are different models of Medicare Advantage plans, each with their own rules that affect the way services should be accessed. Speak to a Medicare agent about your options and the rules that come along with each.


Do Medicare providers prefer Original Medicare or Medicare Advantage?


The truth is that different Medicare providers have different preferences. Some doctors may prefer the structure of a Medicare Advantage plan network while other doctors may prefer the flexibility that Original Medicare provides. The vast majority of Medicare beneficiaries are happy with both the quality of care and access to care they receive under Medicare – whether Original Medicare or Medicare Advantage.


Contact a PBC Agent for Help


Our independent insurance agents are dedicated to assisting people on Medicare and those who are ready to transition from employer coverage to personal retirement coverage. We help kupuna understand their benefits options and apply for additional coverage, as needed. Because we represent all the major Medicare Advantage and supplement plans in Hawaii, we are able to offer unbiased advice; all at no cost to our clients.


At PBC, our clients are our number one priority and we look forward to getting to know you and your needs. Call us today at (808) 738-4500 to see how we may be of assistance.

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