Skip to main content

FOR PATIENTS & FAMILIES

How do I know which Medicare plan is right for me?

“Medicare is so confusing. I don’t even know where to start!”

Pro Tip: Talk to your doctor or provider about your healthcare needs and whether Original Medicare or Medicare Advantage may be right for you.

A Note About Emergency Care

If you are experiencing a medical emergency, always go to the nearest emergency room. Even a Medicare Advantage plan is required to pay for any emergency services (as defined by the plan) at in-network rates.

When can I enroll in a Medicare plan, or change to a new plan?

There are three main times you can enroll in a plan, or make changes to your selection:

Initial Medicare Enrollment Period (around your 65th birthday)

Annual Election Period

Medicare Open Enrollment Period is Oct. 15-Dec. 7 each year

Understand the “Parts”

Medicare Part A covers:

Medicare Part B covers:
Inpatient Hospital Care
Skilled Nursing and Rehabilitation Care
Home Health Care
Hospice Care		 Doctor Services
Outpatient Care & Emergency Room
Durable Medical/Home Medical Equipment
Other Services & Supplies

Medicare Part C is:

Medicare Part D covers:
Medicare Advantage (Instead of Original Medicare) Prescription Drug Benefit

Original Medicare

  • You can use any doctor or hospital that takes Medicare, anywhere in the US
  • Includes Medicare Part A (Hospital Insurance) and Part B (Medical Insurance)
  • You can join Medicare Part D to get Medicare drug coverage.
  • You can purchase Medigap, also called a Medicare Supplement, to cover out-of-pocket costs, such as 20 percent coinsurance.

Medicare Advantage (Part C)

  • If you choose Medicare Advantage, you give up your right to Original Medicare coverage for that enrollment period. In other words, you either have Original Medicare or Medicare Advantage – not both.
  • A Medicare Advantage plan sponsored by a private insurance company is “bundled” to include hospital care, outpatient care, and usually prescription drug coverage.
  • Except for emergency services, a Medicare Advantage plan only fully pays for services furnished by doctors and hospitals that are in its network.
  • You may need prior approval for care and certain drugs.
  • Medicare Advantage plans offer limited coverage for some services not covered by Original Medicare, such as vision, hearing and dental.
  • Medicare Advantage Plans sponsored by Hospitals create a network of their hospital and physician services and give hospitals an opportunity to more closely coordinate care for patients in the network. They might have incentives to encourage patients to use services within their local hospital network.

Compare Original Medicare and Medicare Advantage

There’s no perfect way to compare Medicare coverage, but we’ve provided 5 important questions to consider when selecting your Medicare healthcare coverage.

Pro Tip: You can always visit medicare.gov – NOTE! – other websites with Medicare in the title may be advertising Medicare Advantage plans.

Pro Tip: When considering a Medicare Advantage plan, remember that regardless of whether you are getting care at a hospital that is in network or out of network with the MA plan, non-emergency health services will still require preauthorization and coverage could be denied.

The table below summarizes the differences between Original Medicare and Medicare Advantage.

Original Medicare

Medicare Advantage sponsored by Private Insurance Companies

Medicare Advantage sponsored by Hospitals
Government owned and managed. Not “sold” to consumers. Private insurance alternative, funded by the government. “Sold” directly to consumers. Hospitals partner with insurance companies to create a special network for their hospital services and providers, sold directly to consumers.
Keep the physician you know and trust. Visit any doctor or hospital in the U.S. that takes Medicare Plans likely will not travel with you. You are limited to the physicians and hospitals in your plan’s network and service area, even if you are traveling, move mid-year, or need a specialist in another state. Keep the physicians and hospitals locally that you know and trust within the network determined by your hospital.
Split into different Parts to cover different services. Part A covers hospital care, Part B covers medical/doctor appointments; Part D covers prescription and pharmacy care. Medicare Advantage, also known as Medicare Part C, bundles hospital care, medical/doctor appointments and sometimes prescription care into one. Bundles services but gives hospitals the ability to closely coordinate care with patients.
Rarely requires referrals and prior authorization Requires referrals and prior authorization before care can be delivered or paid for. You are responsible for paying for care that is not approved. May require referrals and prior authorizations but gives hospitals the opportunity to more closely coordinate that care.
Easier to access higher level, specialty care, like hospital visits, surgeries, and skilled nursing or rehabilitative care. Often requires prior approval for specialist visits, surgeries, post-acute, and other care. This can result in delays in care and denials for payment – even after care has been provided. May provide benefit incentives to use care within the hospital network, and give hospitals opportunities to form partnership with local specialty care centers so they are “in network.”
Allows enrollee to manage out-of-pocket costs with Medigap (separate premium) or other supplemental insurance such as Medicaid. Out-of-pocket costs will vary. Cannot use Medigap to help. If you leave a Medicare Advantage plan and choose Original Medicare with a Medigap plan during open enrollment, you might have to pay more for Medigap insurance. Out-of-pocket costs will vary. Cannot use Medigap to help. If you leave a Medicare Advantage plan and choose Original Medicare with a Medigap plan during open enrollment, you might have to pay more for Medigap insurance.
Separate premium for Medicare drug coverage (Part D) Many plans include drug coverage. Many plans include drug coverage.
No annual limit on out-of-pocket costs. Out-of-pocket costs vary and should be considered before making a decision. Out-of-pocket costs vary and should be considered before making a decision.

Top Points to Keep in Mind

  • Oklahoma Hospitals approved by CMS always accept Original Medicare plans (excludes VA hospitals)
  • Original Medicare is accepted throughout the country. If you like to travel, knowing you can get the healthcare you need wherever you go is important.
  • Many hospitals have dropped Medicare Advantage plans due to prior authorization denial rates, slow payments and delays of patient care.
  • Some hospitals are now sponsoring unique Medicare Advantage plans that include their own hospitals and providers. These are different from Medicare Advantage plans sponsored by private insurance companies, and tend to minimize denials due to prior authorization issues.
  • Insurance brokers do not sell Original Medicare. If you purchase a plan from an insurance broker, you have selected a Medicare Advantage plan.
  • Medicare Advantage (MA) plans also often require prior authorization to see specialists, get out-of-network care, get non-emergency hospital care, and more. Each MA plan has different requirements, so MA enrollees should contact their plan to ask when/if prior authorization is needed. Medicare Prescription Drug (Part D) Plans very often require prior authorization to obtain coverage for certain drugs.

Each state is required to offer free counseling help for Medicare Recipients. The Oklahoma Senior Health Insurance Counseling Program (SHIP) provides accurate and objective counseling, assistance, and advocacy relating to Medicare, Medicaid, Medicare supplements, Medicare Advantage, long-term care and other related health coverage plans.

Call the Senior Help Line at (800) 763-2828.

Learn about Medigap

Medigap, also known as Medicare supplement insurance is a way to protect yourself from some of the costs not covered by Medicare. It is also called “Medigap” or “Med Supp” insurance. There are 10 standardized Medicare supplement plans identified by the letters “A” through “N.” Plan F is also available as high deductible plans. The benefits in each plan are identical from company to company.

Medigap supplement insurance is only available with Original Medicare plans. You cannot use Medigap with Medicare Advantage plans.

Each state is required to offer free counseling help for Medicare recipients. The Oklahoma Senior Health Insurance Counseling Program (SHIP) provides accurate and objective counseling, assistance, and advocacy relating to Medicare, Medicaid, Medicare supplements, Medicare Advantage, long-term care and other related health coverage plans.

Call the Senior Help Line at (800) 763-2828.

Medicare Advantage plans sponsored by private insurance companies vary in co-payments and charges for the services they provide. Be sure to read the plan details fully, or reach out to the insurance company offering the Medicare Advantage plan for more information.

Look Beyond the Premium

Medicare Advantage plans may advertise low or no premiums. Generally Original Medicare has a 20 percent co-payment, which may be covered by a Medigap policy or other coverage. Many MA plans offer low or no co-payment obligations. In exchange, full coverage is limited to a specific network of providers. Also, Medicare Advantage plans sponsored by private insurance companies require prior approval by the plan for many services, which may result in delayed or denied care.

All Medicare beneficiaries – whether on Original Medicare or a Medicare Advantage plan – must pay the Part B premium, which is about $125 per month in 2025.

Medicare Open Enrollment Season runs Oct. 15 – Dec. 7, 2024

Now is the time to make sure you’re choosing the best Medicare option for you in 2025.

For more information visit Medicare.gov