As Medicare enrollment season begins, many people find themselves comparing Original Medicare and Medicare Advantage plans. There are important differences to consider before making a switch, especially when it comes to access, approvals, and coverage limits.
With Original Medicare, you can see any provider who accepts Medicare, which is the majority of hospitals, clinics, and doctors across the country. There are no network restrictions, and you don’t need referrals or pre-authorizations for most services. You retain the freedom to choose your healthcare provider, even if you travel or relocate.
Medicare Advantage (Medicare Part C) plans are administered by private insurance companies that contract with Medicare. These plans often bundle extra benefits such as dental, vision, or hearing coverage, features that can sound attractive. However, they generally require you to use a limited network of providers and may require pre-authorization for services such as seeing a specialist, getting lab tests, scheduling hospital stays, or receiving skilled nursing care.
One key concern involves the number of skilled nursing facility (SNF) days covered. Under Original Medicare, eligible patients can receive up to 100 days of SNF care per benefit period, with varying levels of cost-sharing. Many Medicare Advantage plans, however, limit this coverage or apply stricter approval requirements. Patients and families are sometimes surprised to learn that once those approved days run out, the remaining costs must be paid out-of-pocket.
It’s also important to understand that when you enroll in a Medicare Advantage plan, you give up your Original Medicare Part A and B coverage. Your benefits are now managed entirely through the private insurer. If you later decide to return to Original Medicare, you may not always be able to get the same supplemental (Medigap) coverage you had before.
Before making any changes, take time to compare coverage limits, provider networks, and pre-authorization rules. Ask your healthcare provider which plans they accept, and review what happens if you need care while traveling or in another state. Understanding these details now can prevent unexpected costs and disruptions later.
Smith County Memorial Hospital’s Patient Advocate, Lori Dennis, is SHICK (Senior Health Insurance Counseling for Kansas) certified. Please call Lori at (785) 282-6845 ext. 1510 for help with your Medicare vs. Medicare Advantage questions.
Learn more about Medicare vs. Medicare Advantage with these educational handouts from the Kansas Hospital Association: