Section 3: Costs and Coverage
Comparing Your Medicare Options
Consider your choice of doctors, your lifestyle and the costs
ESTIMATED READ TIME: 5 MINUTES
IN THIS ARTICLE
• Your choice of doctors
• Your coverage when traveling
• Your options for additional coverage
• Your expenses
When considering how to customize Medicare to meet your health care needs, you’ll want to weigh the pros and cons of coverage through the federally run original Medicare program or a private Medicare Advantage plan.
Your costs, prescription drug coverage, choice of doctors and ability to get coverage when you travel will differ. Before making a decision, be sure to compare the features of each option.
Your choice of doctors
Original Medicare. With traditional Medicare, you can choose any providers who accept Medicare. You don’t need a referral to see a specialist and you don’t have to worry about your doctor leaving a plan’s network.
About 99 percent of physicians who don’t treat children participate in Medicare, according to the Kaiser Family Foundation. But if you’re looking for a new doctor, you may discover that it’s harder to find one who accepts Medicare. About 1 in 5 primary care doctors aren’t taking new Medicare patients.
Medicare Advantage. This Medicare option resembles a private insurance plan that you may have had through an employer. The most common types are health maintenance organization (HMO) and preferred provider organization (PPO) plans.
Both have networks of doctors, hospitals and other services. You’ll usually pay less if you use in-network providers.
If you have an HMO plan, you may not have any coverage for out-of-network providers except in emergencies. Medicare Advantage HMOs generally have a primary care physician who directs your care, meaning you'll need a referral to see a specialist. With a PPO, you may be able to use out-of-network providers, but you’ll usually have higher copays than you would with in-network providers.
Your coverage when traveling
Original Medicare. With traditional Medicare, you can go to a doctor anywhere in the United States, as long as the provider accepts Medicare.
However, original Medicare generally doesn’t cover medical expenses when you travel outside the U.S. You can buy a supplemental Medigap policy to cover some of the costs of a foreign travel emergency.
Medicare Advantage. These plans have networks of providers usually based in a specific geographic area. The average Medicare beneficiary has a choice of 43 plans in 2023, but your options may be limited in some areas.
So, if you travel frequently or have a vacation home where you spend a lot of time, you may not find providers in your network. If you see an out-of-network provider, your care may not be covered, or you may have to pay more. However, if you’re traveling within the U.S., emergency and some urgent care are covered.
Most Medicare Advantage plans don’t cover health care abroad, although some have limited coverage for emergency care outside the United States.
Your options for additional coverage
Original Medicare. To receive full coverage through original Medicare, you’ll likely have to enroll in four separate plans: Part A, which covers hospitalization; Part B, which covers doctor visits and outpatient services; a Part D prescription drug plan; and Medicare supplement insurance, better known as Medigap, which can help you pay for deductibles and copayments. Most people who have original Medicare coverage buy a Medigap policy if they don’t have supplemental coverage through a retiree health plan or other source.
Medicare Advantage. This option combines parts A and B of original Medicare in one plan. In addition, almost 9 out of 10 of these plans also cover prescription drugs, so you won't have to get separate Part D coverage.
Some of the plans also provide dental, hearing and vision coverage, services that you would have to pay for yourself with traditional Medicare or look at separate private insurance policies. Although Medicare Advantage plans are required to cover the same services as original Medicare, you may have different deductibles and copayments and fewer out-of-pocket costs.
If you select a Medicare Advantage plan, you’re not allowed to purchase a Medigap policy.
Original Medicare. The federal government sets the premium, deductible and coinsurance amounts for Parts A and B. For example, most people pay $164.90 a month in 2023 for the Part B premium, and they’re generally responsible for a $226 yearly deductible and 20 percent of the cost of doctor visits, lab tests and other outpatient services.
Most people don’t have to pay a premium for Part A hospitalization. But they do have to pay a $1,600 deductible for each benefit period they use in 2023, which could amount to more than one period in a year if you face several hospitalizations, and a $400 daily copayment for days 61 to 90 in the hospital per benefit period.
The government also sets maximum deductibles for the Part D prescription drug program. In 2023, Part D deductibles can’t be greater than $505, but plans can have lower or no deductibles. The premiums and cost sharing vary by plan.
Many people who elect original Medicare also purchase a Medigap supplemental policy to help defray many out-of-pocket costs, such as deductibles and coinsurance. Private insurers sell these policies, and the premiums vary.
Medicare Advantage. Enrollees must pay the Part B premium, which is $164.90 a month in 2023 for most people, as well as any Part A premiums if they aren’t eligible for free coverage. They may have to pay a monthly Medicare Advantage premium, too, although many plans don’t charge additional premiums. Enrollees typically are required to pay copayments for a hospital stay and copayments or coinsurance for Part B services, such as doctor visits and X-rays.
Medicare Advantage plans have an annual cap on out-of-pocket expenses, which include deductibles and copayments but not premiums. In 2023, the limit is $8,300 for in-network services although some plans have lower caps. If you choose a Medicare Advantage PPO, the limit is $12,450 for using a combination of in- and out-of-network sevices.
The Centers for Medicare & Medicaid Services’ tools can help you compare your estimated out-of-pocket expenses for various Medicare coverage options. Start by entering your zip code into the Your Medicare Options tool. For a list of Medicare options in your area, use Medicare’s Plan Finder tool.
ORIGINAL MEDICARE VS. MEDICARE ADVANTAGE AT A GLANCE
You may pay more in total for the flexibility of being able to keep your doctors or keep up with health care appointments when you spend a few months away from home. You have to decide what's important to you.
|Original Medicare||Medicare Advantage|
|Doctors and hospitals||Any that accept Medicare patients||Those in a plan's network, sometimes out-of-network services allowed for extra fees|
|Specialists||No referral needed||HMOs often require referral from primary care physician|
|Coverage area||Nationwide||Limited to plan's area, except for emergencies|
|Supplemental insurance||Medigap policy available to buy||Not available|
|Prescription drugs||Never included, but Part D plan available to buy||Almost 9 of 10 plans include prescription drug coverage with cost sharing|
|Costs in 2023||
Part A: Free for most
|Part A: Free for most
Part B: $164.90 a month
Plan premium: Zero to more than $100 a month
Deductible: Most enrollees don't pay a deductible for in-network medical services covered under parts A and B, but some plans charge a deductible of $700 or more. Among those who do, the average in-network deductible is $817. There may be's often a separate deductible for prescriptions.
Copayments: Zero to $50 typically charged each time you see a doctor, access a covered service or buy prescription drugs. You'll usually pay a copayment for the first few days of a hospital stay, such as $325 per day for days 1 through 5.
Coinsurance: Can be 20 percent of covered services and medications
|Out-of-pocket limit||No limit, but buying a Medigap policy can help cover those bills||
In- and out-of-network combined: $12,450
Some plans have lower out-of-pocket limits.
Sources: Medicare, Kaiser Family Foundation and AARP research
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