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Take time to compare original Medicare versus Medicare Advantage

June 24, 2024

Navigating enrollment for Medicare coverage is a process that requires time, and a thorough understanding of the options, with a particular focus on access to providers, medical services, and drugs. For everyone turning 65, including those with primary immunodeficiency (PI), choices must be made whether to use original Medicare or Medicare Advantage as their health insurance. Which type to choose is a decision that should be reached after examining the benefits and drawbacks of each plan.

Keep in mind that original Medicare provides more options because Medicare Advantage plans are run by private insurers and have some of the same restrictions/limitations as other private insurance plans, in areas like formularies and networks.

Original Medicare

Original Medicare is a federal health insurance program that offers benefits, some free but most at a cost, to those 65 and older and to those under 65 who meet specific disability criteria. Depending on your plan type, you may receive coverage for services such as primary medical care, hospital stays, or prescription drugs. The coverage is divided into Parts A, B, C, and D, with other letters assigned to Medigap, or supplemental plans.

Most people turning 65 should enroll in original Medicare Part A, even if they receive health insurance from an employer because most don’t pay a premium for the plan. Part A offers coverage for hospitalization, skilled nursing facilities, hospice care, and some home health care. Part B is optional, but most people enrolled in Part A also choose Part B. Part B covers doctor’s office visits, preventive care, scans and tests, medical equipment, and other medically necessary services, including immunoglobulin (Ig) replacement therapy for certain PIs. Enrollees can also enroll in Part D, which covers prescription drugs. Parts B and D, and sometimes A, require premiums.

Because Part B of original Medicare covers only 80% of the cost of covered services (other than preventative services, which are covered at 100%), enrollees often pay a premium to have a Medigap policy, or supplemental plan, cover the remaining 20%. The Medigap policies, sold by private insurance companies, range in price. Having this supplemental insurance is important for Ig coverage, which is costly. Medigap is only for those who don’t have other insurance through an employer or retirement plan to cover the 20%.

Medicare Advantage

In contrast, Medicare Advantage, also known as Medicare Part C, is an option where enrollees choose from private insurance plans for their healthcare needs. Types of Medicare Advantage Plans include Health Maintenance Organizations (HMOs), and Preferred Provider Organizations (PPOs). To join a Medicare Advantage Plan, participants must enroll in Medicare Parts A and B as an administrative step. Premiums vary by plan.

Choosing a plan

When it comes to choosing a plan that best suits the needs of a person diagnosed with PI, it’s important to remember that, unlike original Medicare, Medicare Advantage plans may apply different rules, costs, and restrictions. Consider these differences between original Medicare and Medicare Advantage:

  • Provider access: With original Medicare, you have the same benefits at any provider or facility that accepts Medicare, and most doctors do accept Medicare. In contrast, Medicare Advantage plans may limit you to in-network providers and facilities or charge more for out-of-network care. Limiting provider access is especially detrimental to a person with PI who has built a network of care that includes an immunologist and other specialists
  • Ig access: Original Medicare allows you to choose the product, and route of administration that is appropriate for you, whereas Medicare Advantage plans may limit your access to Ig. Medicare Advantage plans have formularies of preferred products and may have certain requirements where you have to use the lowest-cost product unless there are medical reasons to step up to the higher-cost product.
  • Costs: With original Medicare, you pay a monthly Part B premium and are responsible for a 20% coinsurance cost after meeting your deductible, or you may purchase a Medigap plan to cover those additional costs. Under a Medicare Advantage plan, cost-sharing varies depending on the plan and you usually pay a copay for in-network care. Medicare Advantage plans may charge a monthly premium in addition to the Part B premium.  
  • Supplemental insurance: Original Medicare allows you the choice to pay an additional premium for a Medigap policy to cover Medicare cost-sharing. You cannot purchase a Medigap policy if you opt for Medicare Advantage.
  • Referrals: Original Medicare does not require referrals for specialists. Medicare Advantage plans may require referrals for specialists.
  • Drug coverage: Under original Medicare, you must sign up for a stand-alone Part D plan if you want prescription drug coverage. Under Medicare Advantage, in most cases, the plan provides prescription drug coverage, but you may be required to pay a higher premium. Both plans have formularies.
  • Other benefits: Original Medicare does not cover vision, hearing, or dental services.  Medicare Advantage plans may cover additional services, including vision, hearing, and/or dental, but those additional benefits may increase your premium and/or other out-of-pocket costs.
  • Out-of-pocket limit: Original Medicare has no out-of-pocket limit, whereas Medicare Advantage plans have a standardized annual out-of-pocket limit.

Immune Deficiency Foundation (IDF) Community Resource Navigator Angela Kotarski said that, in her opinion, original Medicare with a drug plan and a supplemental plan, best fits the needs of most people with PI. People with chronic conditions require the flexibility offered by original Medicare.

“While the Medicare Advantage plans are good for some people, they do pose a lot of restrictions,” she said.

Kotarski also stressed that whether a person chooses original Medicare or Medicare Advantage, they must submit the results of all testing for PI, such as a pneumococcal vaccine challenge, low IgG levels, and a history of recurrent infections results and other diagnostic evaluations, to the plan administrators. Otherwise, enrollees may have to pay out-of-pocket for the health care services or go off of therapy to have these tests redone.

“It’s extremely important that that documentation is on file,” said Kotarski.