Switching From Original Medicare to Medicare Advantage: What to Check First

Many people who start with Original Medicare begin to wonder about Medicare Advantage.

Friends talk about low premiums and extra benefits, and the advertisements in the fall make Advantage plans sound like an easy upgrade.

Sometimes switching is a good decision. Sometimes it brings surprises that are hard to undo.

The way to decide well is to know exactly what changes when you switch.

This guide walks through the questions to answer before you leave Original Medicare,

especially the one that matters most to many people: whether you can keep your doctors.

The two paths in one paragraph

With Original Medicare, the federal program pays its share for covered services directly,

and you can generally see any doctor or hospital in the country that accepts Medicare.

Many people add a separate drug plan and a Medigap policy to cover what Original Medicare does not.

With Medicare Advantage, you get your Part A and Part B benefits through a private plan approved by Medicare,

which usually includes drug coverage and often extra benefits,

but typically uses a network of doctors and hospitals and its own rules.

Question 1: will my doctors be in the network?

Most Medicare Advantage plans are HMOs or PPOs.

In an HMO you generally need to use doctors and hospitals in the plan's network, except in emergencies,

and you may need a referral to see a specialist.

In a PPO you can usually go out of network, but you pay more.

Before switching, make a list of every doctor, specialist and hospital you rely on.

Check each one in the plan's provider directory for next year, and then call each office to confirm they will accept that specific plan.

Directories are not always up to date, so the phone call matters.

Question 2: what will I really pay?

A low or zero premium does not mean low costs.

Medicare Advantage plans charge copays and coinsurance for services, and the amounts vary widely between plans.

Look at the costs for the care you actually use: specialist visits, tests, hospital stays and any ongoing treatment.

Every Medicare Advantage plan has a yearly limit on what you pay out of pocket for covered medical services.

Original Medicare alone has no such limit, which is why many people pair it with Medigap.

Compare your likely costs on both paths, including premiums for Part B, drug coverage and any supplemental policy.

Question 3: are my drugs covered the same way?

Most Medicare Advantage plans include drug coverage, but each has its own drug list, tiers and pharmacy network.

Check every prescription you take, with the right dose, and look for restrictions such as prior authorization.

The official Medicare Plan Finder can estimate your yearly drug costs in each plan.

Question 4: what about prior authorization?

Medicare Advantage plans can require approval in advance for certain services, tests or procedures.

Original Medicare uses prior authorization far less. If you have a condition that needs regular imaging, therapy or specialist care,

ask the plan how its approval process works and how long it usually takes.

Question 5: do I travel or live part of the year elsewhere?

Original Medicare works nationwide with providers that accept Medicare.

Many Medicare Advantage plans cover only emergencies and urgent care outside their service area.

If you spend months away from home, check carefully what the plan covers where you will be.

Question 6: what happens to my Medigap policy?

Medigap policies do not work with Medicare Advantage. If you switch, you would usually drop your Medigap policy.

That decision deserves special care: in many states, if you later want to return to Original Medicare,

insurers may be allowed to consider your health when you apply for a new Medigap policy,

and they could charge more or decline you. Certain situations give you temporary rights to return, but they have limits.

If having a Medigap policy matters to you, talk to a SHIP counselor about your state's rules before you switch.

Look past the advertising

Every fall, television, mail and phone calls promote Medicare Advantage plans with words like "free", "extra benefits" and "money back".

Some of these offers are real features of real plans; others leave out important limits. Remember that plan premiums,

extra benefits and the reduction some plans offer on the Part B premium vary by plan and area,

and none of them matter if your doctors are not in the network or your drugs are not well covered.

Be cautious with anyone who calls you without your permission to sell a plan, and never share your Medicare Number with an unknown caller.

Compare plans yourself with the official Plan Finder, or with a counselor who is not paid to sell insurance.

When you can switch

You can switch from Original Medicare to a Medicare Advantage plan during the fall enrollment period,

from October 15 to December 7, with coverage starting January 1.

Certain life events, such as moving to a new area, can create a Special Enrollment Period at other times.

If you are already in an Advantage plan and change your mind,

the Medicare Advantage Open Enrollment Period from January 1 to March 31 lets you make one change,

including returning to Original Medicare.

A side-by-side worksheet

• My doctors: in network for the plan? Confirmed by phone?
• My hospitals and specialists: in network? Referrals needed?
• My drugs: covered? Tier? Restrictions?
• Yearly costs: premiums plus expected copays on each path.
• Out-of-pocket limit: what is the most I could pay?
• Travel: am I covered where I spend time?
• Medigap: what would I give up, and could I get it back?

Frequently Asked Questions

Do I still pay the Part B premium with Medicare Advantage?

Generally yes. You keep paying your Part B premium, plus any premium the Advantage plan charges.

Are extra benefits like dental or vision worth it?

They can be useful, but check the limits.

Extra benefits should not be the main reason to choose a plan if your doctors or drugs are not well covered.

Where can I get unbiased help?

Your State Health Insurance Assistance Program offers free, unbiased counseling and does not sell insurance.

This guide is general information and is not affiliated with Medicare or any insurance plan.

Sources and Further Reading

• Medicare.gov — Original Medicare: how Original Medicare works.
• Medicare.gov — Medicare Advantage plans: how Advantage plans work, including networks and costs.
• Medicare.gov — Medigap: supplemental policies and when you can buy one.
• SHIP — State Health Insurance Assistance Programs: free, unbiased Medicare counseling.