Original Medicare, unlike Medicare Advantage, does not have out-ofpocket maximums. Those with Original Medicare pay a monthly premium and are subject to 20 percent co-insurance after their deductible is met.
To limit out of pocket costs, Original Medicare enrollees often buy a Medigap policy. But Medigap insurers are not required to sell patients a polity unless they are in their initial six-month open enrollment period when the first start Medicare, or if they have certain qualifying life events. Outside of these periods, Medigap insurers can deny coverage to patients switching from Medicare Advantage to Original Medicare or charge them higher rates based on their medical history and preexisting conditions.
Medicare Advantage, also known as Medicare Part C, is an alternative to Original Medicare coverage and is offered by private health insurers. Medicare Advantage Plans include Medicare Parts A and Band often include additional benefits, such as prescription drug coverage, dental, vision and other services not covered by Original Medicare.
A 2024 Brown University study found that Medicare Advantage beneficiaries with greater health needs disenroll at higher rates over time. Experts speculate that the low premium costs and added perks of Medicare Advantage plans initially attract new enrollees, particularly those who are younger and healthier when they first join.
However, the can feel “trapped” in these plans as they become older and sicker and face restricted access to many services and in some cases higher out of pocket costs.
If a patient with chronic health issues wants to leave Medicare Advantage, they may not be able to switch to Original Medicare due to cost concerns. The lead author of the Brown University study said, “Once you get into Medicare Advantage, if you have a couple of chronic condition and you want to leave … even if [it] isn’t meeting your needs, you might not have any ability to switch back to Original Medicare.
In the home health care segment, authorizations for care of patients with Medicare Advantage plans must be obtained from the insurer and may be denied and viewed as “not medically necessary” despite a doctor ordering the care. With Original Medicare, the care ordered by the doctor is provided as long as it meets the CMS guidelines that apply to both Original Medicare and Medicare Advantage.