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Understanding Medicare Basics

The individual healthcare marketplace can often feel like a labyrinth, especially when it comes to understanding Medicare and its various options.

At OneDigital Advanced Health, we understand the complexity of the healthcare system and are here to help simplify and guide you through your healthcare journey. Having a better understanding of your options will empower you to make informed decisions when you meet the eligibility requirements and it comes time to enroll.

Understanding Medicare:

Medicare is a federal health insurance program designed for individuals aged 65 and older, as well as certain younger individuals with disabilities or specific medical conditions. It consists of different parts that cover specific services:

  • Medicare Part A: Also known as hospital insurance, Part A helps cover inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care services. Most people don't have to pay a premium for Part A if they or their spouse paid Medicare taxes while working.
  • Medicare Part B: Part B is medical insurance that covers doctors' services, outpatient care, medical supplies, and preventive services. It requires a monthly premium, and the amount may vary depending on your income.
  • Medicare Part C (Medicare Advantage): Medicare Advantage plans, also referred to as Part C, are offered by private insurance companies approved by Medicare, such as OneDigital Advanced Health. These plans combine the benefits of Part A, Part B, and often Part D (prescription drug coverage) into a single plan. Medicare Advantage plans typically provide additional benefits, such as vision, dental, and hearing coverage, and may have lower out-of-pocket costs than Original Medicare.
  • Medicare Part D: Part D is prescription drug coverage offered by private insurance companies approved by Medicare. This coverage helps pay for the cost of prescription medications and varies depending on the specific plan you choose. It is important to note that Part D plans are optional, but if you don't enroll when you're first eligible, you may have to pay a late enrollment penalty.

Medicare Advantage Plans: A Closer Look

Medicare Advantage plans are an alternative to Original Medicare, and they offer comprehensive healthcare coverage. Here are a few key features of Medicare Advantage plans:

  • Network-Based Coverage: Medicare Advantage plans usually have a network of healthcare providers, including doctors, hospitals, and specialists. It's essential to understand the network limitations of each plan and ensure that your preferred providers are included.
  • Additional Benefits: Medicare Advantage plans often provide additional benefits not covered by Original Medicare, such as dental, vision, hearing, and wellness programs. These extra benefits can be a valuable addition to your healthcare coverage.
  • Out-of-Pocket Costs: Medicare Advantage plans typically have out-of-pocket costs, including copayments, coinsurance, and deductibles. However, they also have an annual out-of-pocket maximum, which limits your total expenses for the year and provides financial protection.
  • Prescription Drug Coverage: Many Medicare Advantage plans include prescription drug coverage (Part D) within their offerings. This eliminates the need for a separate prescription drug plan, streamlining your coverage and simplifying administration.

Comparing Original Medicare & Medicare Advantage

Consider these things when deciding between Original Medicare and a Medicare Advantage Plan for your health coverage:

Doctor & Hospital Choice

Original Medicare Medicare Advantage
You can go to any doctor or hospital that takes Medicare, anywhere in the U.S. In many cases, you'll need to only use doctors and other providers who are in the plan's network (for non- emergency care). Some plans offer non-emergency coverage out of network, but typically at a higher cost.
In most cases you don't need a referral to see a specialist. You may need to get a referral to see a specialist.


Original Medicare Medicare Advantage
For Part B-covered services, you usually pay 20% of the Medicare-approved amount after you meet your deductible. This is called your coinsurance. Out-of-pocket costs vary - plans may have different out-of-pocket costs for certain services.
You pay a premium (monthly payment) for Part B. If you choose to join a Medicare drug plan, you'll pay a separate premium for your Medicare drug coverage (Part D). You pay the monthly Part B premium and may also have to pay the plan's premium. Plans may have a $0 premium and may help pay all or part of your Part B premium. Most plans include Medicare drug coverage (Part D).
There's no yearly limit on what you pay out-of-pocket. unless you have supplemental coverage – like Medicare Supplement Insurance (Medigap). Plans have a yearly limit on what you pay out of pocket for services Medicare Part A and Part B covers. Once you reach your plan's limit, you'll pay nothing for services Part A and Part B covers for the rest of the year.
You can get Medigap to help pay your remaining out-of-pocket costs (like your 20% coinsurance). Or, you can use coverage from a former employer or union, or Medicaid. You can't buy and don't need Medigap.


Original Medicare Medicare Advantage
Original Medicare covers most medically necessary services and supplies in hospitals, doctors' offices, and other health care facilities. Original Medicare doesn't cover some benefits like eye exams, most dental care, and routine exams. Plans must cover all of the medically necessary services that Original Medicare covers. Most plans offer extra benefits that Original Medicare doesn't cover - like some routine exams and vision, hearing, and dental services.
You can join a separate Medicare drug plan to get Medicare drug coverage (Part D). Medicare drug coverage (Part D) is included in most plans. In most types of Medicare Advantage Plans, you can't join a separate Medicare drug plan.
In most cases, you don't have to get a service or supply approved ahead of time for Original Medicare to cover it. In some cases, you have to get a service or supply approved ahead of time for the plan to cover it.

Foreign Travel

Original Medicare Medicare Advantage
Original Medicare generally doesn't cover care outside the U.S. You may be able to buy a Medicare Supplement Insurance (Medigap) policy that covers emergency care cutside the U.S. Plans generally don't cover care outside the U.S. Some plans may offer a supplemental benefit that covers emergency and urgently needed services when traveling outside the U.S.

Your Team of Advocates

Understanding Medicare and Medicare Advantage plans can be overwhelming, but you don't have to navigate this journey alone. At OneDigital, we're committed to simplifying the complex world of healthcare and helping you make informed decisions. Our team of knowledgeable advisors can guide you through the process, answer your questions, and ensure you find the coverage that best suits your needs.

Ready to enroll? Contact a member of the OneDigital Advanced Health Team to understand your options and begin the enrollment process.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact or 1-800-MEDICARE to get information on all of your options.