Does Original Medicare Have a Network?

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Hi Toni,

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I am turning 65 this August, and I have no idea what I should do. I have coronary heart disease. I am currently on a COBRA policy from my former employer. Right now, all of my medical bills are being paid because I have met my deductible. Well, now I’m concerned about how I should handle Medicare enrollment because my heart specialist says that one of my options to improve my health is to have a transplant. Should I enroll in Original Medicare and get a supplement, enroll in an advantage plan, or stay with my COBRA plan until it ends?

Jeremy, from Tulsa, OK

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Hello Jeremy,

I have great news for you and the Toni Says® readers. There is NO network of hospitals, doctors, or any medical providers for Original Medicare.

I repeat…NO NETWORK!

Not having to worry about finding a network provider or facility is hard to understand for those leaving employer benefits.

Your medical provider must be willing to bill Medicare. How easy is that? There are medical facilities, doctors, and providers available nationwide. This means if you are traveling throughout the US and need medical care, you are covered.

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Recently, I had a phone call from a frantic daughter, who was trying to help her father, who had been diagnosed with pancreatic cancer.

He had chosen a Medicare Advantage HMO when he turned 65. Now, her father must wait until Medicare’s Annual Enrollment Period in the fall to make a change back to Original Medicare because the cancer facility he is using is not in that Advantage plan’s HMO network.

Her father is locked into his Advantage plan and must wait until October 15^th through December 7^th (the Annual Enrollment Period) to make any changes back to Original Medicare for the following year. Fortunately, you don’t have to worry about this, Jeremy. Because you’re turning 65 in August, there’s an enrollment time called Medicare Supplement/Medigap Open Enrollment Period.

As I have said before, this is the best time for someone to purchase a Medicare supplement.

The Medicare Supplement/Medigap open enrollment period lasts for 6 months beginning the first day of the month in which you are 65 or older and have just enrolled in Medicare Part B for the first time.

During this Medicare open enrollment period, you may enroll in a Medicare Supplement and not have to answer “ONE” health question to be accepted by a Medicare Supplement insurance plan. If you decide not to keep your COBRA plan and enroll in a Medicare Supplement, you do not have to worry about your medical care being taken care of because you are in your 6-month Medicare Supplement/Medigap Open Enrollment Period.

⚠️ You should be aware that after the 6-month window, you will have to submit a completed underwritten application answering health questions for a Medicare Supplement to be approved. ⚠️

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I have been advised by healthcare professionals that some of the newest healthcare procedures are not readily approved by Medicare Advantage plans. These procedures are generally approved with Original Medicare, as well as clinical trial prescription drugs that can be rather costly. Jeremy, talk to your medical professional who knows your health situation when you are trying to make your Medicare plan choice.

Original Medicare versus Medicare Advantage

Category	Original Medicare	Medicare Advantage
Doctor & Hospital Choice	-You can go to any doctor or hospital that takes Medicare, anywhere in the U.S. -In most cases, you don’t need a referral to see a specialist.	-In many cases, you can only use doctors and providers within the plan’s network and service area (for non-emergency care). -You may need to get a referral to see a specialist.
Cost	-For Part B-covered services, you usually pay 20% of the Medicare-approved amount after meeting your deductible. -You pay the monthly premium for Part B. If you join a Medicare drug plan, you’ll pay a separate premium for drug coverage (Part D). -There’s no yearly limit on out-of-pocket costs, unless you have supplemental coverage (e.g., Medigap, Medicaid, employer, retiree, or union coverage). -You can buy Medigap to help cover out-of-pocket costs that Medicare doesn’t cover, or rely on employer or Medicaid.	-Out-of-pocket costs vary. Plans may have different out-of-pocket costs for certain services. -You pay the monthly Part B premium and may also have to pay the plan’s premium. Some plans may have a $0 premium and may help cover all or part of your Part B premium. -Plans have a yearly limit for covered Part A and Part B services, with separate limits for in-network and out-of-network services. Once you reach the limit, you pay nothing. -You cannot buy Medigap to cover out-of-pocket costs.
Coverage	-Covers most medically necessary services and supplies in hospitals, doctors’ offices, and other healthcare facilities. -Original Medicare doesn’t cover some services like routine physical exams, eye exams, and most dental care. -You generally don’t need prior authorization for Medicare to cover services or supplies. -You can join a separate Medicare drug plan for drug coverage (Part D).	-Plans must cover all medically necessary services that Original Medicare covers but may use their own criteria to determine medical necessity. -Plans may offer extra benefits not covered by Original Medicare. -You may need prior authorization from your plan for certain services or supplies. -Most plans include Medicare drug coverage (Part D). Many plans don’t allow you to join a separate Medicare drug plan.
Foreign Travel	Generally doesn’t cover medical care outside the U.S. You may buy a Medigap policy to cover emergency care outside the U.S.	Plans generally don’t cover medical care outside the U.S., though some may offer emergency or urgently needed care when traveling abroad.

_{^{Courtesy of Medicare.gov; for more information, visit www.medicare.gov/basics/get-started-with-medicare/get-more-coverage/your-coverage-options/compare-original-medicare-medicare-advantage}}