Medicare vs. Medicare Advantage
Medicare vs. Medicare Advantage (Part C)
Understanding the difference between Original Medicare and Medicare Advantage can help you choose the coverage that best fits your healthcare needs and budget.
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Original Medicare (Part A & Part B)
Original Medicare is coverage provided directly by the federal government.
Includes:
• Part A – Hospital coverage
• Part B – Medical and outpatient coverage
How it works:
• You can see any doctor or hospital in the U.S. that accepts Medicare
• No provider networks
• You generally pay deductibles and 20% coinsurance
• There is no annual out-of-pocket maximum
Does not include:
• Prescription drug coverage (Part D is separate)
• Routine dental, vision, or hearing services
• Extra benefits
Many people add:
• A Medigap (Supplement) plan to help with costs
• A Part D prescription drug plan
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Medicare Advantage (Part C)
Medicare Advantage plans are offered by private insurance companies approved by Medicare and replace Original Medicare for how your benefits are delivered.
Includes:
• At least the same Medicare-covered services as Part A and Part B
• Most plans include prescription drug coverage (Part D)
Often includes extra benefits such as:
• Dental, vision, and hearing
• Fitness memberships
• Over-the-counter (OTC) allowances
• Transportation to medical appointments
• Meal benefits (for eligible members)
• Healthy food and grocery benefits (for those who qualify)
How it works:
• Uses provider networks (HMO or PPO)
• Many plans offer low or $0 monthly premiums
• Includes an annual Maximum Out-of-Pocket (MOOP) limit
• Coverage rules and benefits vary by plan and location
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How the MOOP Works in a Medicare Advantage Plan
MOOP stands for Maximum Out-of-Pocket. It is the most you will pay in copays and coinsurance for covered medical services in a calendar year.
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What Counts Toward the MOOP
• Doctor visit copays
• Specialist copays
• Hospital stays (daily copays)
• Outpatient procedures and surgeries
• Lab work, imaging, and diagnostic tests
• Emergency and urgent care
👉 MOOP does NOT include:
• Monthly plan premiums
• Prescription drug costs
• Non-covered services
• Dental, vision, or hearing services (unless stated by the plan)
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How the Money Comes Out of Your Pocket
• You do not pay the MOOP all at once
• Costs are paid gradually as you receive care
How it happens in real life:
• Each time you see a doctor, have a test, or are admitted to the hospital, you pay a copay or coinsurance
• Those amounts add up toward your MOOP over the year
• Once the MOOP is reached, the plan pays 100% of covered medical services for the rest of the year
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Simple Example (Easy to Understand)
MOOP: $5,000
How MOOP Accumulates Over Time:
• January: Doctor visits → $40
• March: Specialist visits → $120
• June: Outpatient surgery → $300
• August: Two-day hospital stay → $650
👉 Total paid so far: $1,110
Later in the year:
• One more covered medical service → $140
👉 New total paid: $1,250
Since the plan’s MOOP is $5,000, you still have $3,750 remaining before the MOOP is met.
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What Happens Next
• Your out-of-pocket costs continue to add up as you use covered medical services
• Once your costs reach $5,000, you have met the plan’s MOOP
• After that, the plan covers 100% of Medicare-covered medical services for the rest of the year
• The MOOP resets each calendar year and does not roll over
✔️ After the MOOP is reached, you pay $0 for covered medical services for the remainder of the year.
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Why This Matters for Veterans
• If you mostly use VA care, you may rarely pay toward the MOOP
• If you use non-VA doctors, costs can add up slowly or quickly depending on services
• MOOP protects you from unlimited medical bills, but only after it is reached
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Short Version
Do I pay the MOOP all at once?
No. You pay copays and coinsurance as you receive care. Those costs add up over time until the MOOP is reached.
MOOP applies only to covered medical services and does not include premiums, prescription drug costs, or non-covered services. Amounts vary by plan and location.
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Key Differences at a Glance (Plain Language)
• Original Medicare: Nationwide access, fewer rules, fewer extras
• Medicare Advantage: Bundled coverage, extra benefits, cost protections, network-based care
Neither option is “better” for everyone. The right choice depends on your health needs, doctors, prescriptions, travel habits, and budget.
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Need Help Choosing?
Choosing between Original Medicare and Medicare Advantage can be confusing.
I help explain your options clearly so you can make an informed decision — with no pressure.
Anthony’s Healthcare – Your Medicare Guide
Education only. No obligation.
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Important Information & Disclosure
Anthony’s Healthcare provides Medicare education and guidance only. We are not affiliated with or endorsed by the U.S. government or the federal Medicare program.
Medicare Advantage (Part C) plans and Prescription Drug Plans (Part D) are offered by private insurance companies that are approved and regulated by Medicare. Coverage, premiums, deductibles, copayments, coinsurance, provider networks, formularies, service areas, and extra benefits may vary by plan, carrier, county, and contract year and are subject to change.
Extra benefits such as dental, vision, hearing, fitness programs, transportation, over-the-counter allowances, food or grocery benefits, meals, and in-home services are not guaranteed and may have limitations or eligibility requirements.
Information provided on this website is for educational purposes only and does not guarantee eligibility, coverage, benefits, or enrollment. Enrollment is subject to eligibility requirements, enrollment periods, plan availability, and contract renewal with Medicare.