Decoding Medicare vs. Medicare Advantage: Unraveling the Key Differences

A hot topic in our group is Medicare Advantage and the confusion surrounding it.

It’s ESSENTIAL that you understand the difference AND check your client's eligibility. I have gotten burned many times (and so have a lot of my consulting clients) by assuming a client had traditional Medicare when they did not. So what’s the difference? 

Traditional Medicare: 

• Consists of different parts: Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage plans), and Part D (prescription drug coverage).

• Provides comprehensive coverage for a wide range of medical services and treatments.

• Has a set yearly deductible that is the same for everyone 

• Medicare covers 80% with the other 20% covered by a supplemental plan, Medicaid, or patient responsibility 

• You credential directly with Medicare and bill Medicare directly for your services 

• No prior authorization is needed for psychotherapy 

Medicare Advantage:

• Alternative to traditional Medicare, offered by private insurance companies approved by Medicare.

• Often includes additional benefits beyond original Medicare, such as dental, vision, hearing, and prescription drug coverage.

• Involves networks of doctors and healthcare providers, offering a more coordinated approach to care.

• Each plan is managed by the commercial insurer and in most cases you need to be credentialed with that insurance to bill 

• Each plan has its own separate benefits with different co-pays and deductibles 

• May need a prior authorization for services 

Those are the key differences, and a common mistake people have when billing. I share more in my Medicare Billing Course — grab it here:

And if you’re just starting with Medicare, get the credentialing course here:

Don’t forget to check out my note template to help make your documentation a breeze: