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Original Medicare vs Medicare Advantage


While there are many similarities when it comes to comparing Original Medicare vs Medicare Advantage, both are actually very different. One of the most important decisions a beneficiary has to make is what type of Medicare coverage to enroll in. There are multiple factors to take into consideration. It can be easy to make the wrong choice, a choice that you may not be able to undo. In this post, we’re going to compare Medicare and Medicare Advantage side by side so that you can get a clear understanding of how they both work.

Differences Between Original Medicare vs. Medicare Advantage

Original Medicare

With Original Medicare, your benefits are administered by the federal government. Two parts make up Original Medicare, Part A & Part B. Part A is your hospital coverage, Part B is your medical coverage. Beneficiaries pay into both of these parts throughout their working career in the form of Medicare taxes

Medicare Advantage

With Medicare Advantage, your benefits are managed through a private insurance company instead of the federal government. Medicare pays the Medicare Advantage carrier to administer your benefits for both Part A and Part B, under what’s known as Part C. These private insurance companies must follow the guidelines the federal government sets in place.

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Pros and Cons of Original Medicare vs Medicare Advantage

Now that we’ve explained the basic differences between Original Medicare and Medicare Advantage, let’s go over the pros and cons of each.

Pros of Original Medicare

With Original Medicare, the benefits are identical from person to person. There are no copays, no waiting periods, and no pre-existing condition limitations. There are also no networks. You can see any doctor that accepts Medicare. Any out of pocket costs will remain the same regardless of the provider you choose to receive care from. Your coverage will travel with you across the United States.

Cons of Original Medicare

Both Part A and Part B come with a deductible as well as coinsurance. Another downside is that Original Medicare has no maximum out of pocket; so, you can rack up medical bills with no limit to how much you’re responsible for paying out of pocket. There is also no coverage for prescription drugs.

Pros of Medicare Advantage

In some areas, there are plans with zero-dollar premiums available. Some also have a Part B give back option built-in. They have an out of pocket maximum limit. Medicare Advantage plans can come with additional perks like dental, vision, and hearing benefits. Some plans may even include gym memberships, as well as long-term care benefits. Many Part C plans include coverage for prescription medications.

Cons of Medicare Advantage

With Medicare Advantage, the benefits are different from plan to plan. You still have to pay your Part B premium. The biggest downfall to Medicare Advantage is the limited doctor networks. When you need to see a specialist with a small network, access to care can be more challenging. Another con to Part C plans is the high cost per service. Yes, zero to low premiums are appealing, but when you add the additional out of pocket costs you pay as you use the benefits, some find it’s just not worth it.

Unlike Original Medicare, Part C plans come with annual coverage changes. The plan that works for you now, may not work for you next year. These plans also do not travel with you. Lastly, the Maximum Out Of Pocket limit can still break the bank. 

Now that we went over a few of the pros and cons of both Original Medicare vs Medicare Advantage, let’s compare doctor visits, covered services, and costs a little more in detail.

Doctor Visits

When you have Original Medicare, you can see any doctor or specialist that accepts Medicare. You don’t need a referral to see a specialist either. Since plans don’t change annually, you won’t need to worry about your doctor leaving the plan’s network. 

When you have Medicare Advantage, your coverage will be very similar to your employer group coverage. The majority of them are health maintenance organizations and preferred provider organizations.

You will have a primary care physician that directs all your care. Therefore, you need a referral to see a specialist. Physicians are also able to leave the network of the plan at any time. You could find yourself searching for a new primary care physician at any point of the year without notice. 

Covered Services

With Original Medicare, you have a wide range of medical services that are covered. This includes diagnostic tests, durable medical equipment, outpatient surgery, hospitalization, preventive services, and much more. However Original Medicare does not include coverage for routine dental care, vision, or hearing care. 

With Medicare Advantage, you’ll have coverage for the same services Original Medicare covers. In addition, you could also have coverage for some dental, vision, and hearing care. The downside is you may have trouble finding a dentist, eye care practitioner, or audiologists that accepts Medicare Advantage. And the benefits are very limited. 

Costs

Part A is premium-free for most and comes with a deductible (that’s per benefit period) and coinsurance. Part B has a monthly premium and comes with a 20% coinsurance & annual deductible. Original Medicare does not have any copays.

The biggest misconception with Medicare Advantage is that if you choose this route, you don’t have to pay your Part B premium. This is false. You still have to pay the premium for Part B when you enroll in a Medicare Advantage plan. 

Since each Medicare Advantage plan has different out of pocket costs, it’s challenging to predict how much you’ll spend annually. When you go the Medicare Advantage route, you still pay the Part B premium in addition to any monthly premium your Part C plan comes with. Each carrier determines how much cost-sharing you pay.

Since Medicare pays the Part C carrier to take on your risk, they make money out of the gate. That’s how they can afford to offer plans with zero-premium. Then, they collect money from the beneficiary in the form of cost-sharing.

Which is Better, Original Medicare or Medicare Advantage?

Medicare Advantage plans must offer coverage at least as good as Medicare. But, Original Medicare tends to have more flexibility. Most insurance agents agree that some coverage is better than none, making Medicare Advantage plans a tad better than Original Medicare but not as good as Medigap. 

Medicare Advantage plans do work for some individuals, but not all. They are a good option for those who cannot get a Medigap plan for one reason or another, and those under 65 on disability. If you have a rainy day fund, then a Medicare Advantage plan could work for you as well.

If you’re truly looking for comprehensive coverage, then Medigap would make the most sense in addition to a Part D prescription drug plan. With Part A, Part B, Part D, + a Medigap plan, you’ll never have to worry about the costs of your medical expenses during your retirement years. When you compare Part C vs. Medigap, you’ll see why one is better for some and another is better for others.

FAQs

Can you switch from Medicare Advantage to Original Medicare?
Yes, there are two annual enrollment periods that will allow you to leave your Medicare Advantage plan and go back to Original Medicare. You can make this change during the Annual Enrollment Period and the Medicare Advantage Open Enrollment Period. If you qualify for a Special Enrollment Period, you could also leave your Medicare Advantage plan and go back to Original Medicare.
Do Medicare Advantage plans replace Original Medicare?
Medicare replacement plans are another slang term for Medicare Advantage. You still need to have Medicare to enroll in an Advantage plan, but they call these replacement plans because your Part C carrier handles your claim instead of Medicare.
Do Medicare Advantage plans have deductibles?
Yes, some Medicare Advantage plans do have deductibles, but some do not. It’s on a per plan basis.
What is the downside to Medicare Advantage plans?
The downsides to Medicare Advantage plans include limited doctor networks, annual coverage changes, higher cost-sharing, and they don’t travel with you.
How long has Medicare Advantage been around?
The Medicare Modernization Act was signed by President George W. Bush and enacted in 2003.
Do Medicare Advantage plans pay 100%?
After meeting the MOOP, the Medicare Advantage plan will cover 100% of your medical costs.
Are Medicare Advantage plans worth the risk?
This really depends on your situation but in general, it’s riskier sticking with only Original Medicare since there is no out-of-pocket limit. At least with Medicare Advantage, you have a MOOP. However, all the cons listed above may outweigh the pros if the MOOP is the least of your concerns.
How can Medicare Advantage plans be so cheap?
Advantage carriers are paid by Medicare to manage your healthcare benefits. In addition, they collect money from the enrollee in the form of cost-sharing as the benefits are used. This is how they can afford to have cheaper premiums.
Why are they pushing Medicare Advantage plans?
There has definitely been a push from CMS during the Annual Enrollment Period that steered enrollees towards Medicare Advantage. According to Reuters, CMS did not respond to requests for comment on perceptions that its Advantage promotions lack balance, or who it regards as the target audience. The support from the government around Advantage plans is unclear at this time.
Do you have to pay for Medicare Part B if you have an Advantage plan?
Yes, you still have to pay your Part B premium if you have a Medicare Advantage plan. Some plans to offer a Part B give back benefit, but only in some areas.
Why choose Medicare Advantage over Medicare?
There are many reasons to choose Medicare Advantage over Medicare. While these Part C plans aren’t for everyone, they have proven beneficial to many across the United States. In fact, enrollment has tripled since 2005.

How to Compare Original Medicare and Medicare Advantage Plans

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Lindsay Engle

Lindsay Engle is the Medicare expert for MedicareFAQ. She has been working in the Medicare industry since 2017. She is featured in many publications as well as writes regularly for other expert columns regarding Medicare. You can also find her over on our Medicare Channel on YouTube as well as contributing to our Medicare Community on Facebook.

2 thoughts on “Original Medicare vs Medicare Advantage

  1. with the medicare advantage plan we have, we are allowed a sizeable amount for dental and some for vision. Is it cheaper to have straight medicare with medigap or medicare advantage?

    1. Hi Doris! The monthly premium will always be cheaper with a Medicare Advantage plan. They can afford to charge low to zero premiums since Medicare pays the carrier to take on your risk. However, where you end up paying more is in copays, deductibles, and coinsurance. The carrier chooses how much of each service they want to pay. The dental and vision benefits that come with Medicare Advantage plans are not extensive like they are with stand-alone DVH plans. With Medicare + Medigap, your monthly premiums will be more, but your cost-sharing is significantly lower. You won’t have to pay a copay each time you visit the doctor or any coinsurance. It just depends on when you want to spend the money, upfront in monthly premiums, or risk paying more in cost-sharing as you go.

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