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Original Medicare vs. Medicare Advantage


When comparing Original Medicare vs. Medicare Advantage, you find that both options provide similar coverage. However, they are ultimately very different.

One of the most important decisions a Medicare beneficiary makes is the type of Medicare coverage in which they enroll. There are multiple factors to consider when enrolling in a Medicare plan.

Thus, it can be easy to make the wrong choice – a choice that you may not easily be able to undo. In this article, we compare Original Medicare vs. Medicare Advantage, side-by-side, so you can understand how each works.

Differences Between Original Medicare vs. Medicare Advantage

Original Medicare is made up of Medicare Part A and Medicare Part B. When you have Original Medicare, the federal government administers your benefits. Medicare Part A covers hospital benefits and Medicare Part B is your medical coverage. Beneficiaries pay into Original Medicare throughout their working career in the form of Medicare taxes.

On the other hand, with Medicare Advantage, private insurance companies manage benefits. Medicare pays the carrier to administer your benefits under Medicare Part C (Medicare Advantage).

These private insurance companies must follow the guidelines the federal government sets. However, the companies can set their own prices, deductibles, and additional benefits.

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Pros of Original Medicare

Every person who has Original Medicare receives identical benefits. There are no networks, no copays, no waiting periods, and no pre-existing condition limitations. You can see any doctor that accepts Medicare, and any out-of-pocket costs remain the same, regardless of the provider from whom you receive care.

Additionally, your coverage will travel with you across the United States. So, if you live in California, your coverage remains the same if you travel to Ohio, New Jersey, or even Florida. Regardless of which state you are in, Original Medicare coverage does not change.

Cons of Original Medicare

When you enroll in Original Medicare, you are responsible for the Medicare Part B premium, Medicare Part A and Part B deductibles, and Medicare Part A and Part B coinsurances. With these costs, there is no out-of-pocket maximum for Original Medicare.

Alongside the out-of-pocket costs, another con is that Original Medicare does not provide additional benefits. These include dental, vision, hearing, and drug coverage. If you require this coverage, you will have to seek additional policies.

Pros of Medicare Advantage

Some Medicare Advantage plans offer zero-dollar premiums or a Part B give back option. Additionally, all Medicare Advantage plans have a maximum-out-of-pocket limit. This means the plan will completely cover your medical costs after you meet a certain out of-pocket threshold.

Medicare Advantage plans can also come with additional perks like dental, vision, and hearing benefits. Some plans may even include gym memberships, as well as long-term care benefits. Lastly, most Medicare Part C plans include coverage for prescription medications.

Cons of Medicare Advantage

Medicare Advantage benefits vary from plan to plan. Further, you still must pay your Medicare Part B premium.

Yet, the biggest downfall to Medicare Advantage is the limited provider networks. When you need to see a specialist with a small network, access to care can be more challenging.

Another con of Medicare Advantage plans is the high cost per service. While low to zero-dollar premiums are appealing, the out-of-pocket costs you pay as you use the benefits may lead you conclude that your Medicare Advantage plan is just not worth it.

Unlike Original Medicare, Medicare Advantage plans come with annual coverage changes. The plan that works for you now may not work for you next year. So, you constantly have to be on top of your benefits to ensure you are on the right plan.

These plans also do not travel with you. Meaning, if you plan on traveling in your retirement, you will need to find other coverage options.

Lastly, although there is a maximum out-of-pocket limit, you can still end up paying thousands of dollars per year on your health care.

Original Medicare vs. Medicare Advantage: Covered Services

When you have Original Medicare, you can see any doctor or specialist that accepts Medicare. You do not need to obtain a referral to see a specialist. Additionally, because plans do not change annually, you will not 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.

Often, on a Medicare Advantage plan you will have a primary care physician that directs all your care. Therefore, you need a referral to see a specialist.

On top of this, physicians can leave the plan’s network at any time. You could find yourself searching for a new primary care physician at any point of the year without notice.

With Original Medicare, you receive coverage for a wide range of medical services. These include 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 will have coverage for the same services as Original Medicare. In addition, you can receive coverage for some dental, vision, and hearing care, or even prescription drug coverage. The downside is you may have trouble finding a dentist, eye care practitioner, or audiologist that accepts your Medicare Advantage plan.

Original Medicare vs. Medicare Advantage Costs

Original Medicare and Medicare Advantage plans cover similar benefits but come at very different costs. With Original Medicare, every beneficiary pays the same amount for the same services. With Medicare Advantage, each plan has different costs that can change each year.

Below, Henry is trying to decide between enrolling in a Medicare Supplement Plan G or a Medicare Advantage HMO plan. After comparing his out-of-pocket costs for the same medical bill, Henry notices that the Medicare Supplement Plan G saves him the most money in the long run. 

Medicare Supplement Plan G vs Medicare Advantage HMO

Which is Better: Original Medicare or Medicare Advantage?

Medicare Advantage plans must offer coverage at least as good as Original Medicare. Yet, Original Medicare tends to have more flexibility.

Most insurance agents agree that some coverage is better than none. This makes Medicare Advantage plans a tad better than Original Medicare but not as good as Medicare Supplements, which pair with your Original Medicare coverage. Keep in mind that you cannot have both a Medicare Advantage plan and a Medicare Supplement plan at the same time.

Medicare Advantage plans work for some individuals’ needs, but they do not work well for all beneficiaries. They are a good option for those who cannot get a Medicare Supplement plan or for those under 65 on disability.

FAQs

Can you switch from Medicare Advantage to Original Medicare?
Yes, there are two enrollment periods throughout the year that allow you to leave your Medicare Advantage plan and return to Original Medicare. You can make this change during the Annual Enrollment Period and the Medicare Advantage Open Enrollment Period.
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 maximum out-of-pocket limit, your Medicare Advantage plan will cover 100% of your medical costs.
How can Medicare Advantage plans be so cheap?
Medicare pays private insurance companies offering Medicare Advantage plans to manage your health care benefits. In addition, they collect money from enrollees in the form of cost-sharing as they use their benefits. This is how they can afford to have lower premiums.
Do you have to pay for Medicare Part B if you have a Medicare Advantage plan?
Yes, you still have to pay your Medicare Part B premium if you have a Medicare Advantage plan. Some plans offer a Medicare Part B give back benefit, but only in certain areas.

How to Compare Original Medicare and Medicare Advantage Plans

Here at MedicareFAQ, we understand how overwhelming Medicare can be. That is why we dedicate our time to being your ultimate Medicare resource center. Instead of calling each company to find a quote, you can call us, and we will walk you through everything you need to know.

We can even help you sign up for the policy that makes the most sense for you. If you are unsure about which option provides you with the most value, contact one of our agents at the phone number above. Or, you can fill out an online rate form to get your rates now.

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Sources:

  1. Medicare Advantage Plans, Medicare. Accessed March 2022.
    https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/medicare-advantage-plans
  2. Medicare Advantage 2022, KFF. Accessed March 2022.
    https://www.kff.org/medicare/issue-brief/medicare-advantage-2022-spotlight-first-look/
  3. Original Medicare Enrollment and Eligibility, CMS. Accessed March 2022.
    https://www.cms.gov/medicare/eligibility-and-enrollment/origmedicarepartabeligenrol

Jagger Esch

Jagger Esch is the Medicare expert for MedicareFAQ and the founder, president, and CEO of Elite Insurance Partners and MedicareFAQ.com. Since the inception of his first company in 2012, he has been dedicated to helping those eligible for Medicare by providing them with resources to educate themselves on all their Medicare options. He is featured in many publications as well as writes regularly for other expert columns regarding Medicare.

4 thoughts on “Original Medicare vs. Medicare Advantage

  1. Your presentation fails to note that original Medicare out-of-pocket costs can be eliminated by purchasing a medigap (spplement) policy. While the zero premium of MA is enticing to many, if you actually use the plan you can have OOP expenses of around $7,000/each year.

  2. 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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