Original Medicare vs. Medicare Advantage - How Do They Compare?

Navigating the Medicare maze can be overwhelming for beneficiaries. Usually, people qualify for Medicare at age 65 and are automatically signed up if they're receiving Social Security payments unless they take steps to opt-out.

Original Medicare comes in two parts - (Part A and Part B). Part A covers a portion of hospitalization expenses, and Part B applies to doctor bills and other medical costs such as lab tests and preventive screenings. Alternatively, seniors may find better value in a Medicare Advantage (Part C) plan. These plans are offered by private insurance companies regulated by the government, and they must provide coverage comparable to Original Medicare Parts A and B. Most Medicare Advantage plans also include prescription ​drug coverage.

Medicare Advantage plans are similar to individual health insurance policies you may have received through your employer or signed up for on your own through the individual insurance marketplace. They have varying monthly premiums, provider networks, co-pays, coinsurance, and out-of-pocket limits. Most Medicare Advantage plans have a $0 monthly premium, while others come with a monthly premium. You must continue to pay your Part B premium, which is $172 per month for most beneficiaries in 2022.

Whether or not a Medicare Advantage plan costs more, it could be better or worse for you than Original Medicare, depending on your health needs, lifestyle, and budget. You should carefully review the details of each plan and make a choice based on your health, budget, and tolerance for financial risk.

  • Prescription Medications - Original Medicare doesn't cover prescriptions unless you enroll in stand-alone Medicare Part D coverage. (The average monthly cost of Part D will be $33.50 in 2018.) By contrast, about 82 percent of ​​Medicare Advantage plans include prescription drug coverage, according to the Kaiser Family Foundation, a nonprofit, nonpartisan research institute.

  • Out-of-Pocket Costs - Medicare Advantage plans, by law, have an out-of-pocket maximum of no more than $6,700 per year, although programs can choose to have a lower out-of-pocket maximum. Once you hit that limit, the plan pays for all covered expenses. Original Medicare without a supplement has no limit on how much you pay out of pocket. You will continue to pay a portion of the cost for services as you use them.

  • Medical Specialists Under Original Medicare, you don't need authorization from a primary care doctor to see a specialist, whereas Medicare Advantage plans that are designated HMOs could require you to see a primary care doctor first. Preferred Provider Organization (PPO) plans may allow you to see a specialist without a referral, but seeing an out-of-network doctor or specialist would cost you more. Most Medicare Advantage plans are either HMOs or PPOs.

  • Dental and Vision Coverage - Many Medicare Advantage plans have dental and vision coverage. Original Medicare doesn't cover these services so you would have to purchase a stand-alone dental or vision plan at an additional cost.

What's Best for You?

Let's review some of the important points for each Medicare coverage option: With Original Medicare
  • Approximately 80% of your health care costs are covered

  • There is no annual out-of-pocket cap on costs you are responsible for

  • There are no additional premiums to pay

  • You can visit any doctor, hospital, or provider that accepts Medicare

  • Part D prescription drug coverage is not included

  • Routine dental, vision, and hearing coverage are not included

With Medicare Advantage
  • Approximately 80% of your health care costs are covered

  • There are annual out-of-pocket caps on the costs you are responsible for

  • Monthly premiums may be required, although they are usually nominal and sometimes as low as $0 per month

  • You must visit doctors, hospitals or providers that are in the plan's network

  • Many plans include (Part D) prescription drug coverage

  • Many plans cover routine dental, vision, and hearing services

Need Help With The Details?

Rest assured that there are established Advocacy Groups available to help you with your Medicare options. Senior Healthcare Advisors assist thousands of seniors every year to make Medicare choices that are right for them.
The right information at the right time could make all the difference in your Medicare decisions