Original Medicare vs Medicare Advantage: A Side-by-Side Comparison

Original Medicare vs. Medicare Advantage: Which one is better? This is a debate we get into all the time here at Local Medicare Specialists. It seems that most people have strong opinions one way or the other. We’d love to be able to give you a direct answer, but unfortunately, it’s not that simple!

Health insurance is never a one-size-fits-all solution and the same is true when it comes to Medicare. One plan isn’t better than another and what works for you might not work for your family or friends. While we can’t give you a simple answer, we can compare both options for you so that you can choose which one works best in your situation.

Today, we’re going to look at the pros and cons of having Original Medicare or Medicare Advantage. We’ll do a side-by-side comparison so that when it’s time to make a decision, you have a clear understanding of your choices. 

What Is Original Medicare?

Original Medicare is a federal program managed by the government. While most beneficiaries are ones who age into the program at age 65, it’s also available to individuals who have long-term disabilities or who have been diagnosed with certain medical conditions. Original Medicare is made of two parts, Part A and Part B.

Part A is also called hospital insurance or inpatient insurance. It covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. Most people don’t pay a premium for Part A because they (or their spouse) paid Medicare taxes while working. However, Part A does still have deductibles and coinsurance costs. For example, the 2023 deductible is $1,600 per benefit period.

Part B is also known as medical insurance or outpatient insurance. It covers healthcare costs like doctor’s visits, surgeries, diagnostic imaging, and preventive care. Unlike Part A, Part B does have a monthly premium, which can vary based on your income. Part B also has an annual deductible and coinsurance costs. Generally speaking, you can expect Part B to pay 80% of covered services.

If you have Original Medicare, it’s important to remember that it doesn’t cover everything. You’ll likely need a separate Part D plan for your prescription coverage, as well as a policy to cover dental, vision, and hearing services. Many people also choose to enroll in a Medicare Supplement plan that acts as a secondary insurance to Parts A and B.

What Is Medicare Advantage?

Medicare Advantage is also called Medicare Part C. You must enroll in both parts of Medicare (A and B) prior to enrolling in Part C. If you decide to enroll in Medicare Advantage, your coverage will work quite differently.

Medicare Advantage plans are offered by private insurance carriers, not the federal government. If you enroll in a Medicare Advantage plan, all your benefits - even the ones provided by Original Medicare - will be provided by the private insurance company instead. 

All Part C plans have at least as many benefits as you’ll find in Original Medicare. However, they typically offer quite a few more perks. For example, you may have dental, vision, and hearing benefits, as well as gym memberships, prescription drug coverage, and transportation options. This is why many people think of Medicare Advantage as an all-in-one alternative to Original Medicare.

Medicare Advantage premiums are usually very low. Most areas of the country even have plans that offer a $0 monthly premium. Keep in mind that a $0 premium doesn’t mean these plans are free. You’ll still have to pay your Part B premium and the Medicare Advantage plan will have cost-sharing amounts that you’re responsible for.

Now that you have an idea of how Original Medicare and Medicare Advantage plans work, let’s do a side-by-side comparison of the two options.

Original Medicare vs. Medicare Advantage

When comparing these two kinds of plans, it’s essential to consider coverage, cost, and flexibility.

Coverage

Original Medicare offers broad coverage for hospital and medical services but does not include coverage for prescription drugs or routine and preventive dental, vision, and hearing care. Medicare Advantage plans, on the other hand, usually wrap all these benefits into one plan. However, understand that every Medicare Advantage plan is different, so you’ll need to check the plan’s summary of benefits to find out what is included in the plans in your area.

Cost

If you only have Original Medicare, you’ll have a Part B premium. In addition, you’ll be responsible for deductibles and copays associated with the treatment you receive. The most notable point here is that Original Medicare has no out-of-pocket limit. Remember how we said Part B pays about 80% of the cost? That may sound wonderful initially, but what if you have a $100,000 surgery? That 20% can add up quickly.

Also, if you have Original Medicare, you’ll likely want to enroll in Medicare Part D, a Medicare Supplement plan, and a Dental, Vision, and Hearing plan. All these premiums may end up costing you several hundred dollars per month.

As we mentioned earlier, Medicare Advantage plans have low monthly premiums and you won’t need multiple policies since they offer comprehensive coverage. While you will still have cost-sharing responsibilities, each plan has a maximum out-of-pocket (MOOP), unlike Original Medicare. This means that even if you have multiple hospital stays or surgeries during the year, you know your cost is capped.

Flexibility

Original Medicare offers a bit more flexibility than Medicare Advantage plans. Under Original Medicare, you can see any provider that accepts Medicare. Since about 96% of providers take Medicare, you’ll have lots of freedom to choose the providers you want.

Medicare Advantage plans rely on a provider network. Depending on what type of Medicare Advantage plan you have, you may or may not have coverage outside of your network. If you are someone who travels frequently, this could be an issue.

In addition, most Part C plans have rules on how you receive care. Some treatments and prescriptions require prior authorization or a process called Step Therapy. This is generally not the case in Original Medicare, allowing you to get the care you need faster.

Choosing between Original Medicare and Medicare Advantage is a personal decision. It’s important that you consider your unique needs and budget to determine which option is better for you. By working with an agent at Local Medicare Specialists, you can get peace of mind knowing you’ve made the right decision. Our team of experts is here to educate you on all things Medicare and help you enroll in the plans you want. Call us today to schedule your consultation.