What are the Pros and Cons of Medicare Advantage vs Original Medicare?
Fact checked Contributing expert: Kelly Blackwell, Certified Senior Advisor - Published: April 20, 2021
When you become eligible for Medicare, you can choose from one of two main ways to get your Medicare coverage. You can opt for Original Medicare (Part A and Part B) or a Medicare Advantage plan (Part C). It is important to weigh the pros and cons of each, taking into consideration your preferences, needs, and budget.
What you should know
- 1 Medicare beneficiaries can choose to get their health care coverage through Original Medicare or a Medicare Advantage plan, and it is important to explore options based on preferences, needs, and budget.
- 2 Original Medicare allows you to see Medicare-approved providers anywhere in the United States, but depending on how much healthcare you need, costs can be unpredictable.
- 3 Medicare Advantage plans offer more benefits and have a limit on out-of-pocket costs, but generally require use of in-network providers and referrals for specialists.
- 4 Original Medicare is a government plan, while Medicare Advantage plans are managed by private insurance companies. In either case, you pay a Part B monthly premium.
Choosing your Medicare coverage is an important decision, so it is helpful to plan ahead and explore the options available to you. Consider the providers you prefer, and the medications you take, as well as your own health history and potential need to access healthcare services. Visit Medicare.gov to compare Medicare health plans that are available in your area. You can explore supplemental (Medigap) and drug coverage plans (Part D) that you may decide to purchase if you choose Original Medicare.
You can also explore and compare Medicare Advantage plans (Part C), which are an alternative to Original Medicare. Medicare Advantage plans offer the same benefits as Medicare Parts A and B, plus other things that are not covered by Original Medicare such as dental, vision, and hearing benefits. Medicare Advantage plans are offered by private insurance companies that have been approved by Medicare. You must have Medicare Part A and Part B in order to enroll in a Medicare Advantage plan.
What is the difference between Original Medicare and Medicare Advantage?
Primary differences between Original Medicare and Medicare Advantage are related to coverage, choice of providers, and costs. You are considered a Medicare beneficiary with the same rights and protections whether you choose Original Medicare or a Medicare Advantage plan. The government administers Original Medicare, and private insurance companies administer Medicare Advantage plans.
Original Medicare includes Part A (hospital insurance) and Part B (medical insurance). If you have Original Medicare, you can choose to purchase Part D (drug coverage) and/or supplemental coverage (Medigap) to help pay for deductibles and coinsurance related to Parts A and B.
A Medicare Advantage Plan bundles Parts A, B, and usually D together and offers other benefits that Original Medicare doesn’t. You cannot have, and do not need, Medigap insurance if you have a Medicare Advantage plan.
Original Medicare is a fee-for-service health plan. Most people get premium-free Part A, but if you access your benefits, you pay a deductible. There is always a monthly premium for Part B. If you access Part B benefits, after you pay your annual deductible, Medicare pays its share of the Medicare approved amount, and you pay your share of the costs in the form of coinsurance.
Medicare Advantage Plans may or may not have a monthly premium (you will still pay the Part B premium) and vary in their cost sharing requirements. For instance, if you are hospitalized or need to see your physician, you typically pay a copay of a set amount or percentage after you pay an annual deductible.
Costs can vary in either case, depending on which type of insurance you choose and how much healthcare you end up needing. Original Medicare Part A has a deductible of $1,484 for in-patient hospitalizations, and daily co-insurance charges that kick in after 60 days;Part B deductible for 2021 is set at $203. There are no out-of-pocket limits with Original Medicare. Medigap and Part D premiums also vary. Medicare Advantage Plans costs vary depending on which type of plan you choose.
Original Medicare allows you to utilize any doctor or hospital in the U.S. that accepts Medicare assignment (that is, accepts the Medicare-approved amount as full payment). Medicare Advantage Plans may require you to receive your healthcare services from providers (including a PCP), hospitals, and pharmacies that are in-network and in your service area. Some plans allow for out-of-network providers, but will cost more. Most likely you will need prior approval for services, supplies, and medications with Medicare Advantage Plans. Original Medicare does not generally require referrals.
What are the pros of Original Medicare?
- You can see any Medicare-approved provider in the United States.
- For most people, Part A is premium-free.
- Referrals for specialists are generally not required.
- The Medicare hospice benefit pays for services you need if you have a terminal illness.
What are the cons of Original Medicare?
- There is no out-of-pocket maximum, so if you access healthcare services without a supplemental policy, your costs are unpredictable.
- No coverage for services such as dental, vision, or hearing
- You must purchase Part D for drug coverage.
- If you purchase a Medigap policy to supplement Part A and B, you pay monthly premiums upfront, whether you access healthcare or not.
What are the pros of Medicare Advantage?
- Access to the same benefits as Medicare Parts A and B, plus more
- Coverage for services such as dental, vision, hearing, and discounts for gym memberships
- Lower front-end costs with monthly premiums that are lower than those associated with Medigap
- Limit on annual out-of-pocket costs, so if you access healthcare, your maximum costs are more predictable
- Because benefits are bundled together, you do not need to purchase separate drug coverage.
- Women have the right to go directly to an in-network women’s specialist without a referral for routine and preventive services.
- There are a variety of types of Medicare Advantage Plans to choose from.
- As your healthcare needs change, or if your Medicare Advantage Plan changes, you have the opportunity to choose a different plan.
What are the cons of Medicare Advantage?
- Restricted service area, which may be an issue if you travel or reside in a different area for part of the year
- The in-network benefit of cost containment can mean limited choice of providers.
- You may have to wait for prior authorizations for medications and treatments, or spend time up-front trying to get advance plan approval.
- You most likely will need a referral prior to seeing a specialist.
- If you had Original Medicare with a Medigap plan previously, then choose a Medicare Advantage plan, it may be difficult to switch back and return to your previous Medigap plan.
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Kelly Blackwell, Certified Senior Advisor (CSA)
Kelly Blackwell is a Certified Senior Advisor (CSA)®. She has been a healthcare professional for over 30 years, with experience working as a bedside nurse and as a Clinical Manager. She has a passion for educating, assisting and advising seniors throughout the healthcare process.