Original Medicare vs. Medicare Advantage | Everdays

Original Medicare vs. Medicare Advantage: Compare and Make an Informed Choice

When you become eligible for Medicare, it can be challenging to choose between Original Medicare vs Medicare Advantage. What is the difference between Original Medicare and Medicare Advantage? Will one of these choices benefit you more than the other? What is the best choice between Original Medicare and Medicare Advantage plan?


In this guide, we’ll answer these questions and more so that you can make an informed choice about the future of your healthcare. We’ll take a look at what defines Original Medicare vs Medicare Advantage. We’ll pinpoint specific differences that could be the deciding factor between the two for you. We’ll break down what each form of health insurance covers as well as the different types of Medicare Advantage plans that are available for you to choose from. Finally, we’ll give you some advice on how to decide between the two healthcare insurance choices so you can make your decision with ease.


Americans have choices, with over 50 different plans to choose from in most cases. This is good news because it means you’re more likely to find a plan that is tailor-made for your specific situation. But before you can identify that plan, there are numerous factors to consider.


So, if you’re trying to decide between Original Medicare vs Medicare Advantage but struggling to find the information you need to make that decision, keep reading. Let’s jump into the comparison between Original Medicare and Medicare Advantage.

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What is Original Medicare?

Original Medicare is also referred to as Medicare Part A and Medicare Part B. These two parts combined make up the default Medicare option that you are automatically enrolled in if you are collecting Social Security and have turned 65. Medicare Part A covers inpatient and hospital care and Medicare Part B covers outpatient care, doctor’s visits as well as preventative care and its associated costs. Medicare Part B comes with a monthly premium for everyone but, if you’ve worked at a job that paid into Social Security for at least 40 calendar quarters, Part A is premium free.


Both parts of Original Medicare have deductibles and copays, while Part B has coinsurance. Original Medicare does not cover routine vision, dental, hearing care or prescription drugs.


When you are insured with Original Medicare, you can choose any doctor anywhere in the United States that accepts Medicare.


Coverage for Original Medicare is provided by the federal government. For most, eligibility for Medicare Parts A and B begins at age 65.

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What is Medicare Advantage?

Medicare Advantage is also known as Medicare Part C and includes everything that Medicare Part A and Part B cover. It also includes some additional coverage which may include vision, dental, hearing, and prescription drugs. The coverage you end up with depends on what plans are available in your area and which plan you end up choosing.


Medicare Advantage plans are provided by private insurance companies but are approved by Medicare. Like Original Medicare, you are eligible when you turn 65. Some plans are premium free, while other Medicare Advantage plans come with affordable premiums.


There are several different types of Medicare Advantage plans, including Health Maintenance Organization Plans, Preferred Provider Organizations Plans, Private Fee-For-Service Plans, Medical Savings Account Plans, and Special Needs Plans. Let's take a closer look at what each of these means and what kind of coverage they offer.


Health Maintenance Organization (HMO) Plans

A Health Maintenance Organization or HMO plan is a type of plan organized around a network of doctors, health care professionals, and hospitals. These doctors, health care providers and hospitals enter into a contract with the insurance provider for that particular HMO plan that ensures they will provide healthcare services to the plan’s members and will be paid by the insurer. Beneficiaries with this plan must seek medical attention from doctors and other health care providers within this network in order for their healthcare coverage to be valid. Otherwise, they will have to pay for services out-of-pocket.


With an HMO Medicare Advantage plan, you will need to seek a referral from your general practitioner in order to be able to see a specialist of any kind and have those services covered.


HMOs may not be the best choice for those unwilling to part with their existing out-of-network doctor, but for those who are willing, they will have to choose their family doctor from within the network.


HMO plans can cover prescription drug costs if you’ve chosen a plan with that coverage. Additionally, you may be able to select an HMO plan with an out-of-network benefit in order to cover some of the costs of out-of-network care.


Preferred Provider Organization (PPO) Plans

Preferred Provider Organization Plans are Medicare Advantage plans that also work with a network of healthcare providers but they give their members the ability to seek care outside of the network and still have those services covered. This option usually results in a plan that costs more than an HMO plan, but may save you money if you need to seek care outside of your network. You may even be able to choose a family doctor or general practitioner from out of network in exchange for higher premiums.


The name comes from the idea that the plan has “preferred” providers, which means that there is cost incentive for choosing the plan’s preferred doctors, hospitals and other healthcare providers.


Many PPO plans include prescription drug coverage.


Private Fee-For-Service (PFFS) Plans

Private Fee-For-Service plans are a type of Medicare Advantage plan that also works with a network of doctors, hospitals and other healthcare providers. However, you can also see any Medicare-approved doctor who agrees to accept your PFFS plan. This can be risky because the doctor has the right to refuse to accept your plan at any visit, in which case they won’t treat you outside of emergency situations. Therefore, choosing a network doctor is the best bet if you’re insured with a PFFS plan.


If you choose an out-of-network doctor or hospital, it may cost you more. You are also able to see any specialist you need to without a referral from your general practitioner.


A PFFS plan determines how much you will pay when you seek medical care and your healthcare provider will only be able to bill you for the plan-approved costs.


These plans don’t always cover prescription drugs costs but if not, you can buy Medicare Part D for your prescription drug coverage.


Medical Savings Account (MSA) Plans

A Medical Savings Account plan is a type of Medicare Advantage plan that is connected to a medical savings account. Similar to a health savings account not associated with Medicare, your MSA plan is a high deductible plan connected to a medical savings account with which the insured individual will save to pay for medical expenses. Your MSA plan will deposit money into your MSA account so you can use it to pay for your healthcare costs that are incurred before you meet the high deductible as well as medical expenses not covered by your plan. Once you reach your deductible, the plan will cover your health care costs.


As part of your enrollment for this plan, you will be asked to set up a savings account at a financial institution chosen by the MSA plan provider. You will not be able to deposit your own money into this account. Instead, Medicare gives money to your plan which is then deposited into the account for medical expenses.


MSA plans don’t use networks, so you can get care from any doctor or healthcare provider who accepts Medicare. MSA plans also do not cover prescription drug costs.


Special Needs Plan (SNP)

Special Needs Plans are Medicare Advantage plans that are specifically designed for people who have an existing condition or a low enough income. As a beneficiary of this type of Medicare Advantage plan, you’ll have a plan that is especially suited to the needs of your particular condition. You’ll have access to the drugs and care providers that benefit your specific needs. That means your plan will offer care from specialists who treat your condition.


Your plan will be more like an HMO in that you will be encouraged to seek care from within the plan’s network. You will likely need a primary care doctor.


Your coverage will include everything in Medicare Part A and B as well as additional services required by your specific condition and its needs.


You must meet certain conditions in order to be eligible for an SNP plan. First, you must live in the area that the SNP plan serves, and second, you must meet one of the following requirements:

  1. If you suffer from a chronic illness including:
    • Chronic alcohol and other dependence
    • Autoimmune disorders
    • Cancer (excluding pre-cancer conditions)
    • Cardiovascular disorders
    • Chronic heart failure
    • Dementia
    • Diabetes mellitus
    • End-stage liver disease
    • End-Stage Renal Disease (ESRD) requiring dialysis (any mode of dialysis)
    • Severe hematologic disorders
    • HIV/AIDS
    • Chronic lung disorders
    • Chronic and disabling mental health conditions
    • Neurologic disorders
    • Stroke
  2. If you reside in a long-term care facility or require in-home medical care.
  3. If you are eligible for both Medicare and Medicaid.

SNPs are required to have some coverage for prescription drug costs, usually with a focus on drugs associated with your condition.

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The Biggest Differences Between Original Medicare and Medicare Advantage

Original Medicare and Medicare Advantage both cover a lot of the same healthcare costs and expenses. There is a big difference between Medicare Advantage and Original Medicare, though. In fact, there are several significant differences between the two types of Medicare coverage. These differences are going to help you decide which one is best suited to you and your specific health needs. When we compare Original Medicare and Medicare Advantage plans, the main differences that stand out include the choice you’re given with regards to which doctors and hospitals you can seek care from. There is also a cost difference between Original Medicare and Medicare Advantage plans. The services and treatment you’re covered for differ between the two types of coverage. You will also notice that Original Medicare and Medicare Advantage differ when it comes to travel coverage.


Let’s take a closer look at each of these main differences between Original Medicare and Medicare Advantage.


Provider and Hospital Choice

As many Medicare Advantage plans are HMOs, there is a good chance your coverage will extend only to doctors, hospitals, and healthcare providers who are in your plan’s network. Original Medicare, however, lets you choose doctors and hospitals anywhere in the United States who accept Medicare. Let’s illustrate the differences here:

Original Medicare

Medicare Advantage

Doctor Choice

You may choose any doctor that accepts Medicare.

Most Medicare Advantage plans limit your doctor choices to those that are in-network.

Specialist Referrals

Most of the time, you will not need a referral from your doctor to see a specialist.

You are likely to need a referral to see a specialist.

If you have a family doctor and you’re unwilling to switch, you may find that Original Medicare is a better choice for you.


Costs

When we compare Original Medicare and Medicare Advantage costs, we see a lot of differences. From coinsurance and deductibles to premiums and out-of-pocket limits, these differences can add up to a lot of money, depending on your coverage needs. Here’s a quick and easy illustration of those cost differences between the two types of Medicare coverage:

Original Medicare

Medicare Advantage

Coinsurance

You will have to cover 20% of the Medicare-approved amount for services covered by Medicare Part B.

Coinsurance for Medicare Advantage plans depends on the plan.

Deductible

You will have to pay a deductible.

Deductibles are different depending on the Medicare Advantage plan.

Premiums

Plan A is premium-free for most people and Part B requires a monthly premium.

You will pay your monthly Part B premium as well as your Medicare Advantage plan premium, although some Medicare Advantage plans have no premium at all.

Out-of-Pocket Limits

Both Medicare Part and Medicare Part B have no limit on out-of-pocket expenses.

Medicare Advantage plans have yearly limits on out-of-pocket expenses associated with services covered by Medicare Part A and Part B.

Medigap

You can buy Medigap insurance to cover your out-of-pocket costs associated with Original Medicare.

You can’t buy Medigap, but you will not need it.

Benefits and Coverage

The extent of the coverage in each type of Medicare plan may be the biggest difference in Original Medicare and Medicare Advantage. With Medicare Advantage, you’re likely to have some level of coverage for things like dental, vision, and hearing. You’re also likely to have prescription drug coverage included in your Part C plan. However, your insurance provider for your Medicare Advantage plan may require you to seek approval before certain services or treatments in order for them to be covered. Here’s a quick outline of the major differences in coverage when we compare Original Medicare to Medicare Advantage.

Original Medicare

Medicare Advantage

Healthcare Coverage

Original Medicare covers all that is deemed medically necessary, which does not include vision, dental, or hearing in most cases.

Medicare Advantage plans cover everything covered by Original Medicare. They may include additional coverage for things like vision, dental, and hearing. Your coverage will depend on the plans that are available in your area and the plan that you choose.

Prescription Drugs

You will have to purchase additional coverage to have prescription drug costs covered.

Most Medicare Advantage plans cover prescription drug costs.

Approval for Services

You do not need to get approval for treatment prior to receiving it.

You may have to get approval from your insurance provider for some services or treatments before you receive them.

Location, Travel, and International Coverage

When comparing coverage for travel and different locations, the difference between Original Medicare and Medicare Advantage boils down to three main points:

  1. While Medicare Advantage plans often require the beneficiary to stick to treatment and doctors in their plan’s network, Original Medicare allows you to choose any healthcare provider in the United States that accepts Medicare.
  2. Original Medicare will not cover travel emergencies outside of the United States but most Medicare Advantage plans will.
  3. Neither Original Medicare nor Medicare Advantage offer international healthcare coverage, but you may be able to choose supplementary benefits for your Medicare Advantage plan.

Here’s an illustration of these differences:

Original Medicare

Medicare Advantage

Out-of-State Coverage

You can choose any doctor in the US that accepts Medicare.

You must stick to providers in your plan’s network, which may not extend outside of your state.

Travel Emergency

Original Medicare will not cover you while you travel outside of the US.

Most Medicare Advantage plans will cover emergencies that happen while traveling.

International Healthcare Coverage

Original Medicare doesn’t cover treatment you may receive outside of the US.

Most plans don’t offer international healthcare coverage. Whether or not you can choose a supplemental benefit that offers this coverage is dependent on what plans are available in your area as well as which plan you choose.

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Original Medicare vs. Medicare Advantage: Which Should You Choose?

For those trying to choose between Original Medicare and Medicare Advantage, wondering which is the best choice, the answer isn’t always the same for every individual. The best choice for your healthcare coverage is going to depend on a lot of factors that are different for every American.


Medicare Advantage plans offer many more options than Original Medicare does, including coverage for vision, dental, hearing, and prescription drugs. However, Original Medicare is more flexible when it comes to the choice of doctors, hospitals, and your location.


With Original Medicare, you will have to enroll in four different parts in order to cover all of your bases. You’ll need Part A for inpatient care, Part B for doctor’s visits, Part D for prescription drug coverage, and Medigap to fill the gaps in your coverage. Medicare Advantage, of course, has the ability to offer all of the same coverage with one plan. That can make paperwork and filing claims much easier with Medicare Advantage.


There are definite advantages to choosing Medicare Advantage but there are also plenty of benefits when you choose Original Medicare as well. In order to determine which choice is better for you, here are some of the key factors to consider:

  • Choice of healthcare providers - If choosing your doctor is important to you, which can be the case when you have a family doctor already and you don’t want to switch, then Original Medicare is probably your best choice if they aren’t a part of the Medicare Advantage plan network you’re considering.
  • Dental/Vision/Hearing - if coverage for routine dental, hearing and vision care is at the top of your priority list, you might choose a Medicare Advantage plan that includes this coverage.
  • Prescription drug coverage - if you’re looking for a plan that will cover prescriptions, Medicare Advantage is a good choice, although you can get prescription coverage by opting into Medicare Part D in addition to Original Medicare.
  • Chronic illness - If you have a preexisting condition or are at risk of developing a chronic illness, Original Medicare combined with Part D for prescriptions as well as Medigap may offer you the most comprehensive coverage. However, if your condition qualifies you for a Medicare Advantage Special Needs Plan, it might be worth considering that option instead.
  • Travel - If you travel a lot around the United States, Original Medicare is going to meet more of your medical needs than a network-restricted Medicare Advantage plan.
  • International Travel - If you frequently travel outside of the country, Medicare Advantage can offer coverage for emergencies abroad, which might make it your best choice. You may also be able to add supplementary travel coverage.
  • Cost - With limits on out-of-pocket costs, Medicare Advantage plans might end up costing you less in the long run.

Depending on your lifestyle, current health, and your personal preferences, these considerations should help make your choice between Original Medicare and Medicare Advantage pretty clear.

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Can You Change Your Coverage?

Yes, it is possible to switch from Original Medicare to a Medicare Advantage plan or vice versa. If you’re looking to switch from Original Medicare to Medicare Advantage, you’ll have the ability to do so during specific periods of time. These are during:

  • Your Initial Enrollment Period - this runs from three months prior to your 65th birthday to 3 months after it and extends for 7 months total.
  • Open Enrollment Period - this period runs from October 15th to December 7th every year.
  • Medicare Advantage Open Enrollment Period - This lasts from January 1st to March 31st each year.

You may also elect to switch from a Medicare Advantage plan to Original Medicare under the following circumstances:

  • You move out of your plan’s network area.
  • You’re living in long-term care.
  • You’re eligible for Medicaid.
  • You lose your Medicaid eligibility.
  • You have the opportunity to choose insurance through your employment.
  • A mistake has been made by a Medicare employee that affects your coverage.
  • You have been enrolled in Medicare Advantage for less than a year.

Outside of these specific periods and circumstances, you are not allowed to disenroll in a Medicare Advantage plan without penalty.

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Start Planning With Everdays Today

We know this is a lot of information to take in and some of it can be a little bit confusing. You’re not alone. With so many options and variables to consider, choosing what medical coverage you want once your turn 65 can be puzzling. Signing up for your Everdays account is free and it’s the first step to accessing guides and assistance in many different areas including choosing your healthcare insurance plan, budgeting for retirement, investing for the future, and planning your end-of-life wishes. Don’t wait to plan for tomorrow. Sign up for Everdays today!

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© 2022 Everdays, Inc. All rights reserved.

The Everdays mark and the Everdays logo are registered trademarks of Everdays, Inc.
* This app is owned and operated by Everdays, Inc., a Delaware corporation doing business in California as Everdays Moments Insurance Marketing.