Original Medicare vs. Medicare Advantage: Pros and Cons
When you first get Medicare, you’ll enroll in Original Medicare, which includes Part A and Part B. Once you’ve enrolled, you can choose to either stay on Original Medicare or switch to a Medicare Advantage plan.
Many Medicare beneficiaries (over 50%) choose to enroll in a Medicare Advantage plan. These plans bundle Part A and Part B together. Most also provide Part D (prescription drug) coverage. Finally, these plans also tend to come with extra benefits, like flex cards, give back benefits, and dental, vision, and hearing coverage—sweetening the deal for Medicare Advantage planholders.
Staying on Original Medicare has its advantages too. Original Medicare, in general, increases your access to care. With Original Medicare you can see any doctor who accepts Medicare, which is about 90% of doctors nationwide. You also don’t need to get prior authorization for covered services. Finally, you’re able to add a Medicare Supplement (also called Medigap) and/or prescription drug plan to enhance your Medicare coverage.
Key Takeaways:
There’s not one right path for everyone, which Medicare option is best for you depends on your unique set of circumstances.
If you stay on Original Medicare, you can also enroll in a Medicare Supplement plan and/or a prescription drug plan.
Medicare Advantage must provide at least the same coverage as Original Medicare, and often also includes prescription, dental, vision, and hearing benefits.
You can switch from Medicare Advantage to Original Medicare (and vice versa) during the Medicare Open Enrollment Period each fall.
What is Original Medicare?
Original Medicare (also sometimes called Traditional Medicare) is what you enroll in when you first become eligible for Medicare. In fact, you cannot enroll in any other Medicare Part or Plan until you’ve enrolled in Original Medicare, which consists of both Part A and Part B.
Medicare Part A is your hospital coverage. It covers:
Inpatient care in a hospital
Skilled nursing facility care
Inpatient nursing home care
Hospice care
Some home health care
For most people, Part A is free. If you or your spouse hasn’t worked and paid Medicare taxes for 10 or more years, you’ll pay either $278 or $505 each month, depending on how long you or your spouse worked and paid Medicare taxes.
Medicare Part B is your outpatient coverage. It covers:
Doctor’s visits, consultations, and treatments
Outpatient care, including surgeries, diagnostic tests, X-rays, and lab work
Preventive services, such as screenings, vaccinations, and counseling services
Emergency ambulance transportation
Durable medical equipment, such as wheelchairs, walkers, and oxygen supplies
Medications administered in outpatient settings, such as chemotherapy drugs or injectable medications
The standard premium for Medicare Part B is $174.70 (in 2024). Some people with high incomes pay more, and you can learn more about Part B premiums here.
Most people enroll in Original Medicare when they turn 65. If you’re already drawing from Social Security, you’ll be automatically enrolled. Otherwise, you’ll need to enroll during your Initial Enrollment Period (IEP). Your IEP is a seven-month period that starts three months before the month you turn 65 and ends three months after.
Enhancing your Original Medicare coverage
One of the benefits of staying on Original Medicare vs. switching to Medicare Advantage is that you can enroll in a Medigap plan. Medigap plans help fill the gaps in Original Medicare coverage by helping cover the 20% of costs it doesn’t cover. There are ten types of Medigap plans, and each significantly reduces your out-of-pocket costs. When you enroll in a Medigap plan does matter, so it’s important to understand how Medigap enrollment works.
Benefits of Original Medicare
Original Medicare isn’t perfect, but it makes it easy to get the care you need.
You can see any doctor who accepts Medicare
Original Medicare doesn’t have provider networks, and you can see any doctor who accepts Medicare nationwide. This is an incredibly important feature for people who travel often to visit family or snowbirds who split their time between homes! No provider networks also gives you a lot more freedom to choose the medical providers you want.
You don’t need to prior authorization
Medicare Advantage plans have become infamous for requiring (and denying) prior authorization for covered services—even when beneficiaries need the services. When you’re on Original Medicare, whether you have a Medigap plan or not, you don’t need prior authorization for any Medicare-covered services. This gives you quicker, more affordable access to care.
You can add a Medigap plan
Original Medicare doesn’t cover 20% of costs and has no out-of-pocket limit—but you can add a Medigap plan which significantly reduces your out-of-pocket costs. For example, let’s say you have a Medigap Plan G, which is widely considered the most comprehensive. With your Plan G, you don’t owe anything out of pocket for Medicare covered services after you meet your Part B deductible. The Part B deductible is only $240 (in 2024). Especially if you need frequent or expensive care, this is incredible!
Disadvantages of Original Medicare
Original Medicare doesn’t cover everything and, without additional coverage, it leaves beneficiaries vulnerable to skyrocketing costs.
High out-of-pocket costs
While adding a Medigap plan can reduce, and in some cases, almost eliminate your out-of-pocket costs, alone, Original Medicare can result in incredibly high out-of-pocket costs.
No out-of-pocket limit
Because Original Medicare doesn’t have an out-of-pocket limit, we always recommend beneficiaries either add a Medigap plan to their coverage or switch to Medicare Advantage. This is because the lack of an out-of-pocket maximum leaves you vulnerable to catastrophic costs if you need regular or expensive treatments!
No dental, vision, hearing, or prescription coverage
Prescriptions, along with dental, vision, and hearing care are all important for maintaining our health as we age. With Original Medicare, you can enroll in a separate Medicare Part D (prescription drug) plan. There are also dental, vision, and hearing solutions available—but none that will bundle together with your Medicare coverage.
What is Medicare Advantage?
When you enroll in a Medicare Advantage plan, it replaces Original Medicare. However, Medicare Advantage plans must cover at least the same amount as Original Medicare. These plans are popular because they generally provide more benefits, which may include:
Dental, vision, and hearing coverage
Prescription coverage
Fitness perks
Over-the-counter flex cards
Transportation services
Meal services
The average monthly premium for a Medicare Advantage plan is $18. What you pay will depend on where you live and the plan you choose. Many Medicare Advantage plans have $0 premiums. You may be wondering how these plans offer more benefits and charge nothing. It’s important to know that when you enroll in a Medicare Advantage plan, you’re still responsible for your Original Medicare premiums. The cost of those premiums continues to come out of your Social Security, and the government sends it to your insurance carrier.
You can enroll in Medicare Advantage when you first enroll in Medicare or during the Medicare Open Enrollment Period, which occurs every fall from October 15 - December 7. Get more details on when to enroll in Medicare Advantage in this article.
Benefits of Medicare Advantage
There’s a reason that over 50% of Medicare beneficiaries enroll in Medicare Advantage plans. They come with their perks.
Affordability
Medicare Advantage plans provide more comprehensive coverage than Original Medicare alone, with a low or no additional cost. Most Medicare Advantage plans have a $0 premium—and many others have incredibly low premiums.
Compared to Original Medicare with a Medigap plan, there’s no doubt that Medicare Advantage plans cost less. And compared to Original Medicare without a Medigap plan, you can rest assured knowing that there’s a limit to your out-of-pocket costs.
Added benefits
One of the reasons Medicare Plans are so popular is because of the extra benefits they provide for planholders. Many people are surprised when they first learn that Medicare doesn’t cover dental, vision, and hearing care. We talk to many Medicare beneficiaries who are interested in Medicare Advantage plans specifically for dental, vision, and hearing! Prescription coverage bundled into the plan is another attractive benefit. And finally, many people, especially those with low incomes, rely on cash-like benefits to help them get from month to month.
Out-of-pocket limits
Original Medicare doesn’t cover 20% off costs and doesn’t have an out-of-pocket limit. This means that if you need expensive or frequent care, you could be on the hook for thousands, with no upward limit! Medicare Advantage plans each have their own out-of-pocket maximum, saving you from catastrophic costs. In 2024, the out-of-pocket limit for Medicare Advantage plans can’t be more than $8,850.
Disadvantages of Medicare Advantage
You may hear many people say that Medicare Advantage plans are bad. Unfortunately, misleading ads and sales tactics result in many Medicare beneficiaries not understanding all of their options and how their Medicare Advantage plans really work. These are the three key disadvantages of Medicare Advantage plans.
Limited provider networks
Many of us are used to provider networks because they also come with employer-provided health insurance. As we age, it’s important to be able to see the doctors and specialists we prefer. In many cases you can find a Medicare Advantage plan with a network that includes most of your medical providers, but you need to make sure your Medicare advisor checks! Finding new doctors and specialists who are accepting new patients can also be a challenge when your provider network is limited.
Prior authorization requirements
Medicare Advantage plan carriers are becoming infamous for requiring—and denying—prior authorizations for covered services. This limits Medicare beneficiaries’ access to quick and affordable care.
High out-of-pocket costs
While Medicare Advantage plans have a limit on your total out-of-pocket costs for a year, they still have deductibles, coinsurance, and copayments. In many cases, the deductibles are higher than for Original Medicare, and the coinsurance amount is the same (20%). So, while Medicare Advantage plans protect you from catastrophic costs, they don’t significantly reduce your out-of-pocket spending like a Medigap plan.
Which is better: Medicare Advantage or Original Medicare?
There’s not one “best” option for all Medicare beneficiaries.
Pairing Original Medicare with Medigap Plan G and a prescription drug plan is the most comprehensive insurance you can get with Medicare. This combination is generally considered “the best,” but not everyone can afford the monthly premiums that come with Medigap Plan G.
We had a member who lost her Medicaid eligibility after post-Covid Medicaid redetermination. She no longer qualified for financial assistance from Medicaid, but the Part B premium would take up one eighth of her monthly income. Our amazing Advisor, Aastha Chourasia, helped her find a plan with a $102 Part B giveback benefit—ultimately helping her maintain her health coverage and achieving much-needed savings!
This only proves that there truly is no Medicare option that’s best for everyone. That’s why we stress working with an independent Medicare advisor who understands all of your options, takes the time to understand what you need based on your health and financial situation, and helps you choose the right Medicare option(s) for you. We do just this, and our advice is always free.
Schedule a free consultation or call us at (855) 900-2427 to get your questions answered and feel confident in your Medicare decisions.
Switching between Medicare Advantage and Original Medicare
You can switch from Medicare Advantage back to Original Medicare (and vice versa) once each year, during the Medicare Open Enrollment Period. If you’re unhappy with your Medicare Advantage plan, you may also use the Medicare Advantage Open Enrollment Period, which occurs every year from January 1 - March 31.
There is no financial penalty for switching from Medicare Advantage to Original Medicare, or from Original Medicare to Medicare Advantage. The one thing to keep in mind is that if you have a Medigap policy, you cannot also have a Medicare Advantage plan. Furthermore, if you choose to leave Original Medicare for Medicare Advantage, therefore giving up your Medigap policy, you may have a difficult time getting that Medigap policy back later on. To learn more about how and when you can enroll or re-enroll in a Medigap plan, read our Medigap Enrollment guide.
Medicare beneficiaries have options, but trying to understand all of them can feel overwhelming! Our goal at Chapter is to make it easy for you to choose the best Medicare coverage for your specific needs. We’ll answer any questions you have, explain your options, help you compare or switch plans, and ensure that you’re getting the best value from your Medicare.
Schedule a free consultation or call us at (855) 900-2427 to get your questions answered and feel confident in your Medicare decisions.