Original Medicare vs. Medicare Advantage: Here’s How to Know the Difference

Original Medicare is the combination of Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). It’s offered through the Centers for Medicare & Medicaid Services (CMS). Original Medicare can be used at virtually any medical clinic or hospital in the United States. As long as a provider accepts Medicare, you will be able to get healthcare services through them.

Medicare Advantage Plans vs. Original Medicare

The Original Medicare plan is not free of charge. Although the cost of Part A is usually covered, most people pay a premium for Part B. You will pay a 20% coinsurance as well as copayments and deductibles. However, insurance can be added to supplement costs and coverage.

Original Medicare Coverage

Original Medicare plans cover tests, services and items that are considered medically necessary or needed to diagnose and treat your medical condition. They also cover services to prevent illness or detect a condition at an early, more treatable stage.

Related: What Does Medicare Cover and How Does It Work? We Break It Down 

Plan name
Covered
Not covered

Part A

• Hospital stays
• Skilled nursing facility care
• Hospice care
• Some home health care services

• Long-term care /custodial care
• Dental care and dentures
• Eye exams related to eyeglass prescriptions
• Hearing aids and related exams
• Take-home prescription medications
• Routine foot care
• Cosmetic surgery
• Acupuncture

Part B

• Select clinic services
• Outpatient care
• Durable medical equipment
• Preventive care
• Mental health 
• Ambulance services

What is Medicare Advantage?

If you want more comprehensive coverage bundled into one plan, Medicare Advantage may be the answer. Medicare Advantage, or Medicare Part C, offers the same coverage as Original Medicare, along with additional services. Coinsurance rates also may be lower, but your provider network is often limited to a specific area. 

Medicare Advantage is available through private insurance companies, so coverage varies depending on your policy. Often additional coverage is available for:

Prescription drugs

• Routine vision care
• Hearing services
• Dental care 
• Membership in fitness programs

Related: Save Money With an AARP Medicare Supplement Insurance Plan—Here’s the Breakdown

Medicare Advantage Plans

Not all Medicare Advantage plans are the same. Costs and coverage vary depending on the plan and the private insurance company. The most common Medicare Advantage plans include:

• Health Maintenance Organization (HMO) Plans – Generally you must get your care from providers in your network, except for emergency or urgent care. In most cases, you need to choose a primary care doctor and will need a referral for most specialty services.
• Preferred Provider Organization (PPO) Plans – In most cases, you can get health care from any provider, but services will cost more if they are not in the plan’s preferred network. You will not need to choose a primary care provider or get a referral for services.
• Private Fee-for-Service (PFFS) Plans – These plans determine how much you pay vs. your plan for each service you receive. You do not need to choose a primary care doctor or get referrals. Out-of-pocket costs are lower for providers that are in the plan’s network.
• Special Needs Plans (SNPs) – Membership in these plans is limited to those with specific conditions or characteristics. Benefits and network providers are tailored to meet the needs of that group, and you typically must stay in network to receive care.

With so many options, it can be difficult to know which plan to choose. Get the help you need to find the right Medicare Advantage plan for you:

 

Pros and Cons of Medicare Advantage Plans vs. Original Medicare

For the most part, Original Medicare and Medicare Advantage offer the same basic benefits (Medicare Part A and Part B). The differences come in the specific cost details and what options work best for your healthcare needs and lifestyle choices.

Related: Ask Carrie: Does Working Past Age 70 Affect Your Social Security Benefits? 

Original Medicare vs. Medicare Advantage

Benefit
Original Medicare
Medicare Advantage

Provider availability
Services available at hospitals and clinics across the United States
May or may not cover out-of-network services

Out-of-state coverage is typically for emergencies only.

Cost
Most people pay a premium for Part B, but not for Part A.

You pay a 20% coinsurance, copayments and deductibles.*

Some plans have no premiums, but you still have to pay Part B premiums.

Generally you have less out-of-pocket costs and a maximum, yearly limit.

Prescription drug coverage
Limited coverage for certain medications, typically not those you take home.**
Available with most plans.

Extra benefits 
No coverage for most extra services.
Many plans include coverage for dental, eye care, vision and other benefits, but it varies depending on the policy.

*Out-of-pocket costs can be supplemented with a Medigap plan.

**You have the option to add prescription drug coverage with a Medicare Part D plan.

Related: These 50 Inspirational Quotes for Family Caregivers Will Get You Through Tough Days 

Compare Medicare Plans: Original Medicare or Medicare Advantage?

There is an overwhelming amount of information online about Medicare, both good and bad. It’s important to ensure the information you receive is accurate and reliable, so you can make informed decisions about your health insurance. 

If you are considering a Medicare Advantage, Medigap and/or a Medicare Part D plan, speak to a professional who can match you with the top insurance carriers in your area that meet your healthcare needs.

 

Next up, here’s how to be a good caregiver and take good care of yourself, too.

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