As you approach 65, you’ll need to make a Medicare choice. Original Medicare covers the basics, like hospital stays, while Medicare Advantage is an all-in-one plan that can help pay for things like dental, vision and wellness. But each plan has its own costs and eligibility requirements to consider.
Key features of Original Medicare vs. Medicare Advantage
To help you decide which plan is right for your medical needs, we’ve laid out the essential differences in coverage, eligibility, costs and more.
|Coverage||Medical and hospital costs only||Medical and hospital costs, plus most plans cover dental, vision, hearing, wellness and prescription drugs|
|Eligibility||People over 65, and those under 65 with qualifying disabilities||People over 65 who are already receiving Social Security benefits|
|Which doctors can I see?||Any provider who accepts Medicare||It depends on your plan, but you’ll pay more if you go out-of-network|
|Do I need a referral?||No||Usually|
|Costs||Most people don’t pay a premium, but you’ll be charged a 20% coinsurance for Medicare-covered services||It depends on the plan, but you always have to pay the Part B premium|
|Out-of-pocket maximum||None||$7,550, and many plans set a lower limit|
What is Original Medicare?
Original Medicare is the traditional Medicare program run by the federal government. It’s made up of Part A (Hospital Insurance) and Part B (Medical Insurance).
With these plans, you can see any doctor who accepts Medicare and the government covers a portion of the bill. You’ll need to pay a deductible, coinsurance or copay with most services, though Original Medicare limits how much you can be charged if you go to a participating or non-participating provider.
What is Medicare Advantage?
Medicare Advantage is a plan offered by private insurance companies rather than the government. Also known as Medicare Part C, it combines the benefits of Part A and Part B as well as Part D — which is prescription drug coverage.
These bundled plans often provide additional benefits, like vision, hearing and dental care. There’s an annual limit on out-of-pocket costs, so once you meet it, your plan will cover 100% of your healthcare costs. But you may have less flexibility with choosing providers, and some plans limit you to providers in your geographic area.
Is Medigap the same as Medicare Advantage?
No. While Medicare Advantage is often confused with Medigap, they’re separate policies.
Both plans are sold by private health insurance companies, but Medigap policies are designed to supplement Original Medicare and bridge any coverage gaps. To compare, Medicare Advantage plans replace Original Medicare — you can’t have both at the same time.
Also, Medigap policies are standardized, whereas Medicare Advantage plans have key differences — like what’s covered. That’s why it’s important to shop around.
Who can enroll in Original Medicare vs. Medicare Advantage?
You can enroll in Original Medicare if you’re 65 or older and a US citizen or legal permanent resident for at least five years. If you’re under 65, you might be entitled to Medicare if you have a long-term disability, amyotrophic lateral sclerosis (ALS) or end-stage renal disease.
You can only sign up for Medicare Advantage if you already have Medicare Part A and Part B.
What’s covered by Original Medicare and Medicare Advantage?
All enrollees have the same basic benefits, including:
- Medically necessary services to diagnose and treat injuries, illnesses and conditions — like procedures and ambulance trips
- Medical equipment and devices essential to your care — such as wheelchairs, prosthetics and oxygen tanks
- Preventative care — including routine physicals, screening tests and most vaccines and immunizations
Medicare Advantage plans are more comprehensive. They typically cover routine vision and dental care and include Part D, which pays for prescription drugs. Many plans also cover over-the-counter medications, home meal delivery, non-medical transportation and fitness memberships.
What’s not covered?
Neither plan covers you if you’re traveling overseas and need care — even in an emergency.
Original Medicare doesn’t cover:
- Long-term care
- Most prescriptions
- Dental care, including cleanings, fillings and extractions
- Eye exams, contact lenses and glasses
- Hearing aids and exams
- Cosmetic surgery
- Massage therapy
- Routine foot care
While most Medicare Advantage plans offer additional vision, dental, hearing and wellness coverage, they don’t cover medically unnecessary services. In other words, you’ll need to justify why you need a service.
Which healthcare providers can I see?
Under Original Medicare, you can visit any doctor or specialist who accepts Medicare and you don’t need a referral. You should have plenty of options — according to the latest data from the Kaiser Family Foundation, 93% of primary care providers participate in Medicare.
Medicare Advantage works a little differently. There are four main types of Medicare Advantage plans, and the one you pick dictates the doctors you can see:
- Health maintenance organization (HMO) plans require you to see in-network doctors, unless it’s an emergency
- Preferred provider organization (PPO) plans allow you to see any doctor, though you’ll pay more if you go out-of-network
- Private fee-for-service (PFFS) plans let you visit any Medicare-approved doctor — as long as they agree to see you and accept your payment terms
- Special needs plans (SNPs) are open to a small pool of qualifying individuals, including low-income earners, nursing home residents and those with serious health conditions
Most Medicare Advantage plans on the market are HMOs and PPOs, according to the Kaiser Family Foundation. So in most cases, you’d have a primary care doctor who manages your care. HMOs are the most popular, accounting for 60% of enrollees.
How to enroll in Original Medicare vs. Medicare Advantage
You’ll be automatically enrolled in Original Medicare three months before you turn 65 if you’re receiving Social Security or Railroad Retirement Board benefits. The same goes if you’re younger than 65 and have a qualifying disease or disability — like ALS.
If you’re not getting Social Security, you’ll need to sign up for Original Medicare through the Social Security Administration. You can do this online, in person or by calling 800-772-1213. To avoid penalties, aim to enroll in the seven-month window on either side of your 65th birthday.
Since Medicare Advantage is a private plan, you’ll have to apply on your own. The best way to compare plans in your area is by using Medicare’s Plan Finder. Once you’ve found one that suits your needs, there are a few ways to enroll.
- Go to the plan’s site to see if you can sign up online – this isn’t always possible
- Reach out to the insurer to request a paper enrollment form
- Call Medicare at 800-633-4227
Have your Medicare number handy, along with the date your Part A or Part B coverage began.
When can I sign up for Medicare Advantage?
You can sign up for a Medicare Advantage plan in your Initial Enrollment Period — i.e. the three months before you turn 65, the month of your birthday, and three months after that. Otherwise, you can enroll during open enrollment, which runs from October 15 to December 7 each year.
What are the costs of Original Medicare vs. Medicare Advantage?
The costs vary, but you can expect to pay a premium, deductible and coinsurance for Original Medicare. Since Medicare Advantage is private health insurance, each insurer has its own cost-sharing structure — but most people who qualify can lock in a $0 premium, $0 deductible plan.
To give you an idea of what you’ll pay for coverage, this table lays out the 2021 costs of Original Medicare and a standard Medicare Advantage HMO plan, according to Medicare.gov.
|Premium||$0 if you or your spouse paid Medicare taxes for at least 10 years — these are part of the payroll taxes deducted from your paycheck.|
If you don’t qualify, you’ll pay up to $471/month.
|$148.50/month, or more if you’re a high-income earner. Premiums are based on your income level.||Most people pay $0. But note you’ll always need to pay the Part B premium.|
|Deductible||$1,484 per benefit period||$203 per year|
- $0 for medical expenses
- $445 for Part D, if your plan includes that
|Coinsurance||It depends on how long you’re in the hospital.|
- Days 1-60: $0
- Days 61-90: $371 per day
- Days 91 and beyond: $742 per day for up to 60 days
- Beyond “lifetime reserve days:” all costs
|You’ll pay 20% of your medical costs after you’ve met your deductible.|
- $10 for primary care
- $30 for specialist care
- $285 for hospital admissions
|Annual out-of-pocket maximum||N/A||N/A||$7,550 for in-network services. When you reach this limit, you won’t pay anything for services Original Medicare covers.|
Ask an expert: What advice would you give to someone considering a Medicare Advantage plan?
Co-founder of Caribou
The key consideration when choosing between Medicare Advantage or Original Medicare is the network you have access to. Original Medicare is federally recognized, meaning you have access to providers and facilities across the country. Advantage plans, on the other hand, are tied to local networks, and therefore limit your coverage to specific providers within a set geography — similar to ACA or employer-sponsored plans. If you frequently travel or have a home in another state, that can often be a deciding factor between options.
To minimize the costs you pay and maximize availability, you always want doctors and hospitals that are in-network. You also want to consider if you need a referral or not to see specialists or get specialized testing.
You want to make sure your pharmacy and drugs are at the lowest tier and a preferred pharmacy so you can get the best rates on your prescriptions if there is a drug plan.
Secondly, the majority of plans either offer a drug plan and you have to accept what it covers, or they don’t. If they don’t, then you cannot sign up for a drug plan without disenrolling yourself from the Medicare Advantage plan. There are specialized plans that allow you to select a standalone Part D plan. Make sure you know if you have to accept the drug plan offered or can purchase a stand-alone plan.
Maximum out-of-pocket costs
This is the maximum amount you have to pay, minus the drug plan before the Medicare Advantage plan pays 100% of your costs. If you need chemotherapy or ongoing medical equipment (like CPAP supplies), you may pay more than you’d pay with a Medicare Supplement plan.
To give an example, I had a call where the client was getting injections in her eyes monthly. Her Medicare Supplement plan paid 100% after her deductible. When she switched, she was paying $1000 a month in treatment costs, up to the maximum out-of-pocket amount.
Compare alternatives to Medicare
Each plan has its pros and cons. Original Medicare is a government-run program, and it offers predictable premiums and coverage for medical and hospital care — but there are no out-of-pocket limits. Medicare Advantage is a type of private health insurance, and it covers additional services — though you may have less flexibility with doctors.
In the lead-up to open enrollment, compare Medicare plans to choose one that fits your needs and budget.