Medicare Advantage vs. Original Medicare: Which is Right for You?

When it comes to Medicare, beneficiaries have two main options to choose from: Original Medicare and Medicare Advantage. Both options have their own advantages and disadvantages, and it’s important to understand the differences to make an informed decision.

Original Medicare consists of Parts A and B, which cover hospital and medical services, respectively. Beneficiaries can see any healthcare provider that accepts Medicare and may choose to purchase a separate Part D prescription drug plan and/or a Medigap policy to supplement their coverage.

Medicare Advantage (also known as Part C) is an alternative to Original Medicare and is offered by private insurance companies. Medicare Advantage plans must provide at least the same level of coverage as Original Medicare (Parts A and B). 

Still, many plans offer additional benefits such as prescription drug coverage, dental and vision care, and fitness programs. Medicare Advantage plans often have network restrictions, meaning beneficiaries may be limited to seeing healthcare providers within the plan’s network.

Let’s dive into each plan and what they offer you. Alternatively, you can visit medisupps.com for additional up-to-date information.

Original Medicare

Part A: 

Medicare Part A is a component of the federal health insurance program for Americans aged 65 and older and some younger people with disabilities or end-stage renal disease. Part A covers inpatient hospital care, skilled nursing facility care, hospice care, and home health care.

Here’s a closer look at what Part A covers:

1. Inpatient hospital care: This includes care received while admitted to a hospital, such as room and board, nursing care, and meals. Part A also covers medically necessary services and supplies, such as medications, laboratory tests, and diagnostic imaging.
2. Skilled nursing facility care: Part A covers up to 100 days of care in a skilled nursing facility following a hospital stay of at least three days. Skilled nursing care includes services such as physical therapy, occupational therapy, and speech therapy.
3. Hospice care: Part A covers hospice care for individuals with a terminal illness who have a life expectancy of six months or less. Hospice care includes medical and support services, such as pain management, counseling, and social services.
4. Home health care: Part A covers medically necessary skilled nursing care, physical therapy, speech therapy, and occupational therapy provided in the home. Home health care must be ordered by a physician and provided by a Medicare-certified home health agency.

In addition to covering these services, Part A also has some costs that beneficiaries may need to pay. These include a deductible for each benefit period (which is currently $1,600 in 2023), coinsurance for hospital stays longer than 60 days, and daily coinsurance for extended stays in a skilled nursing facility.

It’s important to note that Part A coverage is automatic for most individuals who are eligible for Medicare, and there is typically no monthly premium for Part A coverage. However, some individuals may need to pay a premium if they did not pay enough Medicare taxes while working or if they do not meet certain eligibility requirements.

In summary, Medicare Part A provides coverage for inpatient hospital care, skilled nursing facility care, hospice care, and home health care. While some costs are associated with Part A coverage, it is typically automatic for most Medicare beneficiaries and provides important benefits for those needing medical care. (1)

Part B

Medicare Part B is a component of the federal health insurance program for Americans aged 65 and older and some younger people with disabilities or end-stage renal disease. Part B covers medically necessary services and supplies that are needed to diagnose or treat a medical condition.

Here’s a closer look at what Part B covers:

1. Doctor services: Part B covers a wide range of doctor services, including office visits, specialist care, and some preventive services such as flu shots and cancer screenings.
2. Outpatient care: Part B covers services and supplies that are provided on an outpatient basis, such as diagnostic tests, X-rays, and laboratory services.
3. Medical equipment and supplies: Part B covers durable medical equipment (DME) such as wheelchairs, walkers, and oxygen equipment, as well as some supplies such as bandages and blood glucose monitors.
4. Preventive services: Part B covers a range of preventive services, such as annual wellness visits, mammograms, and colorectal cancer screenings.
5. Ambulance services: Part B covers emergency ambulance services and non-emergency ambulance transportation when it is medically necessary.

In addition to covering these services, Part B has a monthly premium that beneficiaries must pay. There is also an annual deductible for Part B coverage, which is $226 in 2021.

It’s important to note that some services may require a copayment or coinsurance, the portion of the cost the beneficiary is responsible for paying. The copayment or coinsurance amount may vary depending on the service and the provider.

In summary, Medicare Part B provides coverage for medically necessary services and supplies that are needed to diagnose or treat a medical condition. While there is a monthly premium and an annual deductible for Part B coverage, it provides important benefits for those in need of medical care.

Part C/Medicare Advantage

Medicare Part C, also known as Medicare Advantage, is an alternative to Original Medicare (Parts A and B) that is offered by private insurance companies approved by Medicare. Medicare Advantage plans provide all of the coverage of Parts A and B, often including additional benefits such as prescription drug coverage, dental, vision, and hearing benefits, and fitness programs.

Here’s a closer look at what Part C covers:

1. All of the benefits of Original Medicare: Medicare Advantage plans must provide all of the same benefits as Original Medicare, including hospitalization coverage (Part A) and medical coverage (Part B).
2. Prescription drug coverage: Many Medicare Advantage plans include prescription drug coverage (Part D), which can benefit those taking multiple medications.
3. Additional benefits: Many Medicare Advantage plans offer additional benefits that are not covered by Original Medicare, such as dental, vision, and hearing benefits, wellness programs, and transportation services.
4. Out-of-pocket costs: Medicare Advantage plans typically have out-of-pocket costs such as copayments, coinsurance, and deductibles. However, many plans have an out-of-pocket maximum, which is the maximum amount a beneficiary will have to pay for covered services in a given year.
5. Network restrictions: Medicare Advantage plans typically have network restrictions, meaning beneficiaries may have to use specific doctors or hospitals in order to receive covered services. However, some plans offer out-of-network coverage for an additional cost.

It’s important to note that beneficiaries who enroll in a Medicare Advantage plan are still enrolled in Medicare and must continue to pay their Part B premium in addition to any premium required by their Medicare Advantage plan. Additionally, beneficiaries can only enroll in a Medicare Advantage plan during certain times of the year, such as during the annual enrollment period.

In summary, Medicare Part C, or Medicare Advantage, is an alternative to Original Medicare that is offered by private insurance companies approved by Medicare. Medicare Advantage plans provide all of the coverage of Parts A and B, often including additional benefits such as prescription drug coverage, dental, vision, and hearing benefits, and fitness programs.

Factors to help you decide which option is best for you

So which option is right for you? Here are some factors to consider:

1. Healthcare needs: If you have complex medical needs and require frequent medical care, Original Medicare may be a better option as it provides more flexibility in choosing healthcare providers. However, a Medicare Advantage plan may be a better fit if you’re generally healthy and looking for additional benefits like prescription drug coverage.
2. Budget: Original Medicare typically has lower premiums than Medicare Advantage plans, but beneficiaries may need to purchase separate Part D and Medigap policies to supplement their coverage. Medicare Advantage plans often include additional benefits, but may have higher premiums and out-of-pocket costs.
3. Provider choice: If you have established relationships with specific healthcare providers, checking if they accept Medicare before choosing a plan is important. Original Medicare allows beneficiaries to see any healthcare provider that accepts Medicare, while Medicare Advantage plans often have network restrictions. (2)

That’s a wrap

Ultimately, the decision between Original Medicare and Medicare Advantage will depend on your individual healthcare needs, budget, and personal preferences. It’s important to compare all available options and consult with a healthcare professional or Medicare counselor to make an informed decision.