By: Micah Pratt | March 19, 2019

  • Over 37 million Original Medicare enrollees1
  • Most freedom to choose doctors and providers
  • Over 19 million Advantage Medicare enrollees2
  • Most plans include prescription drug coverage

With more than 55 million Americans enrolled in Medicare—a number that could rise to over 92 million by 20503—a record number of adults are faced with the challenge of choosing health coverage after employment.

As you transition from traditional health insurance to Medicare, you may experience uncertainty around knowing what choices you have as a Medicare beneficiary. Understanding the different types of Medicare, like Original Medicare and Medicare Advantage, can ease the uncertainty and confusion surrounding the available options.

We’re here to help. Use this page to get a clearer idea of how Original Medicare vs. Medicare Advantage compare.

Original Medicare vs. Medicare Advantage: Pros and cons

If you’re nearing Medicare enrollment, it’s important for you to understand the differences between Medicare Advantage and Original Medicare. While Original Medicare is fully administered by the US federal government, Medicare Advantage allows you to get Medicare benefits through private health insurance plans. These plans are similar to the health insurance offered by employers or on the individual market.

Original Medicare and Medicare Advantage differ in costs, coverage and benefits, and access to providers. Use the table below to get an idea of some of these key differences.

Original MedicareMedicare Advantage
Your costsPremiums,* deductibles, copayments, and coinsurance set by MedicarePremiums,* deductibles, copayments, and coinsurance set by each plan
Limits on out-of-pocket spendingNo limitsLimits required on all plans (e.g., $6,700 maximum for HMO plans)
Prescription drug coverageMust purchase separate Part D planIncluded with many plans
Extra benefits
(e.g.,dental,vision, and fitness)
NoneIncluded with many plans
Doctor and provider accessCan visit any provider who accepts MedicareMust visit in-network providers or may visit out-of-network providers for a higher cost
Specialist accessNo referrals requiredMay require referrals
Learn MoreLearn More

As you may have noticed, differences between Original Medicare and Medicare Advantage plans are not always straightforward. Choosing the right plan for you is a personal decision based on your unique health and budget needs. If you’d like extra benefits like vision or dental care, a Medicare Advantage plan may seem like an obvious choice. But there are still more aspects to consider when making your decision.

You may want to choose Medicare Advantage if you take prescription drugs. Most Medicare Advantage plans include prescription drug coverage as part of the covered benefits. Just remember that the premium for an Advantage plan with prescription drug coverage may be higher than the combined premiums for Part A (if any), Part B, and a stand-alone Part D plan, so an Advantage plan isn’t always the clearer choice.

It’s also important to think about access to doctors and specialists in your choice of Medicare coverage. A Medicare Advantage plan may present an additional obstacle for you in getting care because Advantage plans often require you to get a referral before seeing a specialist. What’s more, Advantage plans may charge you higher copayments for visiting a doctor outside the plan’s network.

Still, Medicare Advantage may be an attractive choice if you’re open to staying within a provider network and want to limit your out-of-pocket costs. Advantage plans limit your total out-of-pocket spending to no more than $6,700 per year for in-network services—and many plans have even lower out-of-pocket limits. Finally, like mentioned earlier, some Medicare Advantage plans offer benefits Original Medicare doesn’t—like coverage for hearing aids or fitness memberships—which can help you stay healthy and improve your quality of life.

Why you might choose Original Medicare

  • You have the most provider choice: With Original Medicare, you can visit any doctor or provider who accepts Medicare. This offers you the most flexibility in choosing where to get care.
  • You get the freedom to travel: Because you can visit any Medicare-accepting doctor, you don’t have to worry about staying in-network when you travel inside the United States.
  • You pay no additional premium: Most people get Original Medicare Part A premium-free, so you’ll likely pay only one premium for coverage: your Part B premium.
  • You don’t need a referral to see a specialist: Need to see a podiatrist? No problem. Original Medicare lets you see any specialist who accepts Medicare—no referral required.
  • You can add Medicare Supplement coverage: If you think Original Medicare may leave you with too many out-of-pocket costs, you can purchase a Medicare Supplement, or Medigap, plan to help you pay for what’s left over.
  • Your coverage is the same no matter where you live: No matter which state you live in or move to, your Original Medicare coverage goes with you. And aside from yearly changes to certain costs and benefits, you can expect the coverage to stay relatively the same.

Why you might choose Medicare Advantage

  • Many premiums are $0*: Although you may be required to pay a separate premium in addition to your Medicare Part A and/or B premium, many Advantage plans have a $0 monthly premium.
  • Your out-of-pocket costs are limited: Advantage plans have caps, or out-of-pocket maximums, on the total amount you’ll have to pay for care. These limits can protect you from financial burden in case you need expensive medical care.
  • You may get extra benefits: If you’d like coverage for dental, vision, hearing, wellness, or fitness services, you can usually buy an Advantage plan that includes these benefits.
  • You can get coverage for prescription drugs: Many Advantage plans cover prescription drugs—with no extra plan required.
  • You get access to special plan features and benefits: Most insurers offer plan members special services like wellness tools, automated claim processing, mobile applications, and more.
  • You can shop around: In most areas, you can choose plans from several different insurers. Choosing from a variety of coverage options—like copayments, coinsurance, and added benefits—can help you get the right coverage for your needs
  • You can seamlessly transition from commercial insurance: If you’ve been covered by a private insurance plan from an employer or on the individual market, your plan may offer you an easy move to a Medicare Advantage plan—and let you keep many of the same special features and benefits.

Comparing the coverage of Original Medicare and Medicare Advantage

Medicare Advantage plans must provide at least the same amount of medical coverage that you get under Original Medicare. Advantage plans may also give you more personalized care by offering extra benefits like dental, vision, hearing, and fitness and wellness services, which aren’t normally covered by Original Medicare.

Comparing provider access

A key difference between Original Medicare and Medicare Advantage is how accessible doctors, specialists, clinics, and other providers are.

With Original Medicare, you can visit any provider that is enrolled with Medicare and is taking new patients. Medicare Advantage plans may restrict your provider access, but these restrictions may provide you savings on your out-of-pocket costs like cheaper monthly premiums or lower copayments and coinsurance for services.

To get care with Original Medicare, just make an appointment and present your Medicare card. You don’t need to get permission to visit specialists, and you don’t have to choose from different networks of providers in your area.

But with a Medicare Advantage plan, your access to providers varies depending on the type of plan you choose. Health Maintenance Organization (HMO) plans are the most restrictive. Most HMO plans require you to see only doctors within the plan’s network. You may also have to choose a specific primary care doctor and ask for a referral to see a specialist.

Preferred Provider Organization (PPO) Medicare Advantage plans give you more provider choice than HMO plans, but you may still pay more to see a doctor who isn’t in the plan’s provider network. There are additional Medicare Advantage plan types. Learn more about the differences between Advantage plans.

About Original Medicare & Medicare Advantage

The US government created Medicare more than 50 years ago to help cover the medical expenses of older Americans. Since its debut, several elements of the Medicare program changed as the government attempted to expand who is covered, increase the number of ways someone can receive their Medicare benefits, and help control rising health care costs.

One example of these changes was the establishment of Medicare Advantage. Medicare first began allowing individuals to get health care benefits from private health insurance plans in the 1970s. Enrollment in what are now known as Medicare Advantage plans has steadily increased in the following decades. Today, one-third of all Medicare beneficiaries—19 million people—are enrolled in Medicare Advantage plans.4

Learn more:

Your decision: It’s personal

Ultimately, choosing a Medicare plan is a personal decision and should be based on your particular care and budget needs. Consider what’s important to you—whether that’s flexibility in choosing doctors, access to extra benefits, or something else—so you can better choose the Medicare option that’s right for you.


Sources:

1 CMS.gov, “On Its 50th Anniversary, More than 55 Million Americans Covered by Medicare

2 Kaiser Family Foundation, “Medicare Advantage

3 Kaiser Family Foundation, “Projected Change in Medicare Enrollment, 2000–2050

4 Kaiser Family Foundation, “1 in 3 People in Medicare Is Now in Medicare Advantage, with Enrollment Still Concentrated Among a Handful of Insurers

Disclaimers:

* You must continue to pay your Part B premium.