What is the difference between Original Medicare and Medicare Advantage?

Dear Henry, 

Great question! Choosing between Original Medicare and Medicare Advantage is an important step in planning your healthcare coverage. I’d like to help you make an informed choice. Here’s a clear breakdown of both options and the key differences between them. It should help you decide which option best fits your needs.  

Original Medicare is the traditional program offered directly through the federal government. Medicare Advantage plans are private plans that contract with the federal government to provide Medicare benefits. 

Key differences between Original Medicare and Medicare Advantage:

• Costs 
  • Original Medicare 
    • You will owe Part A and Part B costs, including the monthly Part B premium.  
    • You will owe a 20% coinsurance for Medicare-covered services if you see a participating provider and after meeting your deductible. 
  • Medicare Advantage 
    • Your cost-sharing will vary depending on plan.  
      • You will usually pay a copayment for in-network care.  
      • Plans might charge a monthly premium in addition to the Part B premium. 
• Supplemental insurance 
  • Original Medicare 
    • You have the choice to pay an extra premium for a Medigap policy to cover Medicare cost-sharing. 
  • Medicare Advantage 
    • You can’t purchase a Medigap policy. 
• Provider access 
  • Original Medicare 
    • You can see any provider and use any facility that accepts Medicare (participating and non-participating). 
  • Medicare Advantage 
    • You typically can only see in-network providers. 
• Referrals 
  • Original Medicare 
    • You don’t need referrals for specialists. 
  • Medicare Advantage 
    • You typically need referrals for specialists. 
• Drug coverage 
  • Original Medicare 
    • You have to sign up for a stand-alone prescription drug plan. 
  • Medicare Advantage 
    • In most cases, your plan will provide prescription drug coverage. You may be required to pay a higher premium. 
• Other benefits 
  • Original Medicare 
    • Does not cover vision, hearing, or dental services. 
  • Medicare Advantage 
    • May cover additional services, including vision, hearing, and/or dental. Additional benefits may increase your premium and/or other out-of-pocket costs. 
• Out-of-pocket limit 
  • Original Medicare 
    • No out-of-pocket limit. 
  • Medicare Advantage 
    • Annual out-of-pocket limit. Your plan will pay the full cost of your care after you reach the limit. 

You might sign up for Original Medicare and later decide you would like to try a Medicare Advantage Plan–or vice versa. Be aware that there are only certain enrollment periods when you are allowed to make changes. 

Keep in mind that different areas have different Medicare Advantage Plans. A particular plan may not be available where you live. Call 1-800-MEDICARE (633-4227) or your State Health Insurance Assistance Program (SHIP) to find out about plans available in your area. 

Hope this helps! 

-Marci