Choosing between Original Medicare and a Medicare Advantage plan (Part C) is one of the most important decisions for Medicare beneficiaries. Both options cover the core health services, but they differ in structure, costs, provider access, extra benefits, and more. This report provides a detailed comparison – including what each option includes, how much they cost, network flexibility, additional benefits (like dental or vision), quality and satisfaction metrics, and recent trends (policy changes and data from the past 3–5 years). We’ll also summarize key pros and cons of each and include a comparison table for quick reference.
Overview of Original Medicare and Medicare Advantage
What Is Original Medicare?
Original Medicare is the traditional fee-for-service health insurance program provided directly by the federal government. It includes two primary components:
- Part A (Hospital Insurance): Covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care.
- Part B (Medical Insurance): Covers outpatient care, doctor visits, preventive services, durable medical equipment, and some home health services.
Additional Coverage Options
Beneficiaries can customize their Original Medicare coverage by enrolling in additional plans:
- Part D (Prescription Drug Coverage): Offered through private insurers, this plan helps cover the cost of prescription medications.
- Medigap (Medicare Supplement Insurance): Sold by private companies, Medigap helps pay for out-of-pocket costs not covered by Parts A and B, such as copayments, coinsurance, and deductibles.
Key Features of Original Medicare
- No Network Restrictions: You can see any doctor or hospital in the U.S. that accepts Medicare without needing referrals.
- No Prior Authorization: Generally, if a service is covered by Medicare, it does not require prior approval from the program. Any Medicare-approved provider can perform the service without plan permission.
- Coverage Scope: Original Medicare covers most medically necessary services but does not include routine dental, vision, or hearing care, nor non-medical benefits such as transportation or wellness programs.
What Is Medicare Advantage?
Medicare Advantage (MA), also known as Part C, is an “all-in-one” alternative to Original Medicare. These plans are offered by private insurance companies that are approved and regulated by Medicare. Medicare Advantage plans are required to provide at least the same level of coverage as Original Medicare (Parts A and B), and most also include Part D prescription drug coverage, making them a bundled, comprehensive option for many beneficiaries.
Structure and Benefits
While Medicare Advantage plans cover the same core services as Original Medicare, they often include their own rules regarding:
- Provider access (networks): Most plans use HMOs or PPOs, meaning you may need to use in-network providers.
- Referrals: You may need a referral from a primary care doctor to see a specialist.
- Prior Authorization: Many procedures or services require plan approval in advance.
Additional Benefits
A key appeal of Medicare Advantage is the array of extra benefits that go beyond Original Medicare, such as:
- Routine dental, vision, and hearing coverage
- Fitness memberships (e.g., SilverSneakers)
- Over-the-counter (OTC) allowances
- Transportation to medical appointments
- Meal delivery after hospital stays
In fact, nearly all Medicare Advantage plans now offer at least some of these additional benefits to enhance member wellness and satisfaction.
Considerations
- Cost Predictability: Many plans offer low or $0 premiums, but costs can vary based on usage, out-of-network care, and drug coverage.
- Limited Flexibility: You’re typically restricted to providers within the plan’s network.
- Care Management: Plans often emphasize preventive care and care coordination, which may benefit those managing chronic conditions.
Doctor and Hospital Choice (Provider Flexibility and Networks)
Provider Flexibility and Access
One of the standout benefits of Original Medicare is its broad provider flexibility. You can visit any doctor, hospital, or other healthcare provider nationwide that accepts Medicare—without needing referrals in most cases . This makes Original Medicare especially appealing for individuals who:
- Travel frequently
- Live in multiple states during the year
- Prefer choosing their own specialists directly
Since virtually all hospitals and a majority of physicians across the U.S. accept Medicare, you gain unmatched access to care without being restricted by networks. For specialist visits, referrals are typically not required, allowing you to directly see any specialist who accepts Medicare.
There are no network restrictions under Original Medicare, and no need to get plan permission or prior authorization for most services, as long as they are covered by Medicare.
Provider Networks and Access
Unlike Original Medicare, Medicare Advantage (MA) plans typically operate within a defined network of doctors, hospitals, and pharmacies. To receive the lowest out-of-pocket costs, you are generally required to use providers within the plan’s service area and network .
- HMO Plans (Health Maintenance Organization):
Most MA plans are HMOs. These usually require you to: - Select a primary care physician (PCP)
- Obtain referrals to see specialists
- Use only in-network providers for non-emergency care
- PPO Plans (Preferred Provider Organization):
These plans offer more flexibility: - You can visit out-of-network providers (at a higher cost)
- Referrals may not be required to see specialists
- Staying in-network still results in lower costs
Out-of-Network and Emergency Coverage
If you receive non-emergency care outside the plan’s network, your plan may not cover the services at all or may charge significantly more. The exceptions are:
- Emergency care
- Urgent care when traveling
- Out-of-area dialysis
This trade-off between flexibility and cost savings is central to Medicare Advantage. While you might gain additional benefits like vision and dental, you may also lose access to some preferred providers if they are not in-network.
Things to Consider
- If you have specific doctors or specialists, verify that they are in-network before enrolling.
- For individuals in rural areas or who travel often, these network limitations may significantly affect care accessibility.
Original Medicare vs. Medicare Advantage
- Original Medicare:
- Offers greater freedom to choose any provider who accepts Medicare.
- Allows easy access to specialists without referrals.
- Ideal if you want the widest choice of doctors and hospitals.
- Medicare Advantage (Part C):
- Operates through managed care networks (like HMOs or PPOs).
- May restrict provider choice to in-network doctors.
- Requires referrals and care coordination in many cases.
- Works well if your preferred providers are in-network and you’re comfortable with network-based care.
Coverage and Benefits Included
Hospital and Medical Coverage
Both Original Medicare and Medicare Advantage will cover core Medicare benefits, but there are differences in what’s included automatically and how certain services are handled:
Original Medicare Coverage
- Part A (Hospital Insurance) includes:
- Inpatient hospital care
- Skilled nursing facility (rehabilitation) care
- Hospice services
- Limited home health care
- Part B (Medical Insurance) covers:
- Doctor’s visits and outpatient services
- Preventive care (e.g., screenings, vaccines)
- Lab tests and diagnostic imaging
- Durable medical equipment (DME)
- Ambulance transportation
- Mental health care (inpatient and outpatient)
Medicare Advantage Coverage
- MA plans are required by law to cover all services included under Parts A and B.
- They cannot charge more than Original Medicare would for most medically necessary services.
- However, MA plans are administered by private insurers and may:
- Apply prior authorization requirements
- Use medical necessity criteria that differ slightly from Original Medicare
- Enforce utilization management policies
Prescription Drugs (Part D)
Prescription drug coverage is a key area where Original Medicare and Medicare Advantage differ significantly.
Original Medicare and Part D
Original Medicare does not include outpatient prescription drug coverage by default. To receive this benefit, you must enroll in a separate Medicare Part D plan, which is offered through private insurance companies approved by Medicare.
- Each Part D plan has its own formulary (list of covered drugs), tiers, and preferred pharmacy network.
- You will pay a monthly premium in addition to your Part B premium. Plans may vary in copayments, coinsurance, and annual deductibles.
This setup provides flexibility in choosing a drug plan that best fits your needs but requires managing a separate plan from your hospital and medical coverage .
Medicare Advantage and Part D
Most Medicare Advantage plans include Part D prescription drug coverage bundled into the plan—these are known as MA-PD plans.
- Approximately 90% of MA plans include drug coverage as part of their package 【source: medicare.gov】.
- With MA-PD plans, you typically cannot enroll in a separate standalone Part D plan.
- You’ll have one plan card that covers hospital, medical, and prescription drugs, simplifying your coverage.
Supplemental Coverage: Medigap vs. Medicare Advantage
- Original Medicare:
- No annual out-of-pocket limit on cost-sharing (deductibles, coinsurance).
- Many people purchase Medicare Supplement Insurance (Medigap) to reduce financial risk.
- Medigap plans (e.g., Plan G, Plan N) are private insurance policies that:
- Cover deductibles, 20% coinsurance, and other cost-sharing.
- Help make healthcare costs more predictable and affordable.
- Important: Medigap plans only work with Original Medicare – they cannot be used with Medicare Advantage plans.
Medicare Advantage (MA) Plans:
- Do not allow the purchase of a Medigap plan
- Have their own cost-sharing structure, including:
- Copays for services.
- An annual out-of-pocket maximum for covered services.
- Since there is a spending cap built in, Medigap is unnecessary (and not permitted).
Additional Benefits: Dental, Vision, Hearing & More
One of the most notable differences between Original Medicare and Medicare Advantage lies in the availability of extra benefits such as dental, vision, hearing, fitness programs, and wellness services.
Original Medicare: Limited Extra Benefits
Original Medicare is very limited in coverage beyond hospital and medical care. It does not cover:
- Routine dental services, such as cleanings, fillings, extractions, or dentures
- Routine vision exams or glasses/contacts (except after cataract surgery)
- Hearing exams or hearing aids
- Gym memberships, transportation services, or over-the-counter (OTC) benefits
While beneficiaries can purchase standalone dental or vision insurance, or pay out-of-pocket for these services, Medicare itself won’t cover them in most cases 【source: medicare.gov】.
Medicare Advantage: Built-in Extra Benefits
Medicare Advantage plans, in contrast, frequently include extra benefits that Original Medicare does not cover. In fact, nearly all MA plans offer at least some level of additional services 【source: kff.org】.
Common Medicare Advantage extra benefits include:
- Dental: Exams, cleanings, x-rays, and sometimes coverage for fillings, extractions, or dentures (often up to a yearly dollar limit)
- Vision: Routine eye exams, and an annual allowance for eyeglasses or contact lenses
- Hearing: Hearing tests and partial coverage for hearing aids
- Fitness memberships: Often includes access to programs like Silver Sneakers
- Transportation: Rides to and from medical appointments
- Meal delivery: Especially after hospital discharge
- OTC Allowances: Monthly or quarterly stipends to buy non-prescription health items (pain relievers, vitamins, etc.)
The extent and value of these benefits vary significantly by plan. For example:
- One plan might offer $1,000 annually in dental coverage
- Another might limit coverage to two cleanings per year
Foreign Travel Coverage
For individuals who frequently travel outside the United States, understanding how Medicare handles care abroad is essential. Unfortunately, routine healthcare coverage outside the U.S. is limited under both Original Medicare and Medicare Advantage.
Original Medicare and International Travel
Original Medicare generally does not cover medical services received outside the U.S. There are only a few rare exceptions, such as:
- If you are traveling between Alaska and another U.S. state and the nearest hospital is in Canada
- If you’re onboard a cruise ship that is within U.S. territorial waters (within six hours of a U.S. port)
Because of these restrictions, many people who choose Original Medicare opt to purchase a Medigap (Medicare Supplement Insurance) plan that includes emergency foreign travel coverage 【source: medicare.gov】.
- Plans G, F, and some others offer:
- Coverage for emergency care abroad
- 80% reimbursement for covered emergency services
- Up to a $50,000 lifetime maximum
- A $250 annual deductible applies
This supplemental benefit provides significant peace of mind for international travelers.
Medicare Advantage and International Travel
Medicare Advantage plans typically do not cover routine or non-emergency care outside the U.S. However, some MA plans may include limited emergency coverage abroad as an additional benefit.
- Emergency overseas coverage varies by plan and may include:
- Reimbursement for ER visits
- Restrictions on what qualifies as an “emergency”
- Limits on coverage amount and duration
Always check the Summary of Benefits and Evidence of Coverage (EOC) for any MA plan if foreign travel coverage is important to you.
- In summary, Original Medicare offers core coverage for hospital and medical care, with the flexibility to add prescription drug coverage (Part D) and supplemental insurance (Medigap). However, it doesn’t include extra benefits like dental, vision, or hearing. On the other hand, Medicare Advantage combines hospital, medical, and usually drug coverage into a single plan, and often includes additional perks like dental, vision, and wellness programs. The trade-off is that Medicare Advantage plans typically involve provider networks, referral requirements, and prior authorizations, which can limit flexibility in accessing care.
Cost Comparison: Premiums, Deductibles, Co-pays, and Out-of-Pocket Maximums
Cost is often the deciding factor when comparing Original Medicare and Medicare Advantage. Both options can incur premiums and various out-of-pocket costs, but the structure is different. Below we break down the key cost components
Premiums:
Cost Breakdown: Original Medicare
Understanding the costs associated with Original Medicare is essential for budgeting your healthcare in retirement. While Part A is often premium-free, the total out-of-pocket cost for beneficiaries can still add up—especially if you choose to enhance your coverage with Part D and a Medigap policy.
Part A (Hospital Insurance)
- Usually premium-free for most people if you or your spouse paid Medicare payroll taxes for at least 10 years (40 quarters).
- If you do not meet the work requirement, you may pay up to $505/month in 2024, depending on your work history.
Part B (Medical Insurance)
- Everyone pays a monthly premium for Part B.
- In 2024, the standard Part B premium is $174.70/month.
- In 2025, this increases to $185.00/month 【source: cms.gov】.
- Higher-income beneficiaries pay more under Income-Related Monthly Adjustment Amounts (IRMAA).
Part D (Prescription Drug Coverage)
- Offered separately by private insurers.
- Requires an additional monthly premium averaging around $30–$40, though it varies by plan.
- Like Part B, higher-income enrollees may pay an IRMAA surcharge for Part D.
Medigap (Medicare Supplement Insurance)
- Optional coverage purchased from private insurers to cover costs like deductibles and coinsurance.
- Premiums vary widely depending on:
- The plan type (Plan G, Plan N, etc.)
- Your age
- Location
- Insurance company
- Costs typically range from ~$100 to several hundred dollars/month.
Cost Breakdown: Medicare Advantage
While Medicare Advantage (MA) plans are offered through private insurers, enrollees remain in the Medicare program and must still pay the Part B premium. However, Medicare Advantage plans often present a more simplified and potentially cost-effective structure for many beneficiaries.
Required Part B Premium
- You must continue to pay the monthly Part B premium ($185.00 in 2025) 【source: medicare.gov】.
- This is true even if the MA plan itself advertises a $0 premium.
Medicare Advantage Plan Premiums
- Many MA plans have no additional plan premium beyond the required Part B cost.
- In 2023, the majority of enrollees had access to $0 premium plans, and many chose them for affordability 【source: kff.org】.
- Plans with richer benefits or broader provider networks may charge a premium—often $20, $50, or more per month.
Drug Coverage Included
- If the plan includes prescription drug coverage (MA-PD), it is bundled into the plan premium, eliminating the need for a separate Part D plan.
Part B Give-Back Benefit
Some MA plans offer a Part B “give-back” rebate, which reduces the amount you pay for Part B:
- For example, if the plan offers a $50 give-back, your Social Security check would be $50 higher, because Medicare deducts less from it.
- These plans are less common, but worth considering if cost savings are a priority.
Deductibles and Co-pays:
Original Medicare includes separate deductibles for hospital (Part A) and medical (Part B) services. While Part A costs apply per hospital stay, Part B has an annual deductible followed by 20% coinsurance for most services. There are no fixed copays—patients pay a percentage of approved charges. Without supplemental insurance like Medigap, these out-of-pocket costs can add up quickly, especially for serious or ongoing care.
Original Medicare: Costs in Brief
- Part A (Hospital Insurance):
- Deductible: $1,632 per benefit period (2024); can occur more than once a year.
- Coinsurance:
- Days 1–60: $0
- Days 61–90: ~$400+/day
- Days 91+: Higher costs using lifetime reserve days
- Part B (Medical Insurance):
- Annual deductible: $240 (2024), rising to $257 (2025)
- After deductible: Medicare pays 80%, you pay 20% coinsurance
- No fixed copays (you pay 20% of Medicare-approved charges)
- Out-of-Pocket Costs:
- Can be high without Medigap, especially for serious illnesses (e.g., cancer treatments)
- Medigap Plan G: Covers nearly all costs except the Part B deductible
- Medigap Plan F (no longer available to new enrollees): Covered all out-of-pocket costs
Medicare Advantage plans have their own unique approach to cost-sharing. Unlike Original Medicare’s standard 20% coinsurance, MA plans typically use fixed copayments and deductibles that vary by plan. While many offer $0 deductibles for routine care and low copays for doctor visits, costs can add up quickly for those with frequent or serious health needs—up to the plan’s annual out-of-pocket maximum. Understanding these cost structures is key to choosing the right plan.
Medicare Advantage: Costs in Brief
- Deductibles:
- Varies by plan; many have $0 medical deductibles.
- Some plans may have a small deductible for hospital services.
- Part D (drug coverage) may include a deductible up to $505 (2024), but often waived or reduced for generic drugs.
- Co-pays & Coinsurance:
- Examples:
- $10 for a primary care visit
- $45 for a specialist
- $300/day for hospital stay (first 5 days)
- Flat rate for MRIs, X-rays, etc.
- Out-of-Pocket Maximum:
- Every plan has a yearly cap on what you pay for in-network services (varies by plan, but max is $8,850 in 2025).
- Once the cap is reached, the plan pays 100% for covered services.
- General Trends:
- Often lower costs for routine and preventive care (e.g., $0 annual wellness visits).
- Can be more expensive if you have major or frequent health issues and hit the out-of-pocket max.
Quality of Care and Beneficiary Satisfaction
How do Original Medicare and Medicare Advantage compare in terms of quality and the experiences of people enrolled? This is a nuanced area, as quality can be measured by clinical outcomes, access to high-quality providers, preventive care, and patient satisfaction. Here are key points from recent research and surveys:
- How do Original Medicare and Medicare Advantage compare in terms of quality and the experiences of people enrolled? This is a nuanced area, as quality can be measured by clinical outcomes, access to high-quality providers, preventive care, and patient satisfaction. Here are key points from recent research and surveys:
- Access and Coordination: According to that KFF review, access to care (such as ability to see doctors and specialists, or get needed treatments) was reported to be largely similar between the two groups, and there were no consistent differences in wait times or in finding new providerskff.org. However, Medicare Advantage enrollees were more likely to report having a regular source of care (a primary care provider) and to get care coordination support, as many MA plans actively manage patient carekff.org. MA enrollees also reported better experiences in getting prescription drugs they need (likely because the MA plan integrates drug coverage)kff.org.
Preventive Care and Utilization: Medicare Advantage plans often emphasize preventive services. Studies found that MA enrollees are more likely to receive preventive care like annual wellness visits, screenings, and immunizations than those in Original Medicarekff.orgkff.org. This may be due to plan outreach and the structure of managed care. Additionally, MA enrollees were more likely to have a usual source of care (which is linked to better preventive care)kff.org. On the other hand, when it comes to more intensive medical services, utilization patterns differ. MA enrollees tend to have shorter or fewer hospital stays and less use of post-acute care services like skilled nursing facilities or home health care than similar patients in Original Medicarekff.org. It’s debated whether this is because MA plans manage to coordinate care better (avoiding unnecessary hospitalizations) or sometimes restrict access to care. The studies were inconclusive on whether the lower utilization in some areas was associated with better or worse health outcomeskff.org
- Provider Quality: Traditional Medicare may have an edge in certain aspects of provider quality. The KFF review found Original Medicare beneficiaries were more likely to be treated at the highest-rated hospitals and skilled nursing facilities, especially for specialized care (like top cancer centers)kff.org. This makes sense because Original Medicare allows access to any facility, including premier teaching hospitals or nationally recognized specialists, whereas an MA plan might have a narrower network that could exclude some top centers. If you have a condition that you want treated at a specific renowned facility (say, MD Anderson for cancer or the Mayo Clinic), Original Medicare (with or without Medigap) would let you go (assuming the provider accepts Medicare), possibly whereas a given MA plan might not contract with that facility. For routine care, this distinction may not be as important, but for highly specialized needs, it can be.
Cost-Related Challenges in Medicare Plans
Affordability plays a key role in healthcare access, and cost-related issues can impact the overall quality of care. Studies have found that beneficiaries with supplemental coverage—like Medigap—in Original Medicare are less likely to experience cost-related barriers to care compared to those enrolled in Medicare Advantage (MA) plans. This is likely because Medigap covers most out-of-pocket expenses, making it easier for enrollees to get the care they need without worrying about the cost at the time of service.
In contrast, Original Medicare beneficiaries without Medigap reported the highest levels of cost-related problems, such as skipping or delaying care due to expenses. This isn’t surprising, given that Original Medicare alone leaves beneficiaries responsible for 20% coinsurance with no out-of-pocket cap, which can add up quickly for those needing frequent or costly treatments.
Star Ratings and Plan Quality in Medicare
Medicare Advantage (MA) plans receive annual Star Ratings from Medicare, ranging from 1 to 5 stars, with 5 stars indicating excellent quality. These ratings are based on multiple performance metrics, including:
- Customer service
- Chronic condition management
- Preventive care
- Member satisfaction
- Drug safety and usage
Most Medicare Advantage enrollees are in plans rated 4 stars or higher, although recent changes to the scoring system led to slightly fewer plans reaching 4+ stars in 2023 and 2024.
These ratings are a useful tool for comparing MA plan quality, helping beneficiaries make informed choices during enrollment.
On the other hand, Original Medicare does not receive a Star Rating because it is a federal program, not a private health plan. However, Medicare does publish quality ratings for individual providers and facilities, such as:
- Hospital Star Ratings
- Nursing Home Compare
- Physician Compare
As a user of Original Medicare, you’ll need to research provider quality yourself, whereas MA plans often guide members toward a network of pre-vetted providers that meet their quality standards.
Health Outcomes: Medicare Advantage vs. Original Medicare
Research shows no consistent advantage in overall health outcomes or mortality between Medicare Advantage (MA) and Original Medicare. Studies have not found one program to be clearly superior in terms of patient survival or recovery across the board.
- Some research suggests Medicare Advantage may have lower hospital readmission rates, likely due to better care coordination.
- However, other studies show no significant differences in outcomes for common conditions like diabetes or heart disease.
- In reality, the quality of care often depends more on your doctors and healthcare system than the Medicare option you choose.
If you have multiple chronic conditions, MA plans may offer helpful care management tools like nurse hotlines or disease management programs. On the other hand, Original Medicare offers more flexibility, allowing you to consult specialists without network restrictions.
Member Experience & Complaints
- Medicare Advantage (MA) has faced some concerns over denials or delays in care due to prior authorization.
- A 2022 federal report found some MA plans were denying care that Original Medicare would cover.
- In 2023, CMS tightened rules to ensure MA plans align more closely with Original Medicare guidelines.
- While most MA members get needed care, extra steps can cause frustration.
- Original Medicare rarely denies covered services since it doesn’t require prior authorization.
- Disenrollment is generally low but higher among high-need individuals, many of whom switch back to Original Medicare for greater flexibility.
Recent Policy Changes and Trends (Last 3–5 Years)
Medicare Advantage has grown rapidly in recent years, now enrolling over half of Medicare beneficiaries (54% in 2024, up from 19% in 2007). This chart shows the percentage of Medicare beneficiaries enrolled in Medicare Advantage plans from 2007 to 2024, illustrating steady growth. Projections (not shown on this specific chart) estimate Medicare Advantage could exceed 60% of beneficiaries by the early 2030s.
Medicare Advantage Enrollment Surge
- In 2024, 32.8 million people (about 54% of Medicare beneficiaries) are enrolled in Medicare Advantage—surpassing Original Medicare for the first time.
- In 2014, only 30% were in MA; in the early 2000s, it was under 20%.
- Growth is expected to continue, reaching 64% by 2034 (CBO projection).
- Key drivers: $0 premiums, extra benefits, out-of-pocket caps, and aggressive marketing.
- Policymakers are closely monitoring this shift due to its long-term impact on Medicare’s structure and financing.
Medicare Spending & Payments to Medicare Advantage
- The government spends more per person on Medicare Advantage (MA) than on Original Medicare.
- On average, MA plans receive about 122% of what Original Medicare would spend for the same enrollee.
- This led to an estimated $75–$85 billion in extra spending in 2023–2024.
- The higher cost stems from:
- Benchmarks and bonus payments
- Risk adjustment based on diagnosis coding
- Despite the rich benefits offered, this has raised policy concerns about financial sustainability.
- Reforms are under discussion, which could impact future MA premiums or benefits if payment models are changed.
Prior Authorization & Oversight
- Increased scrutiny has been placed on Medicare Advantage (MA) plans over care denials and delays due to prior authorization.
- A 2022 HHS report found that some MA plans were inappropriately denying services that should have been covered.
- In response, CMS implemented new rules in 2024:
- MA plans must use coverage standards no stricter than Original Medicare.
- A 90-day transition period is required when switching plans, allowing time for ongoing treatments to continue.
- Prior authorization processes must be more transparent and streamlined.
- Marketing Oversight:
- Due to misleading sales tactics, CMS now requires:
- Clear disclaimers in all MA marketing (since 2023)
- Standardized, honest communication from agents and brokers
- Due to misleading sales tactics, CMS now requires:
Benefit Improvements
- Legislation like the Inflation Reduction Act of 2022 brought major improvements to Part D drug coverage for all Medicare users:
- 2023: $0 copay for recommended adult vaccines (e.g., shingles, tetanus), and insulin capped at $35/month.
- 2024: 5% coinsurance eliminated in the catastrophic drug coverage phase.
- 2025: Annual $2,000 cap on out-of-pocket drug costs under Part D.
- These changes apply to:
- Original Medicare + Part D plans
- Medicare Advantage plans with drug coverage (MA-PD)
- Level playing field for drug costs.
- Telehealth Expansion:
- Originally expanded during COVID-19 under Original Medicare, and extended through at least 2024.
- Medicare Advantage already offered telehealth, but now Original Medicare also covers many virtual services.
- Preventive Services:
- Original Medicare has continued to expand preventive care access over time.
Equity & Innovation
- Medicare Advantage has expanded Special Needs Plans (SNPs) for:
- People with Medicare + Medicaid
- Chronic conditions
- Those in nursing homes
- SNP enrollment more than doubled from 2019 to 2024, reaching 6.6 million.
- SNPs offer:
- Extra benefits
- Greater support for low-income or high-need populations
- Original Medicare innovations:
- Growth in Accountable Care Organizations (ACOs) and alternative payment models
- Aim to provide coordinated care and cost control without shifting beneficiaries to private plans
Pros and Cons of Original Medicare
To crystallize the discussion, here are the primary advantages and disadvantages of choosing Original Medicare (with or without adding a Medigap and Part D plan):
Pros of Original Medicare:
Broad Provider Access
- Nationwide Access:
- With Original Medicare, you can see any doctor, specialist, or hospital in the U.S. that accepts Medicare — with no network restrictions 【source: medicare.gov】.
- Ideal for Travelers:
This flexibility is especially beneficial for people who travel frequently, split time between states, or want access to renowned medical centers that may not participate in private plan networks. - No Referrals Needed:
In most cases, you do not need a referral to see a specialist — you can schedule visits directly with any Medicare-participating provider 【source: medicare.gov】
- No Plan Oversight of Care: Medicare itself generally does not require prior authorizations for services. If a service is covered by Medicare, you and your doctor decide on your care without an insurance company’s gatekeepingmedicare.gov. This can make getting care smoother and with fewer delays or paperwork compared to managed care plans
- Predictable Coverage with Medigap: If you add a Medigap supplement, your out-of-pocket costs can be almost entirely covered for approved servicesmedigapadvisors.com. This means you might pay higher premiums, but you have very little to no cost-sharing when you actually get care – providing peace of mind and financial protection (effectively a 100% coverage after premiums, especially with Plan G or F). There is also no restricted annual enrollment window for Medigap after your initial enrollment (though acceptance isn’t guaranteed after initial eligibility in many states).
- Flexibility in Drug Plan Choice: You can choose from many stand-alone Part D plans to pair with Original Medicare. This means you can select a drug plan that best fits your medication needs (different plans have different formularies). If your drug needs change, you can switch Part D plans annually without affecting the rest of your coverage. In MA, you’re stuck with the drug coverage your plan offers unless you change the whole plan.
Cons of Original Medicare:
No Out-of-Pocket Limit (Without Supplement)
One of the most significant disadvantages of Original Medicare is that it does not include an annual out-of-pocket maximum. This means:
- You could face unlimited costs in a year if you have a serious illness or require frequent care.
- Unlike Medicare Advantage (MA) plans, which cap your annual spending, Original Medicare leaves you financially exposed unless you purchase Medigap (Medicare Supplement Insurance).
- A single hospitalization or ongoing treatments like chemotherapy could result in thousands of dollars in coinsurance costs.
Multiple Plans and Premiums to Manage
Original Medicare by itself doesn’t cover everything, so most beneficiaries end up layering on:
- Part D (prescription drug coverage)
- Medigap (to cover out-of-pocket costs)
This can lead to:
- Separate premiums for Part B, Part D, and Medigap.
- Complexity in managing multiple plans and billing sources.
- Confusion during annual enrollment periods, especially when trying to coordinate changes in drug plans or supplemental insurance.
No Extra Benefits (Dental, Vision, Hearing, etc.)
Original Medicare does not include routine benefits like:
- Dental cleanings, dentures
- Vision exams, eyeglasses
- Hearing aids and audiology visits
- Gym memberships or wellness perks
These benefits are commonly included in many Medicare Advantage plans, but with Original Medicare, you would need to pay out-of-pocket or purchase standalone coverage.
Potential for High Out-of-Pocket Costs Without a Supplement
If you do not purchase a Medigap plan, you’re responsible for:
- The 20% coinsurance on Part B services (after the annual deductible)
- The Part A deductible per benefit period ($1,632 in 2024)
- Hospital coinsurance for extended stays
- No limit to how much you could owe in a year
This can quickly become a financial burden, especially for people with chronic conditions or serious medical needs.
Navigating Care on Your Own
Unlike Medicare Advantage plans that often:
- Provide care coordination
- Offer disease management programs
- Connect you with nurse hotlines and in-plan specialists
Original Medicare leaves it up to you and your doctor to organize your care. This might be fine for those with straightforward needs, but for individuals managing multiple conditions, it can be overwhelming and fragmented.
Additionally, there is no centralized provider network, so you must verify each provider accepts Medicare and research provider quality yourself (though tools like Medicare.gov’s Hospital Compare can help).
Pros and Cons of Medicare Advantage
Pros of Medicare Advantage:
Additional Benefits Not Covered by Original Medicare
One of the biggest attractions of Medicare Advantage plans is the extra benefits they often include—services that Original Medicare does not cover, such as:
- Dental care (cleanings, fillings, dentures)
- Vision care (eye exams, glasses, contacts)
- Hearing care (hearing aids, audiologist visits)
- Wellness programs (like gym memberships through Silver Sneakers)
- Over-the-counter (OTC) allowances for items like vitamins, pain relievers, or first aid supplies
These perks add substantial value, especially for those who regularly use these services and want to reduce out-of-pocket costs.
All-in-One Convenience
Medicare Advantage simplifies your coverage by combining medical, hospital, and often drug coverage into one plan. This bundled structure means:
- Fewer separate plans to manage (unlike Original Medicare + Part D + Medigap).
- A single insurance card for all services.
- Streamlined customer service from one insurer for all your healthcare questions.
- Some plans also bundle in extra services like transportation, meal delivery, or telehealth options.
This makes Medicare Advantage ideal for people who prefer simplicity and centralization in their health coverage.
Lower (or $0) Monthly Premiums
Many Medicare Advantage plans offer low-cost or even $0 monthly premiums:
- These plans are still funded by Medicare, but competition among insurers can drive down premiums.
- You still pay your Part B premium, but may avoid paying extra for a Part D or Medigap plan.
- For those on a fixed income, lower premiums can make MA plans more accessible and budget-friendly.
It’s important to check out the total cost of care, including copays and deductibles, but for many, the low premiums are a major advantage.
Out-of-Pocket Maximum Protection
Unlike Original Medicare, Medicare Advantage plans are required to set an annual cap on your out-of-pocket spending for covered medical services:
- Once you hit that cap, the plan pays 100% of covered costs for the rest of the year.
- In 2025, the maximum limit is $8,850, though many plans have lower thresholds.
This feature offers financial peace of mind, especially for those worried about unexpected or high medical bills. Original Medicare offers no such cap unless paired with a Medigap plan.
Managed Care May Improve Preventive and Coordinated Care
Most MA plans operate as HMOs or PPOs, which means they often:
- Focus on care coordination across doctors and specialists.
- Offer chronic condition management programs, nurse helplines, and personalized care teams.
- Provide proactive outreach for screenings, vaccines, and wellness visits.
This managed care model may improve preventive care and early detection of health issues, especially for those with multiple or complex conditions. For many beneficiaries, it can mean better overall health outcomes and fewer hospital visits.
Cons of Medicare Advantage:
Restricted Provider Networks
A provider network is a group of doctors, hospitals, and other health care providers contracted with a plan to provide services at negotiated rates.
- MA plans usually require you to use in-network providers to receive full coverage.
- Out-of-network care may be denied or cost more, depending on the plan (HMO vs. PPO).
- Network participation can change yearly, affecting which doctors are available.
- Not ideal for people who live in two places (snowbirds) or travel frequently.
Referral and Authorization Requirements
- A referral is a written order from your primary care doctor to see a specialist.
- Prior authorization is advance approval from the plan before it will pay for certain services.
- Many HMO-style MA plans require referrals before seeing a specialist.
- Prior authorization is often needed for high-cost procedures, tests, or hospital stays.
- This process can delay care and add administrative burden.
- Original Medicare typically doesn’t require these steps.
Potential for High Cost-Sharing During Serious Illness
Cost-sharing refers to out-of-pocket payments like copays, coinsurance, and deductibles that you’re responsible for, even with insurance.
- While MA may have low costs for routine care, serious health events (e.g., cancer) can push you to the plan’s out-of-pocket maximum (up to $8,850 in 2025).
- Over several years, these costs can exceed what you’d pay in Medigap premiums under Original Medicare.
- MA is often pay-as-you-go, while Medigap is pay-upfront-for-peace-of-mind.
Annual Plan Changes & Complexity
Medicare Advantage plans renew each year, and insurers can change benefits, provider networks, and covered drugs.
- You must review your plan annually to ensure it still meets your needs.
- Doctors may leave the network, or your prescriptions may no longer be covered affordably.
- This annual reassessment can be confusing or burdensome, especially for older adults.
- In contrast, Original Medicare + Medigap remains more stable year-to-year.
Geographic Limitations
Medicare Advantage plans operate within specific service areas, usually defined by counties or regions.
- If you move to a new area, your MA plan may no longer be available.
- You’ll likely need to switch plans if relocating—even within the same state.
- People who split time between two homes may find Original Medicare more suitable due to its nationwide provider access.
Limited Trial Period for Medigap if Changing Mind
- Medigap is supplemental insurance you can add to Original Medicare to cover costs like coinsurance and deductibles.
- Guaranteed issue rights mean you can buy Medigap without being denied or charged more due to health issues.
- If you start with Medicare Advantage at age 65, you generally lose your right to buy Medigap later without medical underwriting.
- You get one 12-month trial period to try MA and switch back to Original Medicare with Medigap without restrictions.
- After that, you may be denied Medigap based on health status, locking you into MA.
Conclusion: Making Your Decision
- Both Original Medicare and Medicare Advantage provide comprehensive healthcare coverage, but they do so in fundamentally different ways. Original Medicare stands out for its unmatched flexibility, allowing beneficiaries to see any doctor or specialist nationwide who accepts Medicare, without referrals or network restrictions. When paired with a Medigap supplement, it can virtually eliminate out-of-pocket costs for covered services, offering predictability and peace of mind. This route is often favored by those who prioritize freedom of choice, minimal interference in healthcare decisions, and are willing to pay higher monthly premiums for supplemental coverage in exchange for broader access and greater cost protection.
- On the other hand, Medicare Advantage appeals to individuals who prefer the convenience of an all-in-one plan that often includes additional benefits like dental, vision, hearing, and fitness memberships. These plans typically have low or even $0 premiums and include an annual out-of-pocket cap, which Original Medicare lacks. However, they operate within a network of providers and often require prior authorizations for certain services. For those whose preferred doctors are in-network and who appreciate extra perks and managed care coordination, Medicare Advantage can be an excellent fit.
- In the end, choosing between Original Medicare and Medicare Advantage depends on your personal health needs, budget, lifestyle, and how much flexibility you want in managing your care. Carefully evaluating your priorities will help ensure you choose the Medicare path that best supports your well-being.
