Article-At-A-Glance

• Original Medicare consists of Part A (hospital insurance) and Part B (medical insurance), while Medicare Advantage combines these with additional benefits in one plan
• Medicare Advantage plans typically include prescription drug coverage and extra benefits like dental, vision, and fitness programs that Original Medicare doesn’t cover
• Original Medicare allows you to see any provider nationwide who accepts Medicare, while Medicare Advantage plans usually restrict you to network providers
• Medicare Advantage plans offer financial protection with annual out-of-pocket maximums, a feature not available with Original Medicare alone
• UnitedHealthcare offers Medicare Advantage plans that provide comprehensive coverage options to help seniors manage their healthcare needs and costs

Choosing between Original Medicare and Medicare Advantage is one of the most important healthcare decisions seniors face. Both options provide essential Medicare coverage, but they do so in fundamentally different ways that can significantly impact your healthcare experience, provider access, and out-of-pocket costs. Understanding these differences is crucial to making the right choice for your specific health needs and preferences.

Medicare Choices Made Simple: Advantage vs. Original

Medicare comes in two main flavors: Original Medicare (Parts A and B) administered directly by the federal government, and Medicare Advantage (Part C) offered by private insurance companies approved by Medicare. While both provide the same basic level of hospital and medical benefits, how they’re structured, what they cover beyond the basics, and how much they cost can vary significantly. UnitedHealthcare’s Medicare education resources help seniors understand these options to make informed decisions about their healthcare coverage.

Both Cover Essential Hospital and Medical Services

At their core, both Original Medicare and Medicare Advantage plans must cover all medically necessary services that Original Medicare covers. This includes hospital stays, skilled nursing facility care, home health visits, doctor services, preventive care, lab tests, and more. If Original Medicare covers a service, Medicare Advantage must cover it too (except for hospice care, which Original Medicare still covers even if you have a Medicare Advantage plan).

Medicare Advantage Includes Extra Benefits Like Dental and Vision

Where Medicare Advantage really stands out is in the additional benefits many plans offer beyond what Original Medicare covers. Most Medicare Advantage plans include prescription drug coverage (Part D) and many offer dental care, vision services, hearing aids, fitness memberships, transportation to medical appointments, and even meal delivery after hospital stays. These extra benefits vary by plan but can provide significant value and convenience compared to Original Medicare, which offers none of these additional services.

Original Medicare Offers Nationwide Provider Access

With Original Medicare, you can visit any doctor, hospital, or facility in the United States that accepts Medicare patients. There’s no need to get referrals to see specialists, and you don’t need prior authorization for services. This flexibility is particularly valuable for those who travel frequently, have multiple residences, or simply prefer complete freedom in choosing healthcare providers. Medicare Advantage plans, in contrast, typically limit you to providers within their network and may require referrals and authorizations.

Medicare Advantage Has Out-of-Pocket Limits for Financial Protection

A significant financial advantage of Medicare Advantage plans is their mandatory annual out-of-pocket maximum limit for covered Part A and Part B services. Once you reach this limit, you’ll pay nothing for covered services for the rest of the year. Original Medicare has no such cap, meaning your potential costs could continue to add up if you have serious health issues. This built-in financial protection can provide peace of mind and help keep healthcare costs predictable.

Original Medicare: The Traditional Coverage Option

Original Medicare has been the foundation of senior healthcare in America since 1965. It consists of two parts that work together to provide your basic hospital and medical coverage. Understanding what each part covers—and what they don’t—is essential to making an informed decision about whether Original Medicare is right for you.

Part A: Hospital Insurance Coverage

Medicare Part A covers inpatient hospital care, skilled nursing facility care, nursing home care (as long as it’s not just custodial care), hospice, and home health services. Most people don’t pay a premium for Part A if they or their spouse paid Medicare taxes while working for at least 10 years. However, Part A comes with a deductible ($1,600 in 2023 for each benefit period) and coinsurance for extended hospital or skilled nursing facility stays.

Part B: Medical Insurance Coverage

Medicare Part B covers medically necessary services like doctor visits, outpatient care, preventive services, and durable medical equipment. Unlike Part A, Part B requires everyone to pay a monthly premium ($164.90 for most people in 2023), an annual deductible ($226 in 2023), and typically 20% coinsurance for most services after meeting the deductible. This 20% coinsurance has no cap, meaning that expensive procedures or prolonged illnesses could result in significant out-of-pocket costs.

What Original Medicare Doesn’t Cover

Original Medicare has notable coverage gaps that seniors should be aware of. It doesn’t cover most dental care, eye exams for prescription glasses, dentures, cosmetic surgery, acupuncture, hearing aids, or routine foot care. Perhaps most significantly, Original Medicare doesn’t cover prescription drugs, requiring a separate Part D plan purchase. It also doesn’t cover care received while traveling outside the United States, except in very limited circumstances.

Medicare Advantage: The All-in-One Alternative

Medicare Advantage plans offer a different approach to Medicare coverage by combining multiple benefits into one comprehensive plan. These plans are offered by private insurance companies that contract with Medicare to provide your benefits. They must cover everything that Original Medicare covers (except hospice care, which is still covered by Original Medicare), but they typically include additional benefits and different cost structures.

Combines Parts A and B with Additional Benefits

Medicare Advantage plans bundle Part A and Part B coverage into a single plan. This integration creates a more streamlined experience with one insurance card and one set of plan rules to follow. Most plans also include prescription drug coverage and extra benefits not available in Original Medicare, potentially eliminating the need for multiple separate insurance policies. The consolidated approach can make healthcare more manageable for many seniors who prefer simplicity.

Part D Prescription Drug Coverage Usually Included

While Original Medicare requires a separate Part D plan purchase for prescription drug coverage, most Medicare Advantage plans include drug coverage built right in. These Medicare Advantage Prescription Drug plans (MA-PDs) cover both retail and mail-order prescriptions. Each plan has its own formulary (list of covered drugs), so it’s important to check whether your specific medications are covered and at what cost tier before enrolling in a plan.

Extra Benefits Not Available in Original Medicare

A key advantage of Medicare Advantage plans is their ability to offer benefits beyond what Original Medicare covers. Depending on the specific plan, these might include dental checkups and procedures, vision exams and glasses, hearing tests and hearing aids, over-the-counter allowances for health products, fitness memberships like SilverSneakers, transportation to medical appointments, meal delivery after hospital stays, and even home safety modifications. These extra benefits can significantly enhance quality of life and help manage chronic conditions more effectively.

Cost Differences That Impact Your Wallet

Understanding the cost implications of both Medicare options is crucial for making a financially sound decision. The way you pay for healthcare differs significantly between Original Medicare and Medicare Advantage, affecting not just your monthly budget but also your financial exposure during illness or injury.

Premium Costs Comparison

With Original Medicare, you’ll pay the standard Part B premium ($164.90 for most people in 2023), plus a Part D premium if you want prescription drug coverage (averaging $31.50 monthly in 2023), and possibly a Medigap premium if you want supplemental coverage (which can range from $50 to over $300 monthly). Medicare Advantage premiums vary widely by plan and location, with many plans offering $0 premiums beyond the required Part B premium. Some Medicare Advantage plans even reduce part of your Part B premium, though these typically offer fewer extra benefits.

Deductibles and Copays

Original Medicare has set deductibles for Part A and Part B that change annually. After meeting these deductibles, you typically pay 20% of the Medicare-approved amount for most doctor services with no upper limit. Medicare Advantage plans generally use a different structure with fixed copays for services (like $20 for a primary care visit or $250 per day for hospital stays) rather than percentage-based coinsurance. This copay structure can make costs more predictable, especially for routine care and services used regularly.

Out-of-Pocket Maximum Protection

One of the most significant financial advantages Medicare Advantage plans offer is their mandatory out-of-pocket maximum, which was $8,300 for in-network services in 2023 (though many plans set lower limits). Once you reach this limit, your plan pays 100% of covered services for the remainder of the year. Original Medicare has no such protection, meaning your 20% coinsurance continues indefinitely. For someone facing serious health issues or extensive treatment, this difference can mean thousands of dollars in savings with Medicare Advantage.

The True Cost of Medicare: Beyond Premiums

When comparing costs, it’s important to look beyond monthly premiums. While Original Medicare with supplemental coverage often has higher monthly premiums than Medicare Advantage, the out-of-pocket costs when you actually use healthcare services may be lower with comprehensive Medigap coverage. Medicare Advantage plans typically offer lower premiums but may have higher costs when you use services. Your personal healthcare utilization patterns should guide this decision—frequent healthcare users might save more with Original Medicare plus Medigap despite higher premiums.

Provider Networks: Freedom vs. Coordination

One of the most fundamental differences between Original Medicare and Medicare Advantage is how they approach provider networks and care coordination. This difference affects everything from which doctors you can see to how your care is managed across different healthcare settings.

Original Medicare’s Nationwide Access

With Original Medicare, you can see any doctor or specialist and use any hospital or facility in the United States that accepts Medicare assignment—roughly 93% of all providers. There’s no need to choose primary care physicians, get referrals to see specialists, or worry about whether emergency care while traveling is “in-network.” This flexibility is particularly valuable for those who split time between different locations, travel frequently, or simply value having complete freedom in their healthcare choices.

Medicare Advantage Network Restrictions

Most Medicare Advantage plans use provider networks to control costs and coordinate care. HMO plans typically require you to use in-network providers except in emergencies, while PPO plans allow out-of-network care at higher cost-sharing levels. These network restrictions help keep premiums lower but limit provider choice. Before enrolling in a Medicare Advantage plan, it’s crucial to verify that your preferred doctors, specialists, and hospitals participate in the plan’s network to avoid unexpected costs or having to change providers. For more insight on the importance of reviewing your Medicare plan, check out 5 reasons to review your Medicare plan annually.

Referral Requirements for Specialists

Many Medicare Advantage plans, particularly HMOs, require you to get a referral from your primary care physician before seeing specialists. This referral process aims to ensure coordinated care but can create delays in accessing specialist services. Original Medicare has no such requirements—you can see any Medicare-participating specialist directly without referrals. For those managing complex or multiple health conditions requiring frequent specialist care, this difference in access can significantly impact the healthcare experience. It’s important to review your Medicare plan annually to ensure it meets your healthcare needs.

Prescription Drug Coverage Comparison

Prescription drug coverage represents another major difference between Original Medicare and Medicare Advantage. How you get your medications covered, what you pay, and how convenient it is to use your benefits varies substantially between these options.

How to Get Drug Coverage with Original Medicare

Original Medicare doesn’t include prescription drug coverage, so you’ll need to purchase a separate Part D plan from a private insurer. These standalone plans have their own premiums, deductibles, formularies, and pharmacy networks. You’ll need to manage this coverage separately from your medical benefits, with a separate insurance card and set of rules. While this separation allows you to choose the specific drug plan that best covers your medications, it also adds complexity to your overall Medicare experience.

Medicare Advantage Drug Coverage Integration

Most Medicare Advantage plans include prescription drug coverage as part of their comprehensive benefit package. This integration means one insurance card, one set of customer service contacts, and often better coordination between your drug coverage and medical benefits. Some Medicare Advantage plans also offer enhanced drug benefits like $0 copays for preferred generic medications or reduced costs during the coverage gap. The convenience of this all-in-one approach appeals to many seniors who prefer simplicity in managing their healthcare benefits.

Who Benefits Most From Each Option?

While both Original Medicare and Medicare Advantage provide quality coverage, certain individuals may find one option better suited to their specific circumstances, preferences, and healthcare needs. Understanding which characteristics align better with each option can help guide your decision.

Original Medicare Is Better For:

People who prioritize provider choice and flexibility typically prefer Original Medicare. This includes frequent travelers, “snowbirds” who live in different states seasonally, or those who want absolute freedom to see any Medicare-accepting provider nationwide without referrals or network restrictions. Original Medicare combined with a comprehensive Medigap plan also works well for those who want predictable costs with minimal out-of-pocket expenses when receiving care, even if it means paying higher monthly premiums.

Those with established relationships with specific specialists who might not participate in Medicare Advantage networks often choose Original Medicare to maintain continuity of care. Similarly, people with complex or rare health conditions requiring highly specialized treatment may find the provider flexibility of Original Medicare essential for accessing the specific expertise they need, potentially at centers of excellence nationwide.

Medicare Advantage Is Better For:

Medicare Advantage plans typically benefit those seeking comprehensive coverage in one convenient package. People who want prescription drug coverage, dental, vision, hearing benefits, and fitness programs bundled together often appreciate the simplicity of having everything under one plan. Budget-conscious seniors who prefer lower monthly premiums and are comfortable with network restrictions can find significant value in Medicare Advantage plans, especially those offering $0 premium options.

Those who prefer coordinated care models also tend to favor Medicare Advantage. Many plans offer care coordination services, disease management programs, and wellness initiatives that help manage chronic conditions more effectively. The out-of-pocket maximum protection provided by Medicare Advantage plans also makes them attractive to those concerned about catastrophic healthcare costs, providing financial security that Original Medicare alone doesn’t offer.

Special Considerations for Frequent Travelers

For frequent travelers, especially those who travel internationally, Original Medicare often presents advantages over Medicare Advantage. Original Medicare provides coverage throughout the United States, though it generally doesn’t cover care received outside the country. Medicare Advantage plans typically restrict routine care to network providers in specific service areas, though they must cover emergency care nationwide. Some Medicare Advantage plans offer limited international emergency coverage, but for extensive international travel, a separate travel medical insurance policy is advisable regardless of which Medicare option you choose.

How to Switch Between Plans If You Change Your Mind

The good news about Medicare choices is that they’re not permanent—you have opportunities to change your coverage if your needs evolve or if you’re dissatisfied with your current option. Understanding these enrollment periods helps ensure you can make changes when necessary without coverage gaps or penalties.

Annual Enrollment Period

The Medicare Annual Enrollment Period runs from October 15 to December 7 each year. During this time, you can switch from Original Medicare to a Medicare Advantage plan, change from one Medicare Advantage plan to another, return to Original Medicare from Medicare Advantage, or make changes to your prescription drug coverage. Any changes you make during this period take effect on January 1 of the following year, giving you an annual opportunity to reassess and adjust your Medicare coverage based on your current needs.

Medicare Advantage Open Enrollment Period

If you’re already enrolled in a Medicare Advantage plan, you get another opportunity to make changes during the Medicare Advantage Open Enrollment Period from January 1 to March 31 each year. During this period, you can switch to a different Medicare Advantage plan or return to Original Medicare (with or without joining a separate Medicare drug plan). This extra enrollment window provides flexibility if you discover your chosen Medicare Advantage plan doesn’t meet your needs after using it for a short time in the new year.

Special Enrollment Periods for Life Changes

Beyond the standard enrollment periods, Medicare offers Special Enrollment Periods (SEPs) triggered by specific life events. These include moving outside your plan’s service area, losing other insurance coverage, qualifying for Extra Help with Medicare costs, or your plan leaving the Medicare program. If you qualify for an SEP, you typically have two months from the qualifying event to make changes to your coverage. These special periods ensure you’re not locked into inappropriate coverage when your circumstances change unexpectedly. It’s important to review your Medicare plan annually to stay informed about your options.

Making Your Medicare Decision With Confidence

Choosing between Original Medicare and Medicare Advantage represents one of the most important healthcare decisions you’ll make. Taking a systematic approach to this decision can help ensure you select the option that best meets your personal healthcare needs, preferences, and financial situation.

• Assess your healthcare usage patterns and provider preferences
• Review and compare costs including premiums, deductibles, and potential out-of-pocket expenses
• Consider your need for extra benefits like dental, vision, and hearing
• Evaluate the importance of provider choice versus potential cost savings
• Think about whether you prefer coordinated care or more independent healthcare management

Remember that what works best for your friend or neighbor might not be right for you. Medicare choices are highly personal and should reflect your specific health conditions, financial situation, and preferences regarding how you receive healthcare services.

The good news is that Medicare enrollment periods give you flexibility to change your mind if your initial choice doesn’t work out as expected or if your circumstances change. What matters most is making an informed initial decision based on thorough research and consideration of your unique needs. For instance, it’s beneficial to review your Medicare plan annually to ensure it still meets your healthcare requirements.

Step-by-Step Decision Guide

Start your decision process by listing your current doctors, specialists, and medications. Check whether your preferred providers participate in Medicare Advantage plans available in your area, and whether your medications appear on plan formularies. This provider and prescription verification is often the most important first step in determining which Medicare path might work better for you.

Next, honestly assess your healthcare utilization patterns and financial situation. Do you see doctors frequently? Do you have chronic conditions requiring ongoing care? Are you comfortable with higher monthly premiums in exchange for lower costs when receiving services, or do you prefer lower upfront costs with potentially higher expenses when you need care? These considerations will help clarify whether Original Medicare with supplemental coverage or a Medicare Advantage plan better aligns with your needs.

Questions to Ask Before Choosing

Before making your final decision, ask yourself: How important is keeping my current doctors? How much do I travel or spend time in different locations? Do I want coverage for services like dental and vision? How predictable are my healthcare expenses, and how much financial risk am I comfortable assuming? Am I comfortable with managed care approaches like referrals and prior authorizations? The answers to these questions often point clearly toward either Original Medicare or Medicare Advantage as the better fit for your specific situation.

Where to Get Personalized Help

Free, unbiased Medicare counseling is available through your State Health Insurance Assistance Program (SHIP). These programs provide one-on-one assistance with Medicare questions and can help you compare your specific options. Medicare’s plan finder tool at Medicare.gov also allows you to compare plans based on your specific medications and preferences. Insurance brokers who represent multiple companies can provide personalized recommendations, though remember they may receive commissions from insurers for enrollments.

For more detailed information about Medicare Advantage options, resources like UnitedHealthcare’s Medicare education center can provide valuable insights into plan features, benefits, and considerations to help inform your decision-making process. Additionally, reviewing your Medicare plan annually is crucial, and you can explore 5 reasons to review your Medicare plan annually to ensure it continues to meet your needs.

Frequently Asked Questions

As you navigate your Medicare options, certain questions come up frequently. Understanding these common concerns can help clarify important aspects of both Original Medicare and Medicare Advantage.

• What happens to my existing coverage when I enroll in Medicare?
• Can I keep my current doctors if I choose Medicare Advantage?
• How do Medicare costs change if I have limited income and resources?
• What coverage is available for long-term care needs?
• How does Medicare work with other insurance I might have?

These questions reflect the complexity of Medicare decisions and the need to consider how your choice fits within your broader healthcare and financial picture. The answers often depend on your specific circumstances, which is why personalized counseling can be so valuable in the decision-making process.

Remember that making an informed Medicare choice isn’t just about understanding the options—it’s about understanding how those options align with your personal healthcare needs, preferences, and financial situation.

Can I have both Original Medicare and Medicare Advantage at the same time?

No, you cannot be enrolled in both Original Medicare and Medicare Advantage simultaneously. When you join a Medicare Advantage plan, you’re choosing to receive your Medicare benefits through that private plan rather than through the federal government’s Original Medicare program. You still have Medicare, but your coverage comes from the private Medicare Advantage plan rather than directly from Medicare. You continue paying your Part B premium, and the Medicare Advantage plan becomes responsible for providing all your Part A and Part B benefits (except hospice care, which Original Medicare still covers).

Will my prescription drugs be covered the same way in both options?

Prescription drug coverage works differently between the two Medicare options. With Original Medicare, you need to purchase a separate Part D plan to get drug coverage, with its own premium, deductible, and cost-sharing structure. Most Medicare Advantage plans include drug coverage built in, creating a more integrated experience with a single formulary and set of pharmacy benefits. For more information on how to make the best choice, here are 5 reasons to review your Medicare plan annually.

The specific medications covered and what you’ll pay for them vary widely between different Part D plans and Medicare Advantage plans. Each plan has its own formulary (list of covered drugs) and tier structure that determines your out-of-pocket costs. It’s essential to check whether your specific medications are covered by any plan you’re considering and at what cost tier they fall under.

How do Medicare Supplement (Medigap) plans fit with these options?

Medicare Supplement Insurance, also called Medigap, works only with Original Medicare—not with Medicare Advantage. These policies, sold by private companies, help pay some of the healthcare costs that Original Medicare doesn’t cover, such as copayments, coinsurance, and deductibles. With a comprehensive Medigap plan, you may have very minimal out-of-pocket costs when receiving Medicare-covered services.

If you have a Medicare Advantage plan, it’s illegal for anyone to sell you a Medigap policy unless you’re switching back to Original Medicare. Medicare Advantage plans have their own approach to limiting out-of-pocket costs through their mandatory annual maximum, which serves a similar function to Medigap but works differently. Understanding this distinction is important—you’ll either have Original Medicare plus Medigap (and possibly Part D), or you’ll have Medicare Advantage, but not both simultaneously.

What happens if I’m unhappy with my Medicare Advantage plan?

If you’re dissatisfied with your Medicare Advantage plan, you have several opportunities to make changes. During the Annual Enrollment Period (October 15-December 7) or the Medicare Advantage Open Enrollment Period (January 1-March 31), you can switch to a different Medicare Advantage plan or return to Original Medicare. If you return to Original Medicare, you also have the right to buy a Medigap policy, though in most states after your initial enrollment period, medical underwriting may apply, meaning you could be denied coverage or charged more based on pre-existing conditions.

Do Medicare Advantage plans change their benefits and costs each year?

Yes, Medicare Advantage plans can and often do change their benefits, costs, provider networks, and drug formularies from year to year. These changes typically take effect on January 1, and your plan must notify you of any changes by sending an Annual Notice of Change (ANOC) document by September 30. This notification gives you time to review changes before the Annual Enrollment Period begins on October 15, allowing you to switch plans if the changes don’t meet your needs. This annual variation is one reason why it’s important to review your coverage each year rather than automatically renewing the same plan.

Understanding these differences between Original Medicare and Medicare Advantage empowers you to make the choice that best fits your healthcare needs, preferences, and budget. While navigating Medicare options can seem complex, taking time to understand the fundamental differences helps ensure you select coverage that provides the right balance of benefits, provider access, and cost protection for your unique situation.

UnitedHealthcare offers a range of Medicare Advantage plans designed to provide comprehensive coverage options that may help seniors better manage their healthcare needs while potentially reducing out-of-pocket costs. It’s important to regularly review your Medicare plan to ensure it continues to meet your healthcare needs effectively.