March 18, 2025 | Insurance Disputes

Should you go with an original Medicare or Medicare Advantage plan? This is a major decision that many people have to make. Your decision could determine whether or not you can access the treatment and care you may require in the future. Unfortunately, many people make this decision without truly understanding the benefits and drawbacks of each plan. While both plans provide essential health coverage, they operate very differently. In fact, recent trends show that many beneficiaries are opting to leave Medicare Advantage in favor of the Original Medicare.

Below, we take a look at key differences between Medicare Advantage and Original Medicare.

Key Differences between Original Medicare and Medicare Advantage

• Healthcare Providers

One of the biggest benefits of Original Medicare is that you can see any doctor, hospital or specialist within the country that accepts Medicare. The original Medicare has no network restrictions.

Medicare Advantage typically operates within networks. This means that you may need referrals and may be limited to provider choices. If you choose to go to a healthcare provider outside the network of your plan, you could pay much higher costs or even lose coverage altogether.

This is one of the major reasons why many patients are opting for Original Medicare. The need for referrals or searching for a healthcare provider within the network can cause delay and frustration.

• Coverage and benefits

Original Medicare covers (Part A) hospital stays and in-patient care as well as (Part B) medical services such as doctor visits, outpatient services and some preventative care. It does not cover services such as dental or vision services. It also does not cover prescription drugs. You would need to add a Medigap Plan or pay out of pocket for these additional benefits.

Medicare Advantage offers more coverage. Extra benefits such as dental, vision, hearing and prescription drugs are often included under one plan. Some plans even offer additional benefits such as transportation or fitness memberships. Despite this, many people still complain that the benefits under Medicare Advantage are not as comprehensive as advertised.

• Cost

Original Medicare requires payment of monthly premiums for Part B. You will also be required to pay deductibles and coinsurance (about 20 percent of the costs). If you’re looking to  access treatment not covered under the Original Medicare plan, you would need to buy a Medigap (Medicare Supplement) policy or pay out of pocket. A Medigap policy can significantly reduce your out-of-pocket expenses.

Medicare Advantage plans are advertised as having extremely low monthly premiums. However, many of these plans come with higher copays and deductibles. Many push the limits in terms of out-of-pocket expenses. The cost of a Medicare Advantage plan is therefore much higher when accessing healthcare services.

• Prior-authorization

Original Medicare does not require pre-authorization. You can access the medical services you need when you need them and from any service provider that accepts Medicare. There are therefore fewer denials under the original Medicare.

Medicare Advantage plans require prior authorization for procedures, specialist visits and even medications. This means that the insurer may deny or delay care motivated by the desire to save money.

• Insurance providers

Original Medicare is funded by the federal government. This is unlike Medicare Advantage which is provided by private insurance companies. These private insurance companies are driven by profits. They may therefore resort to underhand tactics to minimize their losses. This includes denying or delaying claims.

• Geographic coverage

Because original Medicare is funded by the federal government, it provides national coverage. This makes it convenient for frequent travelers or anyone relocating. You don’t have to switch insurance companies or search for healthcare providers within the plan’s network. You only need to find a healthcare provider that accepts Medicare.

Medicare Advantage plans are typically restricted to specific states or regions. This means you may have limited access to care when traveling. For those relocating, you may have to switch to a different provider. Many find it easier to switch back to the Original Medicare.

Tips for Choosing Your Health Insurance Plan

There are various factors to consider when deciding between Original Medicare and Medicare Advantage. These include:

• Whether you need coverage for additional benefits such as dental or vision.
• What you can afford? Consider the total cost of the plan including the premiums, copays, deductibles and out-of-pocket expenses.
• Consider how often you leave home. If you’re often on the road and travel outside your network coverage, you would be better off with the Original Medicare.

No matter which option you choose, it is important to note that you can switch from Medicare Advantage to Original Medicare and vice versa when the need arises. Simply ensure that you meet the requirements. Evaluate your needs and what you want out of your plan and make a choice that will meet your needs.

Original Medicare and Medicare Advantage