Difference between Medicare and Medicare Advantage

The 2021 chart below compares the differences between Original Medicare vs. Medicare Advantage. The 2021 Medicare chart shows positive (green), negative (red), and equal value (black). Original Medicare provides you with nationwide coverage and access to more doctors and hospitals without referrals. In comparison, Medicare Advantage provides you with more local or regional coverage for doctors and hospitals in-network. You can see several differences between Medicare Advantage vs. Original Medicare in the chart below.

Medicare Advantage vs Medicare
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Medicare Advantage Plans Costs Less

Medicare Advantage charges copays for each doctor visit or medical service. However, Original Medicare only charges copays for specific diagnostic tests, hospital outpatient, and ER visits. For all other doctor visits and services, Orignal Medicare charges 20% coinsurance.

Original Medicare only covers 80% of Medicare-approved expenses. Thus, you pay 20% coinsurance for most health services. In comparison, Medicare Advantage Plans have no coinsurance costs. Another cost difference is Advantage Plan and Part B premiums.

Premium Costs – Medicare Advantage vs. Medicare

To enroll in Medicare Advantage Plan, you must have Medicare Part B and pay the monthly premium. Thus, Advantage and Original Medicare requires you to pay Part B premium. In 2020, the standard premium for Part B is $144.66. For 2021, congress puts limits on Part B premium increase to 25%.

Furthermore, you may have to pay additional Advantage Plans premiums. In 2020, the average Medicare Advantage premiums are as follows:

  • HMO $23
  • Local PPO $39
  • Reginal PPO $44

Prescription Drugs Costs – Medicare Advantage vs. Medicare

A significant difference between Medicare Advantage vs. Original Medicare is prescription drugs. Most Advantage Plans include prescription drug coverage. For example, HMO plans often have a drug plan, while PPO and PFFS plans may cover prescription drugs.

In comparison, Original Medicare does not cover prescription drugs. Original Medicare requires you to enroll in a separate Part D drug plan to get prescription drug coverage. The last difference is the max out-of-pocket limit.

Max Out-of-Pocket Limit – Medicare Advantage vs. Medicare

According to MedicareResources.org, your Advantage Plan max out-of-pocket limit has increased from $6,700 in 2020 to $7,550 in 2021. However, Medicare Advantage Plans limits vary from plan-to-plan. For example, your maximum out-of-pocket limit could be as low as $0.

However, Original Medicare has no out-of-pocket limit. Therefore, the amount you pay for Medicare services may be more than $7,550. For example, you could pay $10,000 or more. To reduce your out-of-pocket expenses, we recommend you consider a Medicare Supplement (Medigap) plan.

Advantage Plans accept ESRD

In 2021, Medicare Advantage (MA) Plans will now accept all health conditions, including End-Stage Renal Disease (ESRD). Find out how you can join a MA Plan with ESRD. Discover more about ESRD and how to find the right MA Plan.

The same as Medicare Advantage, Original Medicare also accepts all health conditions. Finally, the last difference is the maximum out of pocket limits.

MA Plan Benefits vs. Medicare

Medicare Advantage (MA) Plans may offer you additional benefits, not include in Original Medicare. For example, your MA Plan may include:

  • Dental
  • Vision
  • Hearing
  • Fitness Program
  • Transportation

Learn more about these exclusive MA Plan benefits.

Original Medicare does cover eye exams for diabetes and hearing and balance exams if your doctor orders them. However, these diagnostic tests require copays in a hospital outpatient setting. Furthermore, Original Medicare does not cover hearing aids or exams for fitting hearing aids.

Original Medicare does not pay for outpatient dental services. However, Medicare Part A can pay for inpatient emergency or complicated dental procedures.

Finally, Original Medicare does not offer gym membership. However, Senior Healthcare Direct does offer a new fitness program only for current clients.