Medicare, the U.S. federal health insurance program primarily for seniors aged 65 and over, is a crucial lifeline for millions. Yet, for those approaching the golden age of 65 or making choices for older family members, the world of Medicare can be complex and confusing. At the heart of this confusion often lies the difference between “Original Medicare” and “Medicare Advantage.” Let’s dive deep and unravel these terms, helping you make an informed choice.

Overview of Original Medicare

Original Medicare is the traditional program offered directly through the federal government. It encompasses two main parts:

Part A (Hospital Insurance): Covers inpatient hospital stays, hospice care, and some home health care. Most people don’t pay a premium for Part A if they or their spouse paid Medicare taxes while working.

Part B (Medical Insurance): Takes care of certain doctors’ services, outpatient care, preventive services, and some home health care. Most people pay a standard premium amount for Part B. For coverage in 2024, Medicare trustees anticipate that the Part B premium will be $174.80.

Understanding Medicare Advantage

Medicare Advantage (MA plans/Part C) is Medicare’s all-in-one alternative to Original Medicare. Private insurance companies, approved by Medicare, offer these plans. They encompass both Part A and Part B benefits and often include extra benefits such as dental insurance, hearing and vision services, and wellness care.

Key Differences Between Original Medicare and Medicare Advantage

Costs

Original Medicare – Beneficiaries typically pay a monthly Part B premium, co-insurances, and deductibles. There’s no maximum limit on out-of-pocket expenses.

Medicare Advantage – Premiums, deductibles, and out-of-pocket limits vary by plan. Some may have a $0 premium, but there may be a trade-off in the form of narrower networks or higher deductibles.

Choice of Healthcare Providers

Original Medicare – Patients can see any doctor or specialist they want, as long as they accept Medicare.

Medicare Advantage – Most plans have a network. Seeing a doctor outside of this network may result in higher costs unless it’s a genuine emergency. A provider network may be limited to a specific zip code/s.

Additional Benefits

Original Medicare: Doesn’t include routine vision, dental, or hearing coverage. Prescription drug coverage is bought separately through Part D.

Medicare Advantage: Many plans offer extra benefits, including but not limited to, routine vision tests, dental cleanings, hearing aids, and even wellness program memberships.

Geographical Mobility

Original Medicare: Provides coverage anywhere in the U.S.

Medicare Advantage: Typically limits coverage to a service area unless it’s an emergency. Those who travel frequently might find a Medicare Advantage Preferred Provider Network (PPO) or Private-Fee-for-Service (PFFS) plan more suitable than the least expensive Health maintenance Organization (HMO) plans.

But ultimately, the plan that’s best for you depends in a large part on where you live, and what doctors you want to see. Plan offerings and costs vary by zip code, and there are many Medicare Advantage plans to choose from. In 2023, if you live in:

• A rural area: Average of 27 Medicare Advantage plans available
• A small city (10,000 to 50,000 residents): Average of 31 plans
• A Metropolitan area: Average of 46 plans

Medicare or Medicare Advantage?

It is beyond the scope of this article to provide guidance on whether you should choose Medicare or Medicare Advantage, or which MA plan is right for you. An accurate answer would require factoring in your finances, health, lifestyle, and what plans are available in your area. Currently, slightly more than half (51%) of Medicare beneficiaries chose a Medicare Advantage plan. Your best source of comprehensive information on Medicare and Medicare Advantage is Medicare.gov.

Dental care and Medicare Advantage?

Medicare Advantage (MA) plans often include dental as one of their additional benefits, distinguishing them from Original Medicare which doesn’t cover routine dental care. However, there are some potential disadvantages associated with the dental coverage offered by Medicare Advantage plans:

Limited Scope of Coverage: Many MA plans that include dental benefits only cover basic services like cleanings, exams, and X-rays. More complex procedures such as crowns, bridges, implants, or oral surgeries may not be covered or may only be partially covered, leaving beneficiaries with significant out-of-pocket expenses.

Narrow Provider Networks: Just as with their medical coverage, many MA plans have specific networks of providers. Beneficiaries may be required to see in-network dentists to receive full coverage, and out-of-network services might be covered at a lower rate or not at all. This can limit choices and may mean that a beneficiary can’t see their preferred dentist without incurring higher costs.

Annual Maximum Limits: Some MA dental plans have a cap on the annual amount they will pay for dental services. Once this limit is reached, the beneficiary is responsible for all additional costs for the rest of the year.

Lack of Specialized Care: Some MA dental plans may not cover specialized dental care, like periodontics or orthodontics. Beneficiaries in need of these services might find themselves paying completely out-of-pocket.

Potential for Changes: As with other aspects of MA plans, dental coverage can change from year to year. Beneficiaries may find that a service covered one year may not be covered the next, or the network of approved providers might change.

Join a dental savings plan

Dental savings plans, a trusted alternative to traditional dental insurance, can help make dental care affordable. Plan members report an average savings of 50%* on their dental care at more than 140,000 dentists and specialists nationwide – about 70% of all dental practices in the U.S. There are no annual spending limits or deductibles to worry about, nor restrictions on existing conditions. You can save on the care you need, when you need it – from checkups and cleanings to restorative care, like crowns, root canals, braces, dental bridges, dentures and even dental implants.

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*Discount Health Program consumer and provider surveys indicate average savings of 50%. Savings may vary by provider, location, and plan.