Pros and Cons: Exploring the Differences in Medicare Coverage

How beneficiaries get their care differs depending on the option they choose

Medicare covers most medical services that beneficiaries need but there are differences in how those needs are covered, including which providers you can see, what hospitals and other facilities you can access and how you pay for care. Here are some key differences between original Medicare and Medicare Advantage (MA) plans.

1. Chronic conditions (diabetes, arthritis, heart disease, etc.)

Original Medicare

• You don't need a referral to see specialists.
• You can choose any specialist in the U.S. who accepts Medicare.
• You can get routine tests and treatments without prior authorization.
• Supplies — like test strips, blood-sugar monitors and nebulizers — are covered (usually with a 20 percent cost share).

• You need a separate Part D plan to cover prescription medicines.
• There's no cap on annual out-of-pocket costs, although a supplemental Medigap policy would cover most of them.
• Some diabetes programs are covered, but not most gym fees and weight-loss or healthy lifestyle programs.

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Medicare Advantage

• A primary care doctor typically manages your overall plan. Research suggests this may improve outcomes.
• Many plans cover supplies plus the costs for gym memberships, weight-loss programs and other health services.
• You may be eligible for a Medicare Advantage Special Needs Plan (SNP) that provides care tailored to chronic conditions.

• Most plans require you to use in-network providers. This could mean not being able to see your preferred doctor.
• Academic medical centers offering more advanced treatments may not be in your network.
• Tests and treatments often require pre-authorization.
• The annual cap on out-of-pocket costs can be high — up to $7,550 to $11,300 in 2021.

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2. Weight-loss help

Original Medicare

• If your body mass index is 30 or higher, you may qualify for up to 22 visits for nutritional assessment and counseling in a free obesity management program. Up to two years of Diabetes Prevention Program classes, which include weight loss and nutrition, are covered for people with prediabetes.

• Gym memberships and commercial weight-loss plans aren't covered.

Medicare Advantage

• Plans may offer help with programs like WW (formerly Weight Watchers, which offers AARP members a discount), Jenny Craig or Nutrisystem.
• You may also be able to get a gym membership, such as SilverSneakers.

3. A case of the flu

Original Medicare

• You can go to any doctor or urgent care center that accepts Medicare.
• A flu test may be fully covered. Part D drug plans will cover an antiviral flu drug for as little as $3 to $10 for generics (more for some brand-name drugs).

• Unless you have supplemental insurance like Medigap, you'll pay 20 percent of the cost of a doctor or urgent care visit after meeting your Part B deductible ($203 in 2021).

Medicare Advantage

• Your plan may have a low copay for a visit to any urgent care center.
• Your copay for a flu test could vary from $0 to more than $40.
• Drug coverage for an antiviral is comparable with a Medicare Part D plan.

• You may have to pay up front and request a reimbursement for an out-of-network flu shot.

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4. An emergency appendectomy

Original Medicare

• You can go to any emergency room.

• Unless you have supplemental insurance, you'll pay a share of the ER visit and each medical service you receive, plus a 20 percent coinsurance for emergency room doctor fees.
• You'll pay 20 percent of ambulance costs, if one was used.
• If you're admitted to the hospital, unless you have a supplemental plan, you'll pay a $1,484 deductible for your hospital visit.

Medicare Advantage

• You can get care in any ER, with a copay that could be $50 to $90.
• Your ambulance ride could be free or cost less.

• If admitted to out-of-network hospital, charges may not be covered after you're deemed “stable.”
• If your doctor determines you need a procedure but it's not extremely urgent, you may face high bills unless you switch to a hospital in the network.

5. A screening colonoscopy

Original Medicare

• They are 100 percent covered when done at recommended intervals and by a doctor/facility that accepts Medicare.
• You don't need a referral.

• You have to pay for bowel prep products. Part D drug plans cover them, but you may have a copay.
• If a polyp is removed and biopsied, the procedure becomes diagnostic and you may be responsible for 20 percent of costs. You'll face diagnostic charges, too, if you need a colonoscopy because another test found a potential problem. A supplemental policy may help.

Medicare Advantage

• Screening colonoscopies at recommended intervals are covered 100 percent, provided you use an in-network doctor.
• Some plans pick up the cost if a polyp is found and removed during your screening colonoscopy or if you need a colonoscopy due to a test finding.

• Usually you'll need to use an in-network provider for the procedure.

6. Ongoing pain

Original Medicare

• You can see any specialist who accepts Medicare.
• Covers 80 percent of medically necessary physical and occupational therapy. Supplemental insurance may cover remaining costs.
• Covers up to 20 acupuncture sessions for low-back pain and chiropractic spine manipulation with 20 percent coinsurance.

• Doesn't cover massage therapy or over-the-counter (OTC) pain remedies.

Medicare Advantage

• Massage therapy for pain by a state-licensed massage therapist may be covered.
• You may get a monthly stipend for OTC pain remedies like ibuprofen, as well as for knee braces and back supports.
• Covers physical and occupational therapy with in-network therapists, with copays as low as $10 to $20 in some plans.

• You must use in-network providers or pay more to see an out-of-network expert, except in special cases.
• You may need a referral and approval before seeing a specialist or physical/occupational therapist.

7. Hearing decline

Original Medicare

• Covers hearing exams when used to help diagnose a medical problem. You pay 20 percent after deductible.

• Original Medicare doesn't cover routine hearing exams, hearing aids or exams to fit hearing aids.

Medicare Advantage

• Almost all plans offer some coverage for hearing exams and/or hearing aids.
• Some plans can have a $0 copay for exams and hearing aid fittings. What you'll pay for hearing aids can vary widely.

• You'll likely have to use in-network hearing aid providers.
• You may need prior authorization.

Experts interviewed for this article

Jean Fuglesten Biniek, senior policy analyst at the Kaiser Family Foundation; Anna Schwamlein Howard, principal, policy development, the American Cancer Society Cancer Action Network; Mary Johnson, Medicare policy analyst for the Senior Citizens League; Alicia Jones, director of the Nebraska State Health Insurance Assistance Program (SHIP); Stephanie Krenrich, director of federal relations for the American Cancer Society Cancer Action Network; David J. Meyers, assistant professor, Brown University School of Public Health; Janet Mills, volunteer counselor with Florida's Serving Health Insurance Needs of Seniors (SHINE) program; Sungchul Park, assistant professor of health management and policy at Drexel University; Ginny Paulson, director of the State Health Insurance Assistance Program National Technical Assistance Center; Christina Reeg, program director of the Ohio Senior Health Insurance Information Program; Casey Schwarz, senior counsel for Education & Federal Policy at the Medicare Rights Center; Matthew Shepard, communications director at the Center for Medicare Advocacy; Dan Sherman, founder and president of the NaVectis Group; Joseph Unger, associate professor, Public Health Sciences Division, Fred Hutchinson Cancer Research Center; Ray Walker, director of the Medicare Assistance Program at the Oklahoma Insurance Department

Sari Harrar is an AARP contributing editor who specializes in health and science.