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4 Reasons Why Original Medicare Coverage May Not Be Enough Medical Coverage For You

Medicare has served elderly Americans since 1966. If you are approaching the eligibility age of 65, you may feel overwhelmed by the process. Or perhaps you have been on original Medicare coverage for some time but aren’t sure if you need more coverage. You see the ads on TV for Medicare Advantage plans and Medicare supplements and wonder whether these plans are right for you. What are the pros and cons of Medicare Advantage plans vs. original Medicare coverage?

First, it is important to understand what original Medicare coverage is, what it covers and what it does not cover.

What Is Medicare?

Medicare consists of 4 main parts. Part A: Hospital Insurance and Part B: Medical Insurance are considered original Medicare. Original Medicare coverage will cover most, but not all, medical expenses. 

Medicare Advantage, or Part C, is offered as an alternative to original Medicare. Unlike original Medicare, which is provided through the government, Medicare Advantage plans are offered through private insurance companies. 

The fourth component of Medicare is Medicare Part D. Part D covers prescription drugs. 

The Pros and Cons of Medicare Advantage Plans Vs. Original Medicare Coverage

Both original Medicare coverage and Medicare Advantage plans will cover your basic medical expenses. However, these plans differ in a couple of critical areas. 

Coverage

Original Medicare Part A covers inpatient hospital care, skilled nursing, and hospice care. Part B covers outpatient services, such as doctor visits, x-rays, lab tests, preventative care, emergency room visits, and medical equipment. 

The coverage of Medicare Advantage plans will vary depending on what company and the health plan you choose. Generally, they will cover all the same expenses as original Medicare as well as some additional care not covered by original Medicare. 

Original Medicare coverage does not cover dental, vision, or hearing. It also will not cover nursing home care, anything deemed “not medically necessary,” and prescription drugs. Medicare Advantage plans may cover these and other additional expenses.  

Cost

If you worked for at least ten years as a US citizen and paid into FICA through payroll taxes, your monthly cost for Medicare Part A is $0. In 2023 the Medicare Part B premium starts at $164.90 per month. Both Part A and Part B have a deductible. The Medicare Part A deductible for 2023 is $1,600 per benefit period. The Medicare Part B deductible is $226. 

Medicare Advantage plan premiums will vary depending on your state and the plan chosen. On average, rates are typically between $0-20 per month. Note that this is in addition to your Medicare Part B premium. However, as previously mentioned, a Medicare Advantage plan will cover expenses not covered by Medicare Part B. In most cases, this includes a Medicare Part D prescription drug plan. Medicare Advantage plans do have an out-of-pocket expense limit, usually averaging about $6000. You will also have set copays for all doctor visits and other services. 

Enrollment

If you are taking Social Security, you will automatically be enrolled in original Medicare when you turn 65. If you are still working, you must apply for Medicare. Whether or not you need Medicare coverage will depend on the size of your employer. Employer health insurance will be the primary insurance for employers with more than 20 employees. 

You will need to apply for a Medicare Advantage plan or other Medicare supplements during your open enrollment period. 

Why Original Medicare May Not Be Enough Coverage

Serious caucasian old elderly senior couple grandparents family doing paperwork in their Original Medicare coverage at home using laptop.

Now that you have a basic overview of Medicare let’s discuss five reasons why original Medicare may not be enough medical coverage for you.

  1. Drug Coverage

Prescription drug coverage is a well-known hole in original Medicare. Neither Part A nor Part B will cover prescription drugs. A Kaiser Family Foundation study in 2019 found that 89% of Americans aged 65 and older take prescription drugs. The cost of these medications can become an incredible financial burden. Most Medicare Advantage plans will include Medicare Part D prescription drug coverage. This will greatly reduce the cost of your prescriptions.

  1. Deductibles

For 2023, the deductible for Medicare Part A is $1,600 per benefit period. Thus, you may need to pay this deductible more than one time in a calendar year. After your deductible, your copay is $0 for up to 60 days of inpatient care. Beginning with day 61, your copay will increase significantly, starting at $400 per day until day 90, when they increase again. Medicare Part B has an annual deductible of $226.

  1. Out-of-Pocket Expenses

Medicare Part B will cover 80% of medically necessary expenses from Medicare approved providers. However, there is no out-of-pocket cap. Therefore, you will be responsible for paying for 20% of covered medical expenses, regardless of how expensive that might be. These expenses can easily reach into the hundreds of thousands of dollars. 

  1. Missing Out on Other Benefits

In addition to prescription drug coverage, original Medicare does not cover vision, dental, hearing, nursing home care, and any service deemed “not medically necessary.” On the other hand, a Medicare Advantage plan may include these added services. Many plans also include additional benefits such as gym memberships, flex cards, and a mail-order catalog of over-the-counter items. 

How to Decide What Plan is Right for You

It is important to weigh the pros and cons of original Medicare vs. Medicare Advantage.  Original Medicare provides a valuable service for older Americans. But it does have some significant limitations. That is where a Medicare Advantage plan will come in. Medicare supplement plans and Medicare Advantage plans will fill in the gaps of original Medicare. 

There is no one size fits all recommendation. You have a unique set of circumstances. Whether or not you are retired, your budget, health, doctor preferences, and travel habits will all make a difference. 

The Medicare Family has over 40 years of experience helping seniors get the best coverage possible. Contact us today, and let us help you.

Sylvia Gordon, aka Medicare Mama®, is an expert on all things Medicare and Social Security. She is the 2nd Generation here at The Medicare Family and has served on the advisory boards of major insurance companies like UnitedHealthcare®, Cigna, and Anthem. In her free time, she can be found taking care of her animals (dogs, goats, peacocks, chickens), and reading a good book. Learn More.
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