Pros and Cons: Exploring the Differences in Medicare Coverage

2. Weight-loss help

Original Medicare

Pros

• 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.

Cons

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

Medicare Advantage

Pros

• 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

Pros

• 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).

Cons

• 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

Pros

• 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.

Cons

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

4. An emergency appendectomy

Original Medicare

Pros

• You can go to any emergency room.

Cons

• 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

Pros

• 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.

Cons

• 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

Pros

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

Cons

• 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

Pros

• 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.

Cons

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

6. Ongoing pain

Original Medicare

Pros

• 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.

Cons

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

Medicare Advantage

Pros

• 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.

Cons

• 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

Pros

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

Cons

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

Medicare Advantage

Pros

• 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.

Cons

• 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.