Original Medicare vs Medicare Advantage for Dental, Hearing, and Skilled Nursing in 2026: How Your Plan, Deductible, and Local Facility Change a $12,000 Year
You are looking at a $3,200 crown, a $4,700 pair of hearing aids, and a doctor who mentioned "a few weeks of rehab" after your last hospital stay. You have a plan, and you have a vague sense that Medicare covers "some of this." Before you schedule anything, you should know that the answer depends on four things: which plan you have, whether your deductible has been met, where you live, and which facility you choose.
This post walks through what Original Medicare and Medicare Advantage each do (and don't) pay for dental, vision, hearing, and skilled nursing in 2026. It uses a worked example with three health scenarios, so you can see how the same needs produce very different bills.
What Original Medicare Pays for Dental, Vision, and Hearing: Almost Nothing
Original Medicare (Parts A and B) excludes routine dental care, dentures, routine eye exams and glasses, and hearing aids. There are narrow exceptions. Dental work counts when it is directly tied to a covered procedure, such as an exam before a kidney transplant or heart valve surgery. Part B also covers a medically necessary eye exam for diabetic retinopathy or glaucoma.
For everything else, you pay the full price. If you are in Original Medicare, a Medigap plan does not change that, because Medigap only fills in cost-sharing on services Medicare already covers. We go deeper on this in Original Medicare Pays $0 for Dental, Vision, and Hearing in 2026.
Medicare Advantage plans can add these benefits, and many do. But "covered" usually means an annual allowance, often $1,000 to $2,000 for dental and a smaller amount for hearing, applied only at in-network providers. That leads to the first personal variable: the allowance is a cap, not a guarantee. A $3,200 crown against a $1,500 dental allowance still leaves you with $1,700.
The 2026 Numbers You Need Before Comparing
These are the CMS-published 2026 figures we use throughout the calculations below:
| Item | 2026 amount |
|---|---|
| Part B standard premium | $202.90/month ($2,434.80/year) |
| Part B annual deductible | $283 |
| Part A inpatient deductible (per benefit period) | $1,736 |
| Skilled nursing facility (SNF) days 1–20 | $0 |
| SNF days 21–100 | $217/day |
| SNF after day 100 | You pay everything |
| Medicare Advantage in-network out-of-pocket maximum (limit) | Up to $9,250 |
| Part D out-of-pocket cap | $2,100 |
Two of those rows explain most of the surprises. First, Original Medicare has no out-of-pocket cap for Parts A and B. Second, the SNF benefit has a hard stop at day 100. That includes the skilled nursing days and, importantly, it is separate from long-term custodial care, which neither Original Medicare nor most Medicare Advantage plans pay for.
For the long-term care gap in detail, see Original Medicare Pays $0 After Day 100 in a Nursing Home.
The Worked Example: Same Needs, Three Different Years
Here is a hypothetical beneficiary. All the figures below are illustrative assumptions built on the CMS numbers above, not quotes. You will need to replace them with your own plan's numbers.
Needs this year: one $3,200 crown, one $4,700 pair of hearing aids, and the possibility of a hospital stay followed by skilled nursing.
Option A: Original Medicare + Medigap Plan G. Assume a $170/month Plan G premium ($2,040/year). Plan G covers the Part A deductible and coinsurance, including SNF days 21–100. You still pay the Part B deductible ($283).
Option B: $0-premium Medicare Advantage HMO. Assume a $1,500 dental allowance and a $1,000 hearing allowance, with all providers in-network. Assume a hospital copay of $350/day for five days ($1,750) and an SNF copay of $203/day starting on day 21.
Both options pay the same Part B premium ($2,434.80), and we leave out Part D since it varies by drug list.
Scenario 1: Healthy year, no hospital stay
| Option A (Plan G) | Option B (MA) | |
|---|---|---|
| Part B premium | $2,434.80 | $2,434.80 |
| Plan premium | $2,040 | $0 |
| Part B deductible | $283 | $0 (assumed) |
| Crown after allowance | $3,200 | $1,700 |
| Hearing aids after allowance | $4,700 | $3,700 |
| Total | $12,657.80 | $7,834.80 |
In a quiet year, Medicare Advantage wins by about $4,800. This is the scenario that makes $0-premium plans so popular at enrollment time.
Scenario 2: One hospital stay and a 30-day skilled nursing stay
| Option A | Option B | |
|---|---|---|
| Hospital | $0 (Plan G) | $1,750 |
| SNF (days 21–30 = 10 days) | $0 | $2,030 (10 × $203) |
| Everything else from Scenario 1 | $12,657.80 | $7,834.80 |
| Total | $12,657.80 | $11,614.80 |
MA is still ahead, but only by about $1,043. One admission has erased most of the advantage.
Scenario 3: A serious year (two admissions, long SNF stay)
Now assume your medical costs hit the Medicare Advantage maximum of $9,250.
| Option A | Option B | |
|---|---|---|
| Medical cost-sharing | $0 (already in Plan G premium) | $9,250 (MOOP reached) |
| Everything else | $12,657.80 | $2,434.80 + $5,400 = $7,834.80 |
| Total | $12,657.80 | $17,084.80 |
Here Plan G is cheaper by roughly $4,400. Plan G's cost is nearly fixed. The MA plan's cost depends on how sick you get, and that is exactly what you cannot know in advance.
This is the kind of analysis Toravine runs for you, using your actual plan's copays and allowances, so you don't have to build the spreadsheet yourself.
The Ten-Year View: Premiums That Climb vs. Allowances That Reset
A one-year comparison flatters whichever plan fits your current health. Over ten years, the math shifts in two ways.
Medigap premiums rise with age and inflation. Suppose your $2,040 annual Plan G premium grows 5% a year. Ten years of premiums is 2,040 × ((1.05¹⁰ − 1) ÷ 0.05), or about $25,700. Rate increases and your state's pricing rules (attained-age, issue-age, or community-rated) decide whether that estimate is close.
MA benefits change every year. An allowance that covers your crown this year can be cut next year. Plans also change networks, and a plan can remove your dentist or hospital.
The most important asymmetry is this: in most states, if you leave Medicare Advantage after your first year and want a Medigap policy, the insurer can use medical underwriting and decline you or charge more. That is an irreversible-decision problem. Our analysis of 3,570 Medigap rate rows shows how widely Plan G quotes vary by age and location, which is why the "$170" above is only a placeholder. If you are still weighing the two paths, see the Medicare Advantage $0 premium vs Medigap Plan G 10-year cost comparison.
What the New Research Says About Sicker Beneficiaries
The Medicare Rights Center's coverage of the new KFF poll, "Medicare Beneficiaries With Multiple and Complex Health Needs Face Challenges," focuses on adults who juggle several conditions. The takeaway for our comparison is that these are the people for whom Scenario 3 is not hypothetical. Someone with heart disease, diabetes, and arthritis is far more likely to have multiple admissions and specialist visits than the person in Scenario 1.
If you manage multiple conditions, the useful question is not "which plan has the lowest premium?" It is "what is my realistic worst-year cost, and can I afford it in January?" A $9,250 maximum is a lot of money to have available on short notice. For some people it is a bigger risk than a $2,040 Plan G premium.
Prior Authorization: A Cost That Isn't on Your Premium Sheet
There is another variable that has nothing to do with allowances. Original Medicare has historically used very little prior authorization, while Medicare Advantage uses it heavily. Medicare Rights Center's reporting in "New Records Show Medicare WISeR AI Prior Authorization Model Causing Inappropriate Denials of Care" notes that CMS started a six-year model this January called WISeR (Wasteful and Inappropriate Service Reduction), which brings AI-assisted prior authorization to certain services in Original Medicare in a limited set of states.
That matters for two reasons.
- The Original Medicare advantage is narrowing at the margins. If you live in a WISeR state, a service you assumed needed no approval may now require one. Check whether your planned procedure is on the model's list before you assume it is exempt.
- Denials have a dollar cost. If a plan denies a covered service and you go ahead anyway, you may be billed the full amount while you appeal. For a $14,000 skilled nursing stay, that is a lot of float. See our post on the 95% SNF denial overturn rate for what the appeals math looks like.
Your Facility Is a Price Variable, Not Just a Location
This is where "check MY local facilities before scheduling" comes from.
Healthcare Dive's report, "340B hospitals lag behind peers in charity care spending," adds context. Hospitals in the 340B drug discount program have been criticized for providing less charity care than peers, which is one more reminder that hospital financial behavior differs from one facility to the next. For you as a patient, the practical lesson is that two facilities in the same town can differ on:
- Network status. In an HMO, an out-of-network hospital may mean the plan pays little or nothing outside emergencies.
- Copay structure. MA hospital copays and SNF daily copays vary from plan to plan, and the "days 1–20 at $0" pattern is not universal.
- Cash price for uncovered care. Dental and hearing prices are not regulated by Medicare at all. A crown can differ by hundreds of dollars between two offices. A hearing aid pair bought at a big-box store, an audiologist's office, or online can differ by thousands.
- Ownership. If your plan is owned by the same company that owns the facility, steering can affect where you're sent. See Medicare Advantage Network Steering in 2026.
Before scheduling a non-emergency procedure, do four things: confirm the facility is in your plan's network, ask for the price in writing (including facility fees), ask whether prior authorization is required, and get a second price for any uncovered dental or hearing work.
How to Pay for the Gap When Rates Are High
The gap between what Medicare covers and what you owe often gets financed. NerdWallet's report, "Why the Bond Market's Struggles Are Driving Up Mortgage Rates," describes bond yields at their highest levels in about 20 years, with mortgage rates rising alongside them. For a homeowner who was planning to tap home equity for a big dental bill or a nursing home deposit, borrowing costs more than it did a couple of years ago. That is one reason to check your options before you commit to a service that isn't covered, and to keep some cash aside for a possible deductible or copay. Long-term care costs also don't stop at day 100. With nursing home care running around $9,500/month in many areas, the gap can outlast almost any savings plan.
Where the Numbers in This Post Come From
We built the scenarios above against CMS's published 2026 cost-sharing amounts. Toravine's underlying dataset includes 11,267 rows across four sources: 6,287 rows from the Census ACS Medicare data (for local age, income, and coverage patterns), 1,236 rows of CMS Medicare plan premium data, 3,570 Medigap rate rows, and 174 rows of CMS IRMAA data. The IRMAA data matters here because higher-income beneficiaries pay more than the $202.90 standard Part B premium, which tilts the Plan G vs. MA comparison. If your income puts you in an IRMAA bracket, your Part B line in the tables above is higher for both options.
You can model your own version of these three scenarios at Toravine.
A Checklist Before Your Next Enrollment Period
Use these questions before October 15, or before any procedure you're scheduling:
- What is my worst-year cost? Not the average. Add your premium, your deductible, and your plan's maximum out-of-pocket amount.
- Is my dental or hearing allowance enough? Compare the allowance to the actual local price of the work you need.
- Is my hospital in-network? Check the specific facility, not just the health system's name.
- Am I in a WISeR state, and is my planned service on the list?
- Is my Medigap window still open? If it isn't, switching from MA to Plan G may mean underwriting.
- What happens after day 100? Custodial care is not a Medicare benefit under any of these options.
Medicare is genuinely complicated, and the "right" plan really is different for different people. A plan that is best for the healthy version of you can be the worst plan in the year you get sick. If you haven't re-run the numbers on your own plan recently, do it before the next enrollment period. Toravine lets you compare your actual plan options against your own expected care, so you can see the three scenarios above with your numbers instead of ours.
Data behind this post
The figures above are computed from the product's own reference tables, last refreshed 2026-09-20:
- 6,287 rows from census_acs_medicare
- 1,236 rows from cms_medicare_plan_premiums
- 3,570 rows from medigap_rates
- 174 rows from cms_medicare_irmaa
Sources
- Medicare Beneficiaries With Multiple and Complex Health Needs Face Challenges — Medicare Rights Center
- New Records Show Medicare WISeR AI Prior Authorization Model Causing Inappropriate Denials of Care — Medicare Rights Center
- 340B hospitals lag behind peers in charity care spending: report — Healthcare Dive
- Abortion Is on the Ballot Again as Post-Roe Policies Continue To Evolve — KFF Medicare
- Why the Bond Market’s Struggles Are Driving Up Mortgage Rates — NerdWallet