What Medicare Advantage Is and Whether You Need It

You do not need a Medicare Advantage plan. Original Medicare (Part A and Part B) covers hospital and doctor visits on its own. Medicare Advantage is an alternative way to receive those same benefits — it replaces Original Medicare rather than adding to it — and it comes with trade-offs you should understand before switching.

Medicare Advantage plans are sold by private insurance companies and bundle hospital, doctor, and prescription drug coverage into one plan. They often cost less in monthly premiums than Original Medicare plus a separate drug plan, but they typically limit you to a network of doctors and hospitals, require referrals for specialists, and may charge you more when you use out-of-network care. Whether you need one depends on your health, your doctors, your budget, and how much flexibility matters to you.

Key Takeaways

  • Original Medicare works without a Medicare Advantage plan, and you can stay on it for life if you choose.
  • Medicare Advantage plans usually cost less per month but restrict which doctors and hospitals you can use without paying extra.
  • If you have a chronic condition or see specialists regularly, check whether your current doctors are in the plan's network before enrolling.
  • You can switch from Medicare Advantage back to Original Medicare during the annual enrollment period (October 15 to December 7) or if you move out of the plan's service area.
  • If you stay on Original Medicare, you will need to buy a separate prescription drug plan (Part D) and may want supplemental coverage (Medigap) to cover costs Original Medicare does not.

How Medicare Advantage Plans Work Differently from Original Medicare

Original Medicare is a fee-for-service program run by the federal government. You go to any doctor or hospital that accepts Medicare, pay your share of the cost, and Medicare pays theirs. There is no network, no referral requirement, and no permission slip needed to see a specialist.

Medicare Advantage plans operate differently. You pay a monthly premium to the insurance company, and in return they cover your hospital and doctor visits — but only if you use doctors and hospitals in their network. Most plans require you to pick a primary care doctor who coordinates your care and must refer you to specialists. If you go out of network without a referral, you pay more or the plan may not cover it at all. Some plans also charge you a copay (a flat fee like $20 per doctor visit) or coinsurance (a percentage of the cost) at each visit.

The main advantage is cost: many Medicare Advantage plans have no monthly premium, and they include prescription drug coverage built in. The main disadvantage is control: you have less choice about which doctors you see and less freedom to change doctors without switching plans.

When Medicare Advantage Makes Sense for Your Situation

Medicare Advantage works well if you are generally healthy, see the same few doctors regularly, and those doctors are in the plan's network. It also makes sense if you are on a tight budget and the plan's low or zero premium saves you money compared to Original Medicare plus a separate drug plan and Medigap coverage.

Medicare Advantage can also be a good fit if you want all your coverage in one place and do not mind using the same hospital system or clinic network. Some plans offer extra benefits Original Medicare does not cover — like dental, vision, or fitness programs — which can add value if you use those services.

However, Medicare Advantage is not a good fit if you travel frequently outside your plan's service area, if you have a serious illness that requires specialists outside the network, or if you see doctors in different hospital systems. It is also not ideal if you value the freedom to change doctors without having to switch insurance plans.

When Original Medicare Is the Better Choice

Original Medicare makes sense if you have complex medical needs, see multiple specialists, or your doctors are spread across different hospital systems. Because there is no network, you can see any doctor or specialist who accepts Medicare without needing permission or paying extra (beyond your regular Medicare costs).

Original Medicare is also better if you move frequently or travel often, because your coverage works the same way anywhere in the country. If you have a condition that requires ongoing care from a specific doctor or hospital, Original Medicare gives you the freedom to keep that relationship without worrying about whether they are in your plan's network.

The trade-off is that Original Medicare costs more in total: you pay a monthly Part B premium (currently $164.90 per month for most people in 2024, though this varies by income), you must buy a separate Part D plan for prescriptions, and you may want Medigap coverage to pay the costs Original Medicare does not cover — like deductibles and coinsurance. That combination can add up to more per month than a Medicare Advantage plan, but it gives you more flexibility and choice.

How to Check Whether Your Doctors Are in a Medicare Advantage Plan's Network

Before you enroll in any Medicare Advantage plan, call your current doctors and ask whether they accept that specific plan. Do not assume they accept Medicare Advantage just because they accept Medicare — each plan has its own network, and a doctor may accept one plan but not another.

You can also search the plan's website for a provider directory, which lists all the doctors, hospitals, and specialists in the network. Search for your primary care doctor, any specialists you see regularly, and the hospital you would use for surgery or emergency care. If any of them are not listed, call the plan to confirm — directories are sometimes out of date.

If your doctor is not in the network, ask whether they are planning to join, or whether the plan will make an exception. Some plans will cover an out-of-network doctor if you have an ongoing relationship with them, but you usually have to request this before you enroll. If your doctor will not be covered and you do not want to switch doctors, Original Medicare is the safer choice.

How to Switch Between Medicare Advantage and Original Medicare

You can change from Medicare Advantage to Original Medicare during the annual enrollment period, which runs from October 15 to December 7 each year. Changes take effect on January 1. You can also switch if you move out of your plan's service area or if you lose your plan for other reasons.

To switch, contact Medicare directly at 1-800-MEDICARE or go to Medicare.gov. You do not need permission from your current Medicare Advantage plan. If you switch to Original Medicare, you will need to buy a Part D prescription drug plan and may want to buy Medigap coverage within 63 days of losing your Medicare Advantage plan — if you wait longer, you may pay higher premiums for Medigap.

You can also switch from Original Medicare to Medicare Advantage during the same annual enrollment period. If you have been on Original Medicare for at least one month, you have a may provide right to buy Medigap coverage if you switch back to Original Medicare later, which protects you from being denied or charged more because of pre-existing conditions.

What It Costs: Medicare Advantage vs. Original Medicare

Medicare Advantage plans vary widely in cost. Many have no monthly premium, but some charge $50 to $200 per month. Most include prescription drug coverage, so you do not need to buy a separate Part D plan. However, you will pay copays or coinsurance when you use doctors, hospitals, or prescriptions.

Original Medicare costs a monthly Part B premium (currently $164.90 for most people in 2024, though higher-income people pay more). You also pay a yearly deductible before Medicare starts paying, and you pay 20% of the cost of most services after that. You must buy a separate Part D plan for prescriptions, which costs $5 to $100+ per month depending on the plan. Many people also buy Medigap coverage to pay the costs Original Medicare does not cover, which costs $100 to $300+ per month depending on the plan and your age.

The total cost depends on how much medical care you actually use. If you are healthy and rarely see doctors, Medicare Advantage's low premium saves money. If you have chronic conditions and see doctors frequently, the copays and coinsurance can add up, and Original Medicare plus Medigap may cost less overall.

Frequently Asked Questions

Can I have both Medicare Advantage and Original Medicare at the same time?

No. You must choose one or the other. If you enroll in Medicare Advantage, you are automatically disenrolled from Original Medicare. If you later switch back to Original Medicare, your Medicare Advantage coverage ends.

What happens to my Medicare Advantage plan if I move to a different state?

Most Medicare Advantage plans only work in a specific geographic area. If you move out of that area, your plan will end, usually at the end of the month you move. You will then have a special enrollment period to join a different Medicare Advantage plan or switch to Original Medicare without waiting for the annual enrollment period.

Do I need a referral to see a specialist on Medicare Advantage?

Most Medicare Advantage plans require a referral from your primary care doctor before you see a specialist. If you see a specialist without a referral, the plan may not cover the visit or may charge you more. Original Medicare does not require referrals.

Can I switch from Medicare Advantage to Original Medicare outside the enrollment period?

You can only switch during the annual enrollment period (October 15 to December 7) or if you have a may have access to life event, such as moving out of your plan's service area, losing your plan, or losing other health coverage. If none of these explore, you must wait until the next annual enrollment period.

What if I regret switching to Medicare Advantage?

You can switch back to Original Medicare during the next annual enrollment period. If you have been on Medicare Advantage for at least one month, you have a may provide right to buy any Medigap plan without being denied or charged more because of health conditions, as long as you buy it within 63 days of switching back to Original Medicare.