Medicare Advantage is not the same as Original Medicare — it's a different way to get your Medicare benefits

Original Medicare is a federal health insurance program run directly by the Centers for Medicare & Medicaid Services (CMS). It has two parts: Part A covers hospital stays, and Part B covers doctor visits and outpatient care. You can use any doctor or hospital in the country that accepts Medicare.

Medicare Advantage is a private insurance plan sold by insurance companies like UnitedHealth, Humana, and Anthem. The insurance company receives a fixed monthly payment from Medicare to cover your hospital, doctor, and prescription drug benefits all in one plan. Instead of going to any doctor you want, you typically choose from a network of doctors and hospitals that the insurance company has contracted with.

The key difference: with Original Medicare, the government is your insurer. With Medicare Advantage, a private insurance company is your insurer, and Medicare pays them to provide your coverage.

Key Takeaways

  • Original Medicare is run by the federal government; Medicare Advantage plans are run by private insurance companies that contract with Medicare.
  • Original Medicare lets you see any doctor who accepts Medicare; most Medicare Advantage plans limit you to in-network doctors and hospitals.
  • Original Medicare requires you to buy a separate Part D plan for prescription drugs; Medicare Advantage includes prescription drug coverage in the plan.
  • Medicare Advantage plans often have lower or zero monthly premiums but may have higher out-of-pocket costs when you use care.
  • You can switch between Original Medicare and Medicare Advantage during the annual enrollment period (October 15 to December 7) or if you have a may have access to life event.

How doctor networks work in each plan

With Original Medicare, you can visit any doctor, specialist, or hospital in the United States as long as they accept Medicare patients. There is no network restriction. If your longtime cardiologist accepts Medicare, you can keep seeing them. If you travel to another state and need urgent care, any hospital that accepts Medicare will treat you.

Medicare Advantage plans use networks. Each plan contracts with specific doctors, hospitals, and specialists in your area. If you see a doctor outside the network, you typically pay more out of pocket — sometimes much more. Some plans are Health Maintenance Organizations (HMOs), which require you to use in-network providers except in emergencies. Others are Preferred Provider Organizations (PPOs), which let you see out-of-network doctors but at a higher cost. A few plans are Point of Service (POS) plans, which blend both approaches.

Before you choose a Medicare Advantage plan, you should check whether your current doctors are in the plan's network. If your doctor is not listed, you will need to find a new one or pay out-of-network rates.

Prescription drug coverage: how it differs

Original Medicare does not include prescription drug coverage. If you want coverage for medications, you must buy a separate Part D plan from a private insurance company. You pay a monthly premium for Part D on top of your Part B premium. You choose which Part D plan to buy based on the drugs you take and the pharmacies near you.

Medicare Advantage plans include prescription drug coverage as part of the plan. You do not buy a separate Part D plan. The insurance company decides which drugs are covered, at what cost, and which pharmacies you can use. This can be simpler because everything is in one plan, but it also means the insurance company controls your drug coverage.

If you have Original Medicare and a Part D plan, you can switch your Part D plan every year during the annual enrollment period. If you have Medicare Advantage, you can switch to a different Medicare Advantage plan or to Original Medicare during the same period.

Out-of-pocket costs: premiums versus care costs

Medicare Advantage plans often advertise zero monthly premiums or very low premiums — sometimes $0 to $50 per month. This can look cheaper than Original Medicare at first glance. However, the trade-off is usually higher out-of-pocket costs when you actually use care.

Medicare Advantage plans have deductibles, copays, and coinsurance — the amounts you pay when you see a doctor, get lab work, or fill a prescription. They also have an out-of-pocket maximum, which is the most you will pay in a year. Once you hit that maximum, the plan covers 100 percent of your in-network care for the rest of the year. In 2024, the out-of-pocket maximum for Medicare Advantage plans is capped at $8,050 for in-network care.

Original Medicare has no out-of-pocket maximum. You pay 20 percent of the cost of most services for the life of the plan. Many people with Original Medicare buy a Medigap policy (also called a supplemental insurance plan) to cover the costs that Medicare does not pay. Medigap premiums vary widely depending on the plan and your location.

When you might choose Original Medicare

Original Medicare is often the better choice if you have a longtime doctor or specialist you want to keep seeing, because you can see any doctor without network restrictions. It is also better if you travel frequently or spend time in multiple states, because you can use any Medicare-accepting provider anywhere.

Original Medicare is a good fit if you are willing to buy a Medigap policy to cover the gaps in coverage. Medigap plans are standardized by the federal government, so you can compare them easily and know exactly what is covered. Some people find the predictability worth the extra monthly cost.

Original Medicare may also be better if you take many prescription medications, because you have more control over which Part D plan you choose and can switch plans every year if your drugs or pharmacies change.

When you might choose Medicare Advantage

Medicare Advantage can be a good choice if you are comfortable using a network of doctors and hospitals. If your current doctors are in the plan's network and you do not mind switching if you move, a Medicare Advantage plan can cost less overall, especially if you have predictable health care needs.

Medicare Advantage plans often include benefits that Original Medicare does not cover, such as dental, vision, hearing aids, and fitness programs. If these benefits matter to you, Medicare Advantage may offer better value. Some plans also include meal delivery or transportation to medical appointments.

Medicare Advantage can work well if you do not travel much or if you are willing to use urgent care or emergency rooms outside your home state when you travel. It is also a reasonable choice if you want everything — hospital, doctor, and drug coverage — in one plan and do not want to manage multiple insurance policies.

How to switch between Original Medicare and Medicare Advantage

You can change from Original Medicare to Medicare Advantage, or from Medicare Advantage to Original Medicare, during the Annual Enrollment Period (AEP), which runs from October 15 to December 7 each year. Changes take effect on January 1. You can also switch if you have a may have access to life event, such as moving out of your plan's service area, losing employer coverage, or becoming may be able to access for Medicaid.

To switch, you contact the new plan directly or use Medicare.gov to compare plans and enroll. If you are switching from Medicare Advantage to Original Medicare, you should also buy a Medigap policy during the same enrollment period if you want coverage for the gaps in Original Medicare. If you are switching from Original Medicare to Medicare Advantage, you do not need to do anything with your Medigap policy — it straightforward ends when your Medicare Advantage coverage begins.

If you switch from Medicare Advantage to Original Medicare outside the Annual Enrollment Period without a may have access to life event, you may face a penalty or a gap in coverage. It is important to plan your switch during the open enrollment window.

Questions to ask your doctor or Medicare counselor

Before you choose between Original Medicare and Medicare Advantage, ask your doctor or a Medicare counselor these questions: Is my doctor in the Medicare Advantage plan's network? What are the copays and deductibles for the services I use most often? Do I need to see specialists, and are they in the network? What prescription drugs do I take, and are they covered under the plan's formulary? What is the out-of-pocket maximum, and how much have I spent on health care in the past year?

You can get free, unbiased counseling about Medicare choices from your State Health Insurance information Program (SHIP). SHIP counselors can review your specific situation and help you understand the costs and coverage of different plans. You can find your local SHIP by calling 1-800-MEDICARE or visiting Medicare.gov.

Frequently Asked Questions

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

No. You can have one or the other, but not both. If you enroll in a Medicare Advantage plan, your Original Medicare coverage ends. If you go back to Original Medicare, your Medicare Advantage coverage ends. You can switch between them during the Annual Enrollment Period.

Do I still pay Part B premiums if I have Medicare Advantage?

Yes. You pay your Part B premium to Medicare, and then you pay the Medicare Advantage plan's premium (if it has one) to the insurance company. The insurance company receives a payment from Medicare to cover your benefits, but you are still responsible for your Part B premium.

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

Most Medicare Advantage plans are regional and do not cover you outside their service area. If you move, your plan will likely end, and you will need to choose a new plan in your new location. You can switch plans without penalty when you move, even outside the Annual Enrollment Period.

Can I use Medicare Advantage if I have Medicaid?

Yes, but it is complicated. If you have both Medicare and Medicaid (called "dual may be able to access"), some Medicare Advantage plans are designed for you. These are called Special Needs Plans (SNPs). You should talk to your state Medicaid office and a Medicare counselor before choosing a plan.

What if I am unhappy with my Medicare Advantage plan?

You can switch to a different Medicare Advantage plan or to Original Medicare during the Annual Enrollment Period. You can also switch if you have a may have access to life event, such as moving out of the service area or losing coverage. If you switch to Original Medicare, you should also buy a Medigap policy if you want coverage for gaps in Original Medicare.