Original Medicare and Medicare Advantage are two different ways to get your Medicare coverage

Original Medicare is the federal health insurance program run directly by the Centers for Medicare & Medicaid Services (CMS). It has two parts: Part A covers hospital stays, skilled nursing care, and hospice; Part B covers doctor visits, outpatient care, and preventive services. You use it at any hospital or doctor's office in the country that accepts Medicare.

Medicare Advantage (also called Part C) is an alternative way to get your Medicare benefits. Private insurance companies run these plans on behalf of Medicare. They must cover everything Original Medicare covers, but they do it through their own networks of doctors and hospitals. Most Medicare Advantage plans also include prescription drug coverage and extras like dental or vision — things Original Medicare does not cover.

The choice between them affects which doctors you can see, what you pay out of pocket, and whether you need a separate prescription drug plan. Neither is automatically better; it depends on your health, your doctors, and what you can afford to pay.

Key Takeaways

  • Original Medicare is run by the federal government and lets you see any doctor or hospital nationwide that accepts Medicare, with no network restrictions.
  • Medicare Advantage is sold by private insurance companies and usually limits you to doctors and hospitals in their network, but often includes dental, vision, and prescription drug coverage at no extra premium.
  • Original Medicare requires a separate Part D prescription drug plan; Medicare Advantage plans typically include drug coverage built in.
  • Out-of-pocket costs work differently: Original Medicare has deductibles and coinsurance that can add up; Medicare Advantage has copays and an annual out-of-pocket maximum that caps your total spending.
  • 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 Original Medicare works and what it costs

With Original Medicare, you pay a monthly premium for Part B (currently $164.90 per month in 2024, though this varies by income). You also pay an annual deductible before Medicare starts to pay — $240 for Part A hospital care and $226 for Part B doctor and outpatient care in 2024. After you meet the deductible, you typically pay 20% coinsurance for most services, and Medicare pays the other 80%.

There is no network. You can walk into any hospital or doctor's office in the United States that accepts Medicare, and your coverage works the same way. You do not need permission from a plan to see a specialist. This flexibility is the main reason some people choose Original Medicare, especially if they have doctors they want to keep or travel frequently.

The catch is that your costs are not capped. If you have a serious illness or need a lot of care, your 20% coinsurance can add up to thousands of dollars in a single year. Many people buy a Medigap policy (supplemental insurance) to cover some or all of those costs, but Medigap premiums are separate and can run $100 to $300 per month depending on your age and location.

How Medicare Advantage works and what it costs

Medicare Advantage plans are sold by private insurers like UnitedHealthcare, Humana, Anthem, and others. Most have a $0 monthly premium on top of your Part B premium — the plan itself costs nothing. In exchange, you must use doctors and hospitals in the plan's network, except in emergencies.

Instead of paying a percentage of costs, you pay a copay for each visit — typically $10 to $50 to see a doctor, for example. You also have an annual out-of-pocket maximum, usually between $5,000 and $7,000. Once you hit that limit, the plan pays 100% of covered services for the rest of the year. This cap makes it easier to predict your costs.

Most Medicare Advantage plans include prescription drug coverage, dental (cleanings and exams, sometimes fillings), vision (eye exams and glasses), and hearing aids — benefits Original Medicare does not cover. Some plans also offer gym memberships or transportation to medical appointments. These extras are why many people choose Medicare Advantage, especially if they need regular dental or vision care.

Network restrictions and how they affect your care

The biggest practical difference is the network. With Original Medicare, there is no network — you go where you want. With Medicare Advantage, you must use in-network doctors and hospitals, or you pay much more out of pocket (or nothing is covered at all, depending on the plan).

This matters most if you have a doctor you have seen for years and want to keep. Before you enroll in a Medicare Advantage plan, you can check whether your current doctors are in the network. If they are not, you have to decide whether to switch doctors or choose Original Medicare instead. Plans change their networks every year, so a doctor who is in-network this year might not be next year.

If you need emergency care or urgent care, Medicare Advantage plans must cover it even if the provider is out of network. If you travel outside the plan's service area, emergency care is covered, but routine care is not. Some plans cover out-of-network care in other states if you are a snowbird or travel frequently, so ask about this when comparing plans.

Prescription drug coverage: what you need to know

Original Medicare does not cover prescription drugs. If you choose Original Medicare, you must enroll in a separate Part D prescription drug plan sold by private insurers. These plans have their own monthly premiums (usually $5 to $100 per month) and their own deductibles and copays. You must choose a Part D plan during your initial enrollment period or during the annual enrollment period, or you may face a penalty if you go without coverage.

Medicare Advantage plans almost always include prescription drug coverage as part of the plan. You do not buy a separate Part D plan. The copays for drugs are usually lower than standalone Part D plans, and the plan's out-of-pocket maximum includes drug costs. This is one reason Medicare Advantage can be cheaper overall if you take multiple medications.

Both Original Medicare Part D and Medicare Advantage drug coverage use formularies — lists of drugs the plan covers. Not every drug is on every formulary, and some drugs require prior authorization from the plan before the pharmacy will fill them. If you take a specific medication, check whether it is covered before you enroll.

Switching between Original Medicare and Medicare Advantage

You can change your mind. The Annual Enrollment Period runs from October 15 to December 7 each year. During this time, you can switch from Original Medicare to Medicare Advantage, from Medicare Advantage to Original Medicare, or from one Medicare Advantage plan to another. Changes take effect January 1.

If you have a may have access to life event — you move out of your plan's service area, lose employer coverage, get married or divorced, or experience another major change — you may be able to switch outside the annual enrollment period. You usually have 60 days from the event to make the change.

If you are switching from Medicare Advantage to Original Medicare, you can enroll in a Medigap policy at the same time without waiting or paying a higher premium, as long as you explore within 63 days. This protection is called Medigap open enrollment and applies only when you leave a Medicare Advantage plan. After that window closes, insurers can charge you more or deny you coverage based on your health.

Questions to ask your doctor and your plan

Before you choose, talk to your current doctors. Ask whether they accept Medicare, and if you are considering a specific Medicare Advantage plan, ask whether they are in that plan's network. Ask your doctor whether they think you will need specialist care in the next year, because that affects whether a network restriction will bother you.

If you take prescription medications, use your plan's website or call the plan to check whether your drugs are covered and what the copay will be. Ask whether any of your drugs require prior authorization. If you see a specialist regularly, confirm that specialist is in the network.

Ask your plan directly about out-of-pocket maximums, deductibles, and whether the plan covers care outside the network if you travel. Ask whether there are any waiting periods for dental or vision coverage. These details change year to year, so do not rely on what you heard last year.

Frequently Asked Questions

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

No. You must choose one or the other. If you enroll in Medicare Advantage, your Original Medicare coverage ends. If you switch back to Original Medicare, your Medicare Advantage plan ends. You cannot hold both simultaneously.

What happens to my Medigap policy if I switch to Medicare Advantage?

Your Medigap policy will end when your Medicare Advantage plan starts. If you later switch back to Original Medicare, you can enroll in a new Medigap policy, but you may pay a higher premium if you are older or have health problems. Enroll within 63 days of leaving Medicare Advantage to avoid this penalty.

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

Yes. You pay your Part B premium to Medicare no matter which type of coverage you choose. Most Medicare Advantage plans do not charge an additional monthly premium on top of that, but some do. Check the plan's premium before you enroll.

What if my Medicare Advantage plan drops out of my area?

If your plan stops serving your county, you get a special enrollment period to switch to a different plan or to Original Medicare. You will receive a notice from your plan before this happens, usually several months in advance. You can then enroll in a new plan or switch to Original Medicare without waiting for the annual enrollment period.

Is Medicare Advantage cheaper than Original Medicare?

It depends on your health and how much care you use. Medicare Advantage has lower or no monthly premiums and a capped out-of-pocket maximum, which helps if you need a lot of care. Original Medicare has no network, but you may need Medigap to cap your costs, and Medigap premiums can be high. If you are healthy and see doctors rarely, Medicare Advantage may cost less. If you have chronic conditions or see specialists often, Original Medicare with Medigap might be cheaper overall.