Original Medicare vs. Medicare Advantage: Five Questions Before You Compare Plans

Original Medicare and Medicare Advantage are two different ways to receive Medicare benefits. Neither path is automatically the right choice for every person.

First, separate the two paths

Original Medicare includes Part A and Part B. You can add a separate Part D drug plan. If you are eligible and want help with some Original Medicare cost sharing, you may also consider a Medigap policy.

Medicare Advantage, also called Part C, is offered by private companies approved by Medicare. It provides Part A and Part B benefits and most plans include Part D drug coverage. You still have Medicare, but the plan administers the coverage and sets its network, cost sharing, and plan rules within Medicare requirements.

Question 1: Which doctors and hospitals do you need?

With Original Medicare, you can use any doctor or hospital that takes Medicare anywhere in the United States. Ask whether the provider accepts Medicare assignment, because that can affect what you pay.

With Medicare Advantage, you may need to use doctors, hospitals, and other providers in the plan's network and service area for non-emergency care. Some plans allow out-of-network care at a higher cost, while others generally do not.

Before comparing extras, check:

• every physician and specialist you want to keep;
• the hospitals and outpatient facilities you use;
• whether those providers are accepting new patients under the plan;
• what happens if a provider leaves the network during the year.

A directory is a starting point, not the final confirmation. Verify with both the plan and the provider.

Question 2: What is the total cost structure?

With Original Medicare, you generally pay deductibles and coinsurance as services are used. Medicare.gov states that Original Medicare has no yearly limit on what you pay out of pocket unless you have other coverage such as Medigap, Medicaid, or employer, retiree, or union coverage.

Medicare Advantage plans set their own cost sharing within Medicare rules and have a yearly limit on what you pay for covered Medicare services. The limit, premium, deductibles, copayments, and out-of-network rules vary by plan.

Do not compare plans using the monthly premium alone. Put these items on the same page:

• Part B premium, which generally continues under either path;
• any plan or Part D premium;
• medical and drug deductibles;
• primary-care, specialist, hospital, outpatient, and therapy cost sharing;
• the annual out-of-pocket limit and whether a separate out-of-network limit applies;
• costs for services or items not covered.

Question 3: Are your prescriptions covered at your pharmacies?

With Original Medicare, prescription drug coverage normally comes from a separate Part D plan. Most Medicare Advantage plans include Part D, but not every plan does.

For either path, compare the actual prescriptions you take:

• formulary status;
• tier and expected cost;
• pharmacy network;
• mail-order rules;
• prior authorization, step therapy, or quantity limits;
• whether your preferred pharmacy is preferred, standard, or out of network.

Formularies and pharmacy arrangements can change. Use Medicare's current Plan Compare results and confirm important drugs with the plan.

Question 4: How much plan approval and referral friction can you accept?

Medicare.gov says Original Medicare generally does not require prior authorization for covered services or supplies. Medicare Advantage plans may require prior authorization for certain services or supplies, and some plan types may require referrals to see specialists.

That does not mean every request is approved automatically under Original Medicare or denied under Medicare Advantage. It means the processes differ. If you use frequent imaging, therapy, specialist care, durable medical equipment, or planned procedures, compare the applicable plan rules instead of relying on a general label.

Question 5: Where do you expect to receive care?

Original Medicare can be used with providers that take Medicare throughout the United States. Medicare Advantage plans are tied to a service area and may limit routine non-emergency care to a network, although emergency and urgent care protections apply and specific plans may offer additional travel benefits.

Neither path should be described as broad international medical coverage. Original Medicare generally does not cover care outside the United States, subject to limited exceptions. Some Medigap policies or Medicare Advantage plans may offer limited foreign-travel emergency benefits; check the exact policy or Evidence of Coverage.

Where Medigap fits—and where it does not

Medigap is supplemental insurance designed to work with Original Medicare. It cannot be used to pay Medicare Advantage copayments, deductibles, or premiums.

Under federal law, the Medigap Open Enrollment Period lasts six months and starts the first month you have Part B and are 65 or older. During that period, insurers generally cannot deny a policy they sell because of pre-existing health problems or use medical underwriting to charge more for those problems.

After that one-time period, options may be more limited or more expensive unless a guaranteed-issue protection or state rule applies. People under 65 may have different rights because federal law generally does not require insurers to sell them Medigap; state law may provide additional protections.

A neutral comparison worksheet

Before choosing, list:

1. doctors, hospitals, and facilities;
2. prescriptions and preferred pharmacies;
3. expected appointments, treatments, and travel;
4. monthly premiums and likely cost sharing;
5. the worst-case annual cost you could reasonably face;
6. network, referral, and prior-authorization rules;
7. Medigap timing and state protections;
8. employer, retiree, union, Medicaid, VA, or TRICARE coverage that could be affected.

Then use Medicare's official plan comparison tools for your ZIP code. For free, personalized, non-sales counseling, locate your State Health Insurance Assistance Program (SHIP).

If you are approaching Medicare eligibility

The free Turning 65 Medicare Checklist helps you organize enrollment dates, doctors, prescriptions, and coverage questions before comparing plans.

What this guide cannot decide

This page does not recommend Original Medicare, Medicare Advantage, Medigap, or a specific company or plan. The right comparison depends on current plans available in your location, provider participation, prescriptions, other insurance, eligibility, expected care, finances, and personal preferences. Verify all plan-specific details in the current Summary of Benefits and Evidence of Coverage and with Medicare.gov.