Original Medicare vs. Medicare Advantage: What's the Difference?

Original Medicare and Medicare Advantage are two ways to receive your Medicare Part A and Part B benefits.

Both provide coverage for medically necessary hospital and medical services.

But they work differently when it comes to doctors, costs, prescription drugs, and insurance company requirements.

Understanding these differences can help you choose coverage that fits your healthcare needs and budget.

Original Medicare vs. Medicare Advantage Comparison

Medicare Advantage benefits, premiums, and provider networks vary by plan and location.

How Doctor and Hospital Access Differs

One of the most important differences is where you can receive medical care.

With Original Medicare

You can visit any doctor or hospital in the United States that accepts Medicare.

You generally don't need a referral to see a specialist, and most services don't require prior authorization.

With Medicare Advantage

Most plans use an HMO or PPO network.

• HMO plans generally require in-network providers for non-emergency care, with certain exceptions.
• PPO plans usually allow out-of-network care, but you may pay more.
• Prior authorization may be required before the plan covers certain procedures, imaging tests, medical equipment, or rehabilitation services.

Medicare Advantage plans must cover emergency and urgently needed care, including when you're outside the plan's service area.

Provider networks, copayments, and covered supplemental benefits can change each year.

Review your plan's Annual Notice of Change before deciding to renew your coverage.

How Much Does Each Option Cost?

Both options require you to pay your Medicare Part B premium, although some Medicare Advantage plans help pay part or all of it.

The biggest difference is how your remaining healthcare expenses are handled.

Original Medicare Costs

Original Medicare has deductibles and coinsurance.

For most Part B-covered services, you pay 20% of the Medicare-approved amount after meeting your annual Part B deductible.

Original Medicare alone doesn't have an annual out-of-pocket maximum.

However, you can purchase a Medigap policy to help cover many of these expenses.

Your total monthly costs may include your Part B premium, a Medigap premium, and a separate Part D prescription drug plan premium.

Medicare Advantage Costs

Medicare Advantage plans have their own copayments, coinsurance, and deductibles.

Some plans offer a $0 monthly plan premium, but that doesn't mean medical care is free.

You may pay copayments for specialist visits, outpatient procedures, hospital stays, and other services.

Every Medicare Advantage plan has an annual out-of-pocket limit for covered Part A and Part B services.

Prescription drug costs and certain supplemental benefits generally don't count toward that medical limit.

Why Medigap Makes a Difference

Medigap is supplemental insurance that works alongside Original Medicare.

Depending on the policy, it helps pay Medicare deductibles, copayments, and coinsurance.

Some Medigap policies cover nearly all Medicare-approved Part A and Part B cost-sharing, leaving relatively predictable medical expenses.

Medigap policies require an additional monthly premium and generally don't cover prescription drugs, routine dental care, or routine vision services.

Medigap can't be used to pay Medicare Advantage copayments or deductibles.

For many people, the practical comparison looks like this:

The first combination generally provides greater provider flexibility and more predictable expenses for Medicare-covered medical care.

The second may have lower monthly premiums and additional benefits, but costs and access depend on the particular plan.

What About Prescription Drug Coverage?

Original Medicare doesn't ordinarily cover medications you pick up at a pharmacy.

You can purchase a separate Medicare Part D prescription drug plan.

Most Medicare Advantage plans include Part D coverage.

Whichever option you choose, check that your medications are covered, your pharmacy participates, and your estimated yearly prescription costs are affordable.

Can You Switch Between Original Medicare and Medicare Advantage?

Yes — Medicare provides enrollment periods when you can change how you receive your coverage.

But switching to Original Medicare doesn't automatically guarantee that you can buy a Medigap policy.

Your six-month federal Medigap Open Enrollment Period generally starts the first month you're both 65 or older and enrolled in Medicare Part B.

It doesn't restart just because you leave Medicare Advantage.

Outside that window and other protected situations, insurers in most states can use medical underwriting.

That means your health history could affect your eligibility or premiums.

Some people qualify for guaranteed issue protections, such as when a Medicare Advantage plan ends coverage, or you move outside its service area.

Federal trial rights may also protect people who try Medicare Advantage for the first time and switch back within the first 12 months, provided they meet the specific eligibility requirements.

The Medigap policies available under those protections depend on the circumstances.

Learn more about Medigap enrollment rights on Medicare.gov.

Which Option Is Better for You?

Neither option is automatically the best choice for everyone.

Original Medicare with Medigap may appeal to people who want nationwide provider access, fewer insurance company restrictions, and more predictable expenses when receiving Medicare-covered care.

Medicare Advantage may appeal to people who prefer lower monthly plan premiums, included prescription coverage, and extra benefits such as dental or vision.

Before deciding, consider these questions:

• Do your preferred doctors and hospitals participate?
• Do you travel or live in more than one state?
• How much could you pay during a year with significant medical expenses?
• Would you rather pay higher monthly premiums or pay more when receiving care?
• Are you comfortable with networks and prior authorization requirements?
• Can you qualify for Medigap now, and could that change later?

For more information, see Medicare.gov's official Original Medicare and Medicare Advantage comparison.