Original Medicare vs. Medicare Advantage: Questions to Ask
Choosing between Original Medicare and Medicare Advantage depends on your doctors, budget, travel plans and health needs. These questions can help you compare.
The short version
- Original Medicare offers broad provider choice; Medicare Advantage typically uses networks.
- Medicare Advantage plans have an annual out-of-pocket limit; Original Medicare does not unless you add Medigap.
- Your choice affects future options, especially for buying a Medigap policy later.
In this guide
One of the biggest decisions when you join Medicare is whether to choose Original Medicare or a Medicare Advantage plan. Neither is right for everyone. The best choice depends on your health, budget, preferred doctors and lifestyle.
How they differ
Original Medicare (Parts A and B)
- Run by the federal government.
- You can generally see any doctor or hospital in the U.S. that accepts Medicare.
- Referrals are generally not needed to see specialists.
- You usually pay 20 percent coinsurance for most Part B services after the deductible, with no annual out-of-pocket limit.
- Drug coverage requires a separate Part D plan.
- Many people add a Medigap policy to help with out-of-pocket costs.
Medicare Advantage (Part C)
- Offered by private insurance companies approved by Medicare.
- Usually uses a network of doctors and hospitals (HMO or PPO).
- May require referrals and prior authorization for some services.
- Has an annual out-of-pocket limit for covered Part A and B services.
- Usually includes drug coverage.
- Often includes extra benefits, such as routine dental, vision, hearing or fitness programs.
- You cannot use a Medigap policy with Medicare Advantage.
Questions to ask yourself
About your doctors
- Are my current doctors, specialists and hospitals in the plan's network?
- How important is it to me to see any provider who accepts Medicare without needing referrals?
About costs
- What can I afford in monthly premiums?
- How much could I pay if I had a serious illness or hospital stay?
- Do I prefer predictable costs, or am I comfortable paying as I go?
About travel and where you live
- Do I spend part of the year in another state?
- Do I travel often within the U.S. or abroad?
- What plans are available in my area?
About prescriptions
- Are all my medications covered, and at what cost?
- Which pharmacies are in-network?
About extra benefits
- How much would I actually use extra benefits like dental or vision?
- What are the limits on those benefits?
About plan rules
- Does the plan require prior authorization for services I am likely to need?
- How does the plan handle care outside its network?
Think about the future: Medigap timing
If you start with Original Medicare, your Medigap Open Enrollment Period is the six months starting the first month you have Part B and are 65 or older. During this time, insurers generally cannot deny you a policy or charge more due to health conditions.
If you choose Medicare Advantage first and later want to switch to Original Medicare with Medigap, you may have to answer health questions and could be denied or charged more, depending on your state and circumstances. Some states have additional protections. This is an important factor to consider.
Neither option covers everything
Neither Original Medicare nor most Medicare Advantage plans cover long-term custodial care, such as help with daily activities in a nursing home or at home. Planning for long-term care is a separate consideration.
Get personalized help
- Medicare Plan Finder at Medicare.gov to compare plans.
- 1-800-MEDICARE (1-800-633-4227).
- Your State Health Insurance Assistance Program (SHIP) for free, unbiased counseling.
Take your time and compare carefully. Terrameritavi is an independent publication and is not affiliated with Medicare or any insurance company.
