When you enroll in Medicare, one of the biggest decisions you’ll face is how you want to receive your coverage. There are two main approaches: Original Medicare and Medicare Advantage. They cover the same core services but work quite differently. This guide breaks down those differences so you know which questions to ask when you review your options. It comes to you from Apple IPA.
Key Takeaways
- Original Medicare is run by the federal government and includes Part A and Part B.
- Medicare Advantage (Part C) is offered by private insurers approved by Medicare.
- Provider networks, referrals and prior authorization are often the biggest differences.
- Costs are structured differently, so compare the full picture, not only the premium.
- Annual Open Enrollment runs October 15 through December 7.
In This Guide
What Is Original Medicare?
Original Medicare is the traditional Medicare program administered by the federal government.
It includes:
- Medicare Part A: Hospital Insurance
- Medicare Part B: Medical Insurance
With Original Medicare, you can generally visit any doctor or hospital in the United States that accepts Medicare. In most cases, you don’t need a referral to see a specialist.
People with Original Medicare can also choose to add:
- A separate Part D prescription drug plan
- Medicare Supplement Insurance, also known as Medigap
- Other qualifying coverage, such as certain employer, retiree or Medicaid coverage
What Is Medicare Advantage?
Medicare Advantage, also called Part C, is another way to receive Medicare benefits.
These plans are offered by private insurance companies approved by Medicare. They must cover Medicare Part A and Part B services, and most include prescription drug coverage.
Many plans also offer additional benefits that Original Medicare generally doesn’t cover, such as certain dental, vision or hearing benefits.
Side-by-Side Comparison
| Feature | Original Medicare | Medicare Advantage |
|---|---|---|
| Administered by | Federal government | Private insurers approved by Medicare |
| Includes | Part A and Part B | Part A and Part B services, plus often Part D |
| Choice of doctors | Any provider in the U.S. that accepts Medicare | Often a plan network |
| Specialist referrals | Generally not required | Varies by plan |
| Prior authorization | Less common | May be required for some services |
| Annual out-of-pocket limit | None for Parts A and B on their own | Yes, for covered Medicare services |
| Drug coverage | Separate Part D plan | Included in most plans |
| Extra benefits | Generally limited | Often dental, vision, hearing |
| Medigap | Can be added | Generally not used with these plans |
Provider Networks Can Be Different
One of the most important differences involves doctors and hospitals.
With Original Medicare, you can generally see any doctor or hospital that accepts Medicare anywhere in the United States.
Medicare Advantage plans may require you to use doctors and other providers within the plan’s network for non-emergency care. Some plans provide out-of-network coverage, but the costs and rules can be different.
Referrals and Prior Authorization
Original Medicare generally doesn’t require referrals to see specialists.
Medicare Advantage plans may have different requirements. These can include referrals for certain specialist visits and prior authorization for some services or treatments.
The exact rules depend on the plan. Review each plan’s requirements instead of assuming every Medicare Advantage plan works the same way.
How Costs Can Differ
Original Medicare and Medicare Advantage also structure costs differently.
Original Medicare
You generally pay a portion of the Medicare-approved amount for covered services after applicable deductibles. Original Medicare itself doesn’t have an annual out-of-pocket limit for Part A and Part B services, unless you have supplemental coverage such as Medigap or certain other insurance.
Medicare Advantage
These plans have an annual out-of-pocket limit for covered Medicare services. Premiums, deductibles, copayments and other costs vary by plan.
When you compare, look beyond the monthly premium. Consider deductibles, copays and coinsurance, and the annual out-of-pocket limit as well.
What About Prescription Drugs?
With Original Medicare, prescription drug coverage is generally obtained through a separate Part D plan. Many Medicare Advantage plans include Part D coverage as part of the plan.
If prescription medications are important to your care, check both the plan’s formulary (its list of covered drugs) and the pharmacies that participate in the plan.
Extra Benefits and Travel
Many Medicare Advantage plans add benefits such as dental, vision or hearing, but the details and limits vary a lot by plan. Review exactly what is included before you assume a benefit is covered.
Travel is worth considering too. Original Medicare lets you see providers nationwide that accept Medicare. Medicare Advantage plans may limit non-emergency care outside their network or service area, so ask how a plan handles care when you are away from home.
Questions to Ask When Comparing Coverage
When you review Medicare options, consider questions such as:
- Does my current doctor accept this coverage?
- Are my specialists included?
- Are my preferred hospitals in the network?
- Are my prescription medications covered?
- Which pharmacies can I use?
- What are the premiums and deductibles?
- What are my expected copayments or coinsurance?
- Is prior authorization required for services I may need?
- What is the plan’s annual out-of-pocket limit?
- Will the coverage work for me if I travel?
There isn’t one set of answers that applies to everyone. Your health care providers, medications, location, budget and other insurance coverage can all be relevant.
Reviewing Your Medicare Coverage
Medicare provides specific enrollment periods during which you can make changes to your coverage.
The Medicare Open Enrollment Period is October 15 through December 7 each year. During this period, people with Medicare can make certain changes to Medicare Advantage and Part D coverage.
Frequently Asked Questions
What is the main difference between Original Medicare and Medicare Advantage?
Original Medicare is run by the federal government and lets you see any provider that accepts Medicare. Medicare Advantage is offered by private insurers and often uses provider networks.
Does Original Medicare have an out-of-pocket limit?
Not for Part A and Part B on their own. Supplemental coverage such as Medigap may help with out-of-pocket costs. Medicare Advantage plans have an annual out-of-pocket limit for covered Medicare services.
Do Medicare Advantage plans include drug coverage?
Most do. With Original Medicare, drug coverage is generally obtained through a separate Part D plan.
Do I need a referral to see a specialist?
Original Medicare generally doesn’t require referrals. Medicare Advantage plans may require them for certain specialist visits, depending on the plan.
When can I change my Medicare coverage?
The Open Enrollment Period, October 15 through December 7, lets you make certain changes to Medicare Advantage and Part D coverage. Other enrollment periods may apply to your situation.
Need Official Answers?
Visit Medicare.gov or call 1-800-MEDICARE.
Looking for a doctor, specialist or clinic? The Apple IPA provider directory can help you explore health care providers in your area.
This article is for general informational purposes only. It is not medical, insurance, legal or financial advice. Medicare rules, benefits and costs can change. Always verify current information with Medicare.gov or your Medicare plan. To find providers, visit appleipa.org.
