Original Medicare vs Medicare Advantage: How to Decide

The two paths

When you enroll in Medicare, you choose one of two ways to receive your benefits. Original Medicare is Parts A and B run by the federal government, usually paired with a standalone Part D drug plan. Medicare Advantage (Part C) is a private plan approved by Medicare that delivers your Part A and B benefits and usually includes Part D.

You can switch between the two during the Annual Election Period each fall, and in some other situations. So this is not a once-and-forever decision, but it is one worth getting right the first time.

Doctors and hospitals

With Original Medicare you can go to any doctor or hospital in the country that accepts Medicare, with no referrals. Most do.

Medicare Advantage plans typically use a network. HMO plans usually require you to use network providers and get referrals for specialists. PPO plans let you go out of network, generally at a higher cost. Before choosing an Advantage plan, confirm that every doctor you rely on is in the network for the coming year, because networks change.

What you pay

Under Original Medicare you pay the Part B premium, the Part A and Part B deductibles, and generally 20 percent of the approved amount for Part B services. There is no annual limit on that share, which is why many people add additional coverage.

Under Medicare Advantage you keep paying your Part B premium, plus any plan premium. You pay copays or coinsurance as you use care, and the plan has a yearly out-of-pocket maximum for covered Part A and B services. Once you reach it, the plan pays 100 percent for the rest of the year. The maximum is set within limits Medicare publishes each year and differs by plan.

Prescription drugs

Original Medicare does not include outpatient prescription coverage. You add a standalone Part D plan and pay its premium separately.

Most Medicare Advantage plans include drug coverage. Either way, the plan's formulary and pharmacy pricing determine what your medications actually cost, so compare using your real prescription list, not the premium alone.

Extra benefits

Original Medicare does not cover most routine dental, vision, or hearing care. Many Medicare Advantage plans add some of these, along with items like fitness memberships or over-the-counter allowances. The value of these extras varies widely by plan, and they should be weighed after doctors, drugs, and costs, not before.

Travel and multiple homes

Original Medicare works the same everywhere in the United States, which suits people who travel often or split time between states. Medicare Advantage plans are tied to a service area, and routine care outside it may be limited to emergencies and urgent care unless the plan has a travel benefit. If you spend months away from home each year, raise this early.

Questions to answer before you choose

We walk through these with you using your own doctor and medication list, and compare plans from the carriers we represent. There is no charge for the conversation.

• Are all of my doctors and my preferred hospital in the plan's network for next year?
• What will my exact medications cost under each option, at the pharmacy I use?
• Could I afford a bad year with no out-of-pocket cap, or do I want a guaranteed ceiling?
• Do I travel or live part of the year somewhere else?
• Which extras would I actually use?