Original Medicare and Medicare Advantage, Side by Side

Here is how the two Medicare paths generally handle the things people care about most.

Keeping my current doctors

To confirm any doctor takes your coverage, call their office and ask for the billing or insurance person, the number on a bill from that office usually reaches them directly. Plan directories are often out of date, so the office's answer is the one to trust.

Original Medicare

You can see any doctor or hospital in the country that accepts Medicare, and most do. There are no networks to check, and no referrals needed for specialists.

Medicare Advantage

Each plan has its own network of doctors and hospitals. Whether you need referrals depends on the plan type: HMO plans usually require them, while PPO plans usually do not.

Confirm: Before deciding anything, call each of your doctors' offices and confirm they take the exact plan you are considering.

The cost of my prescriptions

Original Medicare

Drug coverage comes from a separate Part D plan you choose, unless you already have drug coverage from somewhere else, like a retiree plan or the VA. Each fall you can switch drug plans without touching the rest of your coverage.

Medicare Advantage

Most plans include drug coverage as part of the plan, and that plan's drug list and pharmacy pricing apply. Changing to a plan with a better fit for your medications means changing your whole plan, which you can also do each fall.

Confirm: Before choosing any plan, check that your exact medications are on its drug list and what they cost at your pharmacy.

Monthly premium costs

Original Medicare

You pay the Part B premium, plus a premium for a drug plan if you choose one. Many people also pay for a Medigap policy, which covers most of what Original Medicare would otherwise leave to you.

Medicare Advantage

You pay the Part B premium, and many plans add little or no premium on top of it. Your other costs come as copays and coinsurance when you use care, up to the plan's yearly maximum.

Confirm: Premiums are only part of the picture. Add up the full cost of each path for you, every premium plus what you would pay when you actually use care. A SHIP counselor can help you do this for free.

Out-of-pocket costs

Original Medicare

After your deductible, you generally pay about 20 percent of the cost of covered outpatient care, with no yearly limit under Parts A and B alone. Many people add a Medigap policy, which covers most or all of that share in exchange for its monthly premium.

Medicare Advantage

You pay the plan's copays and coinsurance as you use care. Every plan has a yearly maximum on what you pay for covered medical services, with drug costs counted separately.

Confirm: Ask what a good year and a heavy-use year would each cost you on the two paths. A SHIP counselor can walk through this with you.

Coverage when I travel

Original Medicare

Your coverage works anywhere in the United States, at any doctor or hospital that accepts Medicare. Coverage outside the country is very limited.

Medicare Advantage

Emergency and urgent care are covered anywhere in the United States. Routine care away from home depends on the plan's rules, network, and service area.

Confirm: If you spend part of the year in another state, ask how each option handles routine care there.

Avoiding enrollment penalties

Penalties come from when you sign up, not from which path you choose. Signing up late for Part B or Part D without coverage that counts, like from a current employer, can add an ongoing amount to your premiums, and the deadlines are the same on both paths.

Original Medicare

You meet the deadlines by enrolling in Parts B and D on time.

Medicare Advantage

You meet the same deadlines, since joining a plan requires Parts A and B, and most plans include drug coverage.

Confirm: Your enrollment windows depend on your work and coverage situation. The guide's enrollment chapters map them, and Social Security can confirm your dates.

Understanding plan options

Original Medicare

The choices are which pieces to add: a Part D drug plan, and possibly a Medigap policy. You can see any Medicare doctor with any of them.

Medicare Advantage

The choice is which single plan to pick, since medical and usually drug coverage come bundled. Plans differ in networks, costs, and extras, and you can review your plan each year.

Confirm: The resources page at the end of this guide links to the official plan finder for your ZIP code. Bring your summary, or take it to a SHIP counselor first.

Recent health changes or a new diagnosis

Original Medicare

Your coverage works the same regardless of your health, and you are free to seek out any doctor or specialist in the country who accepts Medicare.

Medicare Advantage

Your plan's network and rules still shape your care when your health changes. Whether care outside the network is covered, and at what cost, depends on the plan type.

Confirm: If your health is changing, ask hard questions before choosing or switching: which specialists you could see, how long appointments take, and what happens if the care you need is not in the network. A SHIP counselor can help you ask them.

Medicare's rules and amounts change over time. This page describes how the two paths generally work as of the date above. Confirm the details for the current year at Medicare.gov or with a SHIP counselor.