Every year during Medicare Open Enrollment (October 15 through December 7), millions of Americans face the same choice: stick with Original Medicare or switch to a Medicare Advantage plan. The decision affects everything from your monthly premiums to which doctors you can see. Here is what you need to know to make the right call for your situation.
What Is Original Medicare?
Original Medicare is the federal health insurance program administered directly by the government. It has two main parts:
- Part A (Hospital Insurance): Covers inpatient hospital stays, skilled nursing facility care, hospice, and some home health services. Most people pay no premium for Part A.
- Part B (Medical Insurance): Covers doctor visits, outpatient care, preventive services, and medical equipment. The standard 2024 premium is $174.70/month.
Original Medicare does not cap your out-of-pocket spending and does not cover most prescription drugs (that is Part D), dental, vision, or hearing. Many people add a Medigap supplemental policy to cover cost-sharing gaps.
What Is Medicare Advantage?
Medicare Advantage (Part C) is offered by private insurers approved by Medicare. These plans must cover everything Original Medicare covers, but they often bundle additional benefits like prescription drug coverage, dental, vision, hearing, fitness memberships, and telehealth.
Many Medicare Advantage plans have $0 premiums beyond the Part B premium you still pay. However, they typically operate as HMO or PPO networks, meaning your choice of doctors and hospitals may be restricted.
Side-by-Side Comparison
Cost
Original Medicare: You pay 20% of most Part B costs with no cap. Adding a Medigap plan (Plan G averages $100-$200/month) eliminates most cost-sharing. Total monthly cost with Medigap and Part D: typically $250-$400/month.
Medicare Advantage: Often $0 additional premium. But you face copays and coinsurance, and out-of-pocket maximums typically range from $4,000-$8,300/year. If you need significant care, costs can add up quickly.
Provider Choice
Original Medicare: Accepted by approximately 93% of non-pediatric physicians nationwide. You can see any provider who accepts Medicare — no referrals required for specialists.
Medicare Advantage: Restricted to the plan network. Out-of-network care can be very expensive or not covered at all. You may need a referral to see a specialist. If you travel frequently or live part-time in another state, network restrictions can be a major drawback.
Prescription Drugs
Original Medicare: Requires a separate Part D plan for drug coverage. You choose the plan that best covers your specific medications.
Medicare Advantage: Most plans bundle drug coverage. However, the drug formulary (list of covered drugs) is determined by the insurer and can change annually.
Extra Benefits
Original Medicare with Medigap: No extras — just comprehensive, flexible health coverage.
Medicare Advantage: Dental, vision, hearing aids, gym memberships, and other perks are genuinely valuable, especially if you need hearing aids, which can cost $3,000-$6,000 out of pocket otherwise.
Prior Authorization
This is where many Medicare Advantage enrollees get frustrated. Private insurers can require prior authorization — advance approval — before covering certain procedures, tests, or hospital stays. Original Medicare does not require prior authorization for most services. A 2022 HHS report found that Medicare Advantage plans denied prior authorization requests at a significant rate, and many denials were later overturned on appeal.
Who Should Choose Original Medicare?
Original Medicare with Medigap tends to be the better choice if you:
- Have complex or chronic health conditions requiring frequent specialist care
- Want maximum flexibility in choosing doctors and hospitals
- Travel frequently or split time between states
- Want to see any hospital in the country, including top cancer centers
- Prefer predictable monthly costs over variable copays
Who Should Choose Medicare Advantage?
Medicare Advantage tends to be the better choice if you:
- Are generally healthy and use healthcare services infrequently
- Want dental, vision, and hearing coverage bundled in one plan
- Have limited income and want to minimize monthly premiums
- Live in an area with strong Medicare Advantage networks
- Want the simplicity of one card for most health needs
The Switching Problem
Here is a critical warning: switching from Medicare Advantage back to Original Medicare may be harder than you think. If you want to add Medigap coverage after leaving Medicare Advantage, insurers in most states can deny you or charge higher premiums based on health conditions, unlike when you first enroll at 65. Only a few states have guaranteed issue rights for Medigap at any time.
This means the decision is not simply try Medicare Advantage and switch if you do not like it. Getting locked out of Medigap coverage could be costly if your health changes.
Frequently Asked Questions
Can I have both Original Medicare and Medicare Advantage?
No. When you enroll in Medicare Advantage, your care is managed through the private plan instead of Original Medicare. You are still technically enrolled in Medicare Parts A and B and still pay the Part B premium, but the Advantage plan pays your claims.
What is the Medicare Advantage out-of-pocket maximum?
In 2024, Medicare sets the out-of-pocket maximum for Medicare Advantage plans at $8,850 for in-network services. Some plans set lower limits. Once you hit the cap, the plan covers 100% of covered services for the rest of the year. Original Medicare has no cap without Medigap.
Can I switch plans every year?
Yes. During Annual Open Enrollment (October 15 through December 7), you can switch from Original Medicare to Medicare Advantage, switch between Advantage plans, or return to Original Medicare. Changes take effect January 1. There is also a Medicare Advantage Open Enrollment period (January 1 through March 31) that allows one additional switch.
Do Medicare Advantage plans cover care outside the U.S.?
Generally, no. Most Medicare Advantage plans only cover emergency care outside the U.S. If you travel abroad frequently, consider a travel insurance policy with medical coverage or a Medigap plan that includes foreign travel emergency benefits.
Use Medicare Plan Finder at Medicare.gov to compare plans in your ZIP code, and consider speaking with a SHIP (State Health Insurance Assistance Program) counselor, who provides free, unbiased help to Medicare beneficiaries.