Original Medicare vs Medicare Advantage

Whether you are new to Medicare or considering a change to your current coverage, it’s important to evaluate your options to determine which type of Medicare coverage best fits your needs. This guide compares Original Medicare and Medicare Advantage side by side, explains how each option works, and walks through key factors such as costs, provider access, medications, and lifestyle to help you decide which option may be the better fit for you. 

What is Original Medicare? 

Original Medicare, also known as traditional Medicare, is the federal program that includes Part A (hospital insurance) and Part B (medical insurance) that is available to most people age 65 and older or those with qualified disabilities.  

• Part A typically covers inpatient hospital care, skilled nursing facility care after a qualifying hospital stay, hospice, and some home health care. 

• Part B helps pay for doctor visits, outpatient services, durable medical equipment, and preventive care and screenings. 

With Original Medicare, you can see any provider nationwide that accepts Medicare. There are no provider networks, and you do not need referrals to see specialists.  

Original Medicare costs include: 

Part A 

• Part A premium (typically $0 for most people) 

• Part A deductible 

• Part A coinsurance and copays 

Part B 

• Part B monthly premium 

• Part B deductible 

• Part B coinsurance (usually 20% of the Medicare-approved amount for Part B services).  

Original Medicare does not cover outpatient prescription drugs; that coverage is provided through a separate Part D plan. Medicare supplement insurance is additional insurance that works with Original Medicare to help pay certain Part A and Part B out-of-pocket costs.  

What is a Medicare Advantage plan? 

Medicare Advantage (Part C) plans, offered by Medicare-approved private insurers, cover the same services as Part A (hospital) and Part B (medical), but typically have different cost-sharing than Original Medicare. Each plan sets their own deductibles, copays and coinsurance. Many plans also include additional features like prescription drug coverage (Part D), and benefits for dental, vision, and hearing services.¹ 

Medicare Advantage plans must cover all services offered by Original Medicare (except hospice, which remains covered by Original Medicare).³ Most plans use provider networks— to receive full coverage for services, you typically must receive care from a provider within your plan’s network. Plan types include HMOs, PPOs, Private Fee-for-Service (PFFS), and Special Needs Plans (SNPs). To enroll, you must have Medicare Part A and Part B and live within the plan’s service area. You cannot combine a Medicare Advantage plan with Medicare supplement insurance.

What is the difference between Original Medicare and Medicare Advantage? 

The table below highlights key differences between Original Medicare and Medicare Advantage, including provider access, costs, prescription drug coverage, and extra benefits. This comparison can help you understand how each option is structured and what you might want to consider when reviewing your Medicare coverage choices. 

In addition to coverage structure and cost, Original Medicare and Medicare Advantage also differ in how care is managed behind the scenes—particularly when it comes to prior authorization, claims processing, and appeals.² Knowing how these administrative processes work can help you set realistic expectations for accessing care, plan for potential approvals or out-of-pocket costs, and decide which coverage option better fits how often you use healthcare and how you prefer to manage it. 

Prior authorization requirements 

Prior authorization requirements can vary significantly between Original Medicare and Medicare Advantage. With Original Medicare, prior authorization is generally limited to a small number of services and is less commonly required, allowing providers to deliver most covered care without advance plan approval. Medicare Advantage plans, by contrast, often require prior authorization for certain services, procedures, or prescription drugs. These requirements are set by the plan and can differ depending on plan type, provider network, and the service being requested. 

Processing claims 

Claims processing also works differently under each option. With Original Medicare, providers typically submit claims directly to Medicare, and Medicare pays its share automatically after the claim is processed. Beneficiaries usually do not need to file claims themselves when seeing a provider who accepts Medicare. Under Medicare Advantage, claims are handled by the private insurance company that administers the plan. In-network providers generally submit claims on your behalf, but costs, copays, and coverage determinations are based on the plan’s specific rules. Read our guide on filing Medicare reimbursement claims to learn more about the Medicare claims process.

Appealing coverage decisions 

Filing appeals follows different paths as well. Original Medicare uses a standardized, nationwide appeals process with defined levels of appeal and timelines. Medicare Advantage plans must follow Medicare’s appeal requirements, but the initial review is handled by the plan itself, and processes can vary by insurer.

Choosing the right option for your healthcare needs 

Choosing between Original Medicare and Medicare Advantage is a personal decision that depends on how you use healthcare, what costs you’re comfortable with, and how you prefer to access care. Reviewing your medical needs, budget, lifestyle, and prescription drug use can help you understand which option may better align with your priorities and provide the level of flexibility or cost predictability you’re looking for. 

1. Your care needs: Consider how often you see doctors, whether you see specialists, and any ongoing conditions or therapies.  

   • Original Medicare offers nationwide access without referrals and can be paired with Medicare supplement insurance and a Part D plan.  

   • Medicare Advantage plans typically have provider networks and require referrals for specialists. They often include drug coverage and extra benefits. 

2. Your budget: Add up monthly premiums (Part B, plus any plan premium), deductibles, and likely copays or coinsurance.  

   • Original Medicare has no annual out-of-pocket maximum for Part A and Part B services. If you are considering Medicare supplement insurance, factor in those premiums and what portion of unexpected out-of-pocket costs it covers. Medicare Advantage plans have an annual out-of-pocket maximum, which limits your exposure, but deductibles, copays and coinsurance for services can still add up. 

3. Lifestyle and location: Take into account whether you plan to travel or spend part of the year in a different state.  

   • Original Medicare offers broad provider access. If you’re traveling domestically, you can see any provider in the U.S. that accepts Medicare. (Original Medicare typically does not cover medical care received while traveling internationally).  

   • Medicare Advantage plans vary in the level of coverage they offer if you travel outside of your plan’s service area or provider network. Some plans may provide benefits for emergencies abroad. 

4. Medications: List your prescriptions and compare formularies.  

   • For Original Medicare, review standalone Part D options that match your medications and preferred pharmacies. 

   • For Medicare Advantage plans with drug coverage, check tiers, prior authorization rules, and pharmacy networks to estimate total drug costs. 

When each option may fit better 

Original Medicare may fit if you want nationwide access to providers, don’t want network restrictions or referrals, and prefer the option to pair coverage with Medicare supplement insurance and/or a Part D plan. 

Medicare Advantage may fit if your doctors and hospitals are in-network, don’t mind referrals, and prefer the convenience of a single plan, often including Part D benefits. 

 There is no single right choice between Original Medicare and Medicare Advantage. The best option depends on your health needs, budget, and how you prefer to access care. Understanding these differences can help you evaluate trade‑offs such as provider access, flexibility, and cost structure. For additional context, comparing Medicare Advantage with Medicare supplement insurance, which works with Original Medicare to help manage out‑of‑pocket costs, can further clarify your options. 

Frequently asked questions 

Q1. Can I switch from Medicare Advantage to Original Medicare? 

Yes. You can switch from a Medicare Advantage plan back to Original Medicare during certain enrollment periods, such as the Medicare Annual Enrollment Period (Oct. 15 to Dec. 7) or the Medicare Advantage Open Enrollment Period (Jan. 1 to March 31). If you switch, you may also have the option to enroll in a Medicare Part D drug plan, and you can apply for a Medicare supplement plan, though acceptance may depend on medical underwriting. 

Q2. Do I need a Part D plan if I have Medicare Advantage? 

If your Medicare Advantage plan includes prescription drug coverage (also known as an MA-PD plan), you generally do not need a separate Part D plan and usually cannot enroll in one. If your Medicare Advantage plan does not include drug coverage, you may be able to join a standalone Part D plan. 

Q3. Can I use Medicare supplement insurance with Medicare Advantage? 

No. Medicare supplement (Medigap) policies are designed to work only with Original Medicare. You cannot enroll in a Medicare supplement insurance policy if you have a Medicare Advantage plan. 

Q4. How much does Medicare Advantage cost compared to Original Medicare? 

Costs vary. Medicare Advantage plans often have low or $0 monthly, but you’ll still pay your Part B premium and your plan will also have deductibles, copayments, and/or coinsurance. With Original Medicare, you’ll also owe the Part B premium and will have deductibles and copays and/or coinsurance for services. If you have a Medicare supplement plan, it will help cover out-of-pocket costs but will also have its own monthly premium. 

Sources 

¹ Medicare.gov. PDF: Understanding Medicare Advantage Plans. Retrieved on March 31, 2026, from www.medicare.gov/publications/12026-understanding-medicare-advantage-plans.pdf 

² Centers for Medicare & Medicaid Services (CMS). PDF: Original Medicare vs. Medicare Advantage. Retrieved on March 30, 2026, from www.cms.gov/files/document/mln8659122-original-medicare-vs-medicare-advantage.pdf 

³ MedPAC.gov. Web page: Including hospice benefit in the MA benefit package. Retrieved on April 24, 2026, from www.medpac.gov/including-hospice-benefit-in-the-ma-benefit-package/  

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