Medicare Advantage vs. Original Medicare: how to choose

Two ways to get Medicare

When you join Medicare, you choose between two main paths. Original Medicare is run by the federal government and includes Part A (hospital insurance) and Part B (medical insurance). Medicare Advantage, sometimes called Part C, is offered by private insurance companies approved by Medicare. It covers everything Part A and Part B cover, but the plan sets its own rules, networks and costs.

Neither choice is right for everyone. The best fit depends on your health, your doctors, your budget and how much you travel. You pay the Part B premium either way; it is $202.90 a month for most people in 2026.

How Original Medicare works

With Original Medicare, you can see any doctor or hospital in the country that accepts Medicare, and you generally don't need a referral to see a specialist. After the Part B deductible, you usually pay 20% of the Medicare-approved amount for doctor visits and outpatient care.

Original Medicare has no yearly limit on what you pay out of pocket, and it doesn't cover most prescription drugs or routine dental, vision or hearing care. That's why most people with Original Medicare add a separate Part D drug plan, and many add a Medicare Supplement Insurance policy, also called Medigap, to help pay the 20% and other gaps.

How Medicare Advantage works

Most Medicare Advantage plans are HMOs or PPOs with a network of doctors and hospitals. In an HMO you usually must use the network except in emergencies, and you may need a referral to see a specialist. A PPO lets you go out of network, but at a higher cost. Plans usually cover a local or regional service area, so non-emergency care while traveling may be limited.

Most plans include Part D drug coverage. Many charge no premium beyond Part B, though some do, and you pay copays and coinsurance as you use care. Many plans add extra benefits that Original Medicare doesn't cover, such as some dental, vision, hearing or fitness benefits. What's covered and how much varies widely from plan to plan.

Prior authorization

Medicare Advantage plans can require prior authorization, meaning the plan must approve certain services, tests or drugs before you get them. If the plan says no, you can appeal. Ask any plan you're considering which services need approval.

Original Medicare has historically used prior authorization for very few services. That is starting to change in some places. Starting January 1, 2026, a federal pilot called WISeR requires prior authorization for a short list of services, such as certain spine procedures, steroid pain injections and knee arthroscopy for osteoarthritis, in Original Medicare in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. It is scheduled to run through 2031.

Out-of-pocket limits

Every Medicare Advantage plan must cap what you pay each year for covered Part A and Part B services. For 2026, the federal ceiling is $9,250 for in-network care, and $13,900 for combined in-network and out-of-network care in plans like PPOs. Many plans set lower limits. For 2027, the in-network ceiling is reported to rise to $9,850, according to the National Council on Aging. Always check the actual limit for the plan you're considering in Medicare's Plan Finder or the plan's documents.

Original Medicare has no cap on its own. A Medigap policy can fill that gap, but it comes with its own monthly premium.

Medigap, and the catch if you switch back

You can't use a Medigap policy with a Medicare Advantage plan. Medigap only works with Original Medicare.

The best time to buy Medigap is your Medigap Open Enrollment Period, the 6 months that start the month you're 65 or older and enrolled in Part B. During that window, insurers must sell you any policy they offer, regardless of your health.

If you join Medicare Advantage and later want to return to Original Medicare with a Medigap policy, you may not be guaranteed one. Some people have trial rights. For example, if you dropped a Medigap policy to join Medicare Advantage for the first time, you generally have 12 months to switch back and get Medigap without health questions. After that, in most states insurers can review your health history and deny coverage or charge more. A few states, including Connecticut, Maine, Massachusetts and New York, offer stronger protections.

When you can switch

• Open Enrollment, October 15 to December 7: switch between Original Medicare and Medicare Advantage, change plans, or join or change a drug plan. Changes start January 1.
• Medicare Advantage Open Enrollment, January 1 to March 31: if you're in a Medicare Advantage plan, you can switch to another one or go back to Original Medicare once.
• Before leaving a Medicare Advantage plan, line up any Medigap policy and Part D plan you'll need.

How to compare, and free help

List your doctors, hospitals, prescriptions and pharmacy. Then compare total yearly costs, not just premiums, in the Plan Finder on Medicare.gov. Check whether your doctors are in each plan's network, which services need prior authorization, and each plan's star rating.

For free, unbiased help, contact your State Health Insurance Assistance Program (SHIP), whose counselors don't sell insurance, or call 1-800-MEDICARE (1-800-633-4227). Be wary of ads and callers promising extra benefits. This is general information, not insurance or financial advice.