Turning 65 or changing Medicare coverage can come with a lot of questions. Two main options are available for getting your Medicare health coverage: Original Medicare and Medicare Advantage (Part C).
Neither option works exactly the same way. Understanding the differences in provider choice, costs, prescription coverage, and benefits can help you have a more informed conversation with your healthcare team or Medicare counselor.
Original Medicare includes Medicare Part A, which covers hospital services, and Part B, which covers medical services and supplies. With Original Medicare, you can generally see any doctor or hospital that accepts Medicare anywhere in the United States.
You can also add:
Original Medicare generally does not include routine dental, vision, or hearing coverage, although some services may be covered under specific circumstances.
Medicare Advantage is an alternative way to receive your Medicare coverage through a Medicare-approved private health plan. These plans include Part A and Part B coverage, and most include prescription drug coverage as well. Many plans also offer additional benefits that Original Medicare generally doesn’t cover, such as certain dental, vision, and hearing benefits.
Medicare Advantage plans can have different rules for receiving care. Depending on the plan, you may need to use a network of doctors and hospitals, choose a primary care provider, obtain referrals for some specialists, or receive prior authorization for certain services.
| Original Medicare | Medicare Advantage | |
|---|---|---|
| Doctor choice | Generally, any doctor or hospital that accepts Medicare | Typically use providers in the plan’s network for non-emergency care |
| Prescription coverage | Part D can be added separately | Most plans include Part D |
| Extra benefits | Generally requires separate coverage for benefits such as dental or vision | Many plans offer additional benefits |
| Referrals | Usually not required for specialists | May be required, depending on the plan |
| Prior authorization | Generally not required for most covered services | May be required for certain services |
| Out-of-pocket limit | No yearly limit under Original Medicare unless you have supplemental coverage | Plans have a yearly limit for covered Medicare services |
| Medigap | Can be purchased to help with certain out-of-pocket costs | Cannot be used with Medicare Advantage |
The specific costs, networks, benefits, and rules vary by Medicare Advantage plan.
Cost is an important part of comparing coverage, but looking only at the monthly premium doesn’t tell the whole story.
With Original Medicare, you generally pay a Part B premium and a share of the cost for covered services. You can purchase Medigap and Part D coverage separately, which may add additional premiums. Original Medicare does not have a yearly out-of-pocket limit unless you have supplemental coverage.
Medicare Advantage plans also require you to continue paying your Part B premium. Depending on the plan, you may have an additional monthly premium, copayments, or coinsurance. Medicare Advantage plans have a yearly out-of-pocket limit for covered Medicare services.
When comparing plans, consider the costs you might actually use throughout the year, including doctor visits, prescriptions, specialist care, hospital services, and other healthcare needs.
Your preferred doctors and hospitals can be an important consideration.
With Original Medicare, you can generally see any provider who accepts Medicare. With Medicare Advantage, you’ll typically need to use providers in your plan’s network for non-emergency care, although some plans may provide out-of-network coverage at a higher cost.
Before choosing a plan, check whether your:
If you choose Original Medicare and want prescription drug coverage, you can enroll in a separate Part D plan.
Most Medicare Advantage plans include Part D prescription coverage. Because coverage, formularies, pharmacies, and costs can vary, check your specific medications before enrolling or changing plans.
Bring an up-to-date medication list when comparing plans so you can check whether your prescriptions are covered and what your costs may be.
Before enrolling in or changing Medicare coverage, consider asking:
You can also use Medicare’s official plan comparison tools or contact your local State Health Insurance Assistance Program (SHIP) for free, personalized Medicare counseling. SHIPs are not connected to any insurance company or health plan.
Medicare coverage isn’t necessarily a one-time decision. Depending on your circumstances, there are specific enrollment periods when you may be able to join, switch, or drop Medicare coverage.
During the Annual Enrollment Period, October 15 through December 7, people with Medicare can review their coverage and make certain changes for the following year. Medicare recommends reviewing your plan each year because premiums, benefits, provider networks, and other plan details can change.
If you’re new to Medicare or experiencing a qualifying life event, you may have different enrollment opportunities.
Choosing Medicare coverage can feel overwhelming, especially when you’re comparing unfamiliar terms, costs, networks, and benefits. Start by thinking about how you currently receive care and what matters most to you.
Review your doctors, prescriptions, expected healthcare needs, and total potential costs rather than focusing on just one feature of a plan.
Champion Health Plan is here to help you stay informed about your Medicare coverage options. Take time to understand your choices, review your plan details, and talk with a qualified Medicare resource if you have questions about your coverage.
This article is for educational purposes only and is not a substitute for official Medicare guidance or personalized insurance advice. Medicare rules, costs, benefits, and plan availability can change. Visit Medicare.gov or speak with a qualified Medicare counselor for information about your individual situation.
