Original Medicare vs. Medicare Advantage
Key Takeaways
- Older Americans typically receive Medicare in one of two ways: Original Medicare (Parts A and B)Original Medicare is a fee-for-service health insurance program available to Americans aged 65 and older and some individuals with disabilities. Original Medicare is provided by the federal government and is made up of two parts: Part A (hospital insurance) and Part B (medical insurance). and Medicare Advantage (Part C)Medicare Advantage (Medicare Part C) is health insurance for Americans aged 65 and older that blends Medicare benefits with private health insurance. This typically includes a bundle of Original Medicare (Parts A and B) and Medicare Prescription Drug Plan (Part D). .
- The eligibility requirements are the same for Original Medicare and Medicare Advantage.
- Original Medicare is provided by the federal government. Medicare Advantage is sold by private insurance companies.
- Medicare Advantage must cover at least the same things as Original Medicare, but often includes more benefits.
- Medicare Part A and Medicare Part B have set costs. Pricing for Medicare Advantage depends on each plan.
Understanding the differences between Original Medicare (Parts A & B) and Medicare Advantage (Part C) can help you make an informed choice about your health insurance. Original Medicare is the federal health insurance program and covers inpatient hospital care as well as doctor’s visits, lab work, and durable medical equipment. Medicare Advantage plans are offered by private insurance companies and offer the same coverage as Original Medicare, but often bundled with additional benefits.
Keep reading to learn more about the different benefits, costs, and provider networks of Original Medicare and Medicare Advantage.
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Original Medicare vs. Medicare Advantage At a Glance
| Original Medicare | Medicare Advantage | |
|---|---|---|
| Part A | Yes | Yes |
| Part B | Yes | Yes |
| Part D | No; you can enroll in a stand-alone Part D plan | Sometimes; some plans include Part D benefits or you can enroll in a stand-alone Part D plan |
| Additional Benefits | No | Sometimes; some plans include vision, dental, etc. |
| Premium (2025) | Part A: Usually $0, but some people pay $285 or $518 per month; Part B: Usually $185 | Varies; some plans charge supplemental premiums in addition to Part A and/or B premiums |
| Deductible (2025) | Part A: $1,676 per benefit period; Part B: $257 | Varies; some plans have a $0 deductible |
| Copay and Coinsurance | Yes; varies by service | Yes; varies by plan and service |
| Annual out-of-pocket Maximum (2025) | None; you can enroll in Medigap to reduce out-of-pocket costs | Varies; out-of-pocket maximums capped at $9,350 for in-network and $14,000 for in- and out-of-network combined |
| Compatible with Medigap | Yes | No |
Overview of Original Medicare
Original Medicare is a health insurance program offered by the U.S. government. Original Medicare has two parts:- Part A, hospital insurance: Part A helps cover inpatient care at hospitals, hospice, skilled nursing facilities, and some other medical facilities.
- Part B, medical insurance: Part B provides partial medical coverage for doctor’s visits, therapies, lab work and durable medical equipment. It also covers 100% of most preventive services.
- They receive Social Security Disability Insurance (SSDI)
- They have been diagnosed with Amyotrophic Lateral Sclerosis (ALS) or End-Stage Renal Disease (ESRD)
Original Medicare Add-Ons
Original Medicare doesn’t cover all areas of healthcare. For those costs, consider additional coverage offered by private insurance companies.- Part D, prescription drug coverage: Part D plans cover prescription drugs, helping to make medication costs more manageable.
- Medicare Supplement insurance, or Medigap: Medigap plans help cover your Original Medicare copays, deductibles, and coinsurance. Some Medicare Supplement plans also provide some international emergency care coverage.
Costs For Original Medicare
Specific healthcare costs vary from person to person, but Original Medicare has relatively standardized rates across the country.- Premiums: A premium is the monthly amount you pay for insurance.
- Part A Premium: Many people have no Part A premium. Some people who haven’t paid as much in Medicare taxes may have a premium of $285 or $518 each month in 2025.
- Part B Premium: The Part B premium for 2025 is $185 each month.
- Deductibles: A deductible is the amount you must pay before your insurance will start covering costs. The Part A deductible for 2025 is $1,676 for each benefit period. The Part B deductible is $257 and only has to be paid once a year.
- Copays: A copay is the flat-rate amount you pay for a service. Copays aren’t common in Original Medicare, but Part A does have some copays for hospital stays.
- Coinsurance: Coinsurance is similar to copays, but based on a percentage of the service cost rather than a flat rate. 20% is the common Part B coinsurance rate, with exceptions for preventive care.
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Overview of Medicare Advantage
Medicare Advantage plans – also known as Medicare Part C – are private insurance plans that include all the same coverage as Original Medicare and may also bundle in other benefits. Additional benefits may include vision, dental, hearing, Part D prescription drugs, and more. People who have Medicare Parts A & and B are eligible for Medicare Advantage.
The Medicare Advantage plans available depends on where you live. Some counties have numerous options while others have fewer, with an average of 34 available plans per county in 2025.
Many Medicare Advantage plans use provider networks to keep costs low. Some plans allow out-of-network care, but you typically pay more for that care.
Specialized Medicare Advantage Plans
Medicare Advantage plans called Special Needs Plans (SNP) are available to people with specific healthcare needs. These plans offer more specialized benefits.
- Chronic Condition Special Needs Plan (C-SNP): C-SNP plans are for beneficiaries with a long-term medical condition that requires ongoing medical treatment. Benefits may include coverage for specialists in the chronic condition, relevant prescription drug coverage, and other health services.
- Dual Eligible Special Needs Plan (D-SNP): A D-SNP plan is for people who are enrolled in both Medicare and Medicaid. The plan coordinates the coverage of both programs, typically covers copays and coinsurance, and may offer benefits like vision, dental, health and more.
- Institutional Special Needs Plan (I-SNP): Beneficiaries who need the level of services provided by a long-term care facility are eligible for I-SNP plans. These plans reduce travel for appointments and typically cover things like prescription drugs, durable medical equipment, in-patient hospital care, and more.
All Special Needs Plans have Care Coordinators who assist members in getting the services they need.
Costs For Medicare Advantage
When you consider a Medicare Advantage plan, look at these costs. Think through how they interact with each other and how they will add up each month and across a whole year to plan your budget.
- Premiums: A premium is the monthly amount you pay for insurance. Some Medicare Advantage have an additional premium to the amount you pay for Part B, but 75% of people in Medicare Advantage during 2024 had a $0 premium.
- Deductibles: A deductible is the amount you must pay before your insurance will start covering costs. The deductible for Part C depends on the plan you choose.
- Copays: A copay is the flat-rate amount you pay per service appointment, such as each time you see your doctor.
- Coinsurance: Coinsurance is a percentage of the service cost. For example, your insurance may cover 85% of costs, making you responsible for covering the remaining 15%.
- Out-of-network fees: Because most Medicare Advantage plans have a network of providers who’ve agreed on the price of services, using an out-of-network provider typically comes with extra costs.
- Out-of-pocket maximum: An out-of-pocket maximum (sometimes abbreviated MOOP) adds up the money you spend in copays and coinsurance on covered services. Once you hit the maximum, your plan pays for 100% of your covered health expenses for the rest of the plan year.
How to Choose Between Original Medicare and Medicare Advantage
So how do you choose between a Medicare Advantage plan vs. Original Medicare? First, know that regardless of what you choose, you’ll always have access to the hospital and doctor services that Parts A and B cover. Here are some differentiating factors to consider:
- Health network: Original Medicare does not have a network of providers, which means you can go to any doctor or facility that accepts Medicare. Medicare Advantage plans typically cover a specific network of doctors and facilities. Check the networks offered by Medicare Advantage plans in your county. Is there a network that includes your current providers?
- Prescription coverage: Original Medicare does not cover the drugs you pick up from a pharmacy. To get prescription drug coverage, you must enroll in a separate Part D plan. However, many Medicare Advantage plans bundle in prescription drug coverage, which can make coordination of care easier. Look at the available plans and compare formularies (drug coverage lists) – which plans cover your medications? What are the price differences for Part D versus a Medicare Advantage plan?
- Benefit costs: With Original Medicare, you will need to pay as an individual or find a stand-alone plan for vision, dental, hearing, and more. Medicare Advantage plans can bundle coverage for those services. Compare the cost between a Medicare Advantage plan with those benefits versus Original Medicare with standalone plans.
Enrolling In Medicare
Once you’ve made your choice between Original Medicare and Medicare Advantage, it’s time to enroll. Take these next steps with confidence that you’ve made an informed decision about your health insurance.
Original Medicare Enrollment
You enroll in Original Medicare through the Social Security Administration. If you are receiving Social Security or Railroad benefits before age 65, you will be enrolled in Medicare automatically. If you’re not automatically enrolled, you can visit your local Social Security office or enroll online at the Social Security website.
You typically need to enroll during your Initial Enrollment Period, which starts three months before your 65th birthday and ends three months after your birthday.
Medicare Advantage Enrollment
You can only enroll in Medicare Advantage if you’re already enrolled in Parts A and B. Once you’ve chosen the Medicare Advantage plan that you want, you can enroll online or over the phone with an insurance company or with a licensed agent or broker. Agents and brokers can also help you explore your plan options.
No matter how you choose to enroll, have resources handy with your personal information, your Medicare card, and a list of your doctors and prescriptions. You’ll typically complete this enrollment during your Initial Enrollment Period or the Annual Enrollment Period (Oct. 15 – Dec. 7).
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Putting It All Together
Original Medicare covers inpatient hospital stays and medical services and doesn’t use provider networks. Medicare Advantage plans cover everything required by Original Medicare and may bundle in more services like vision, dental, or prescription drugs. However, these plans usually have a provider network.
Both types of Medicare plans have their pros and cons, so consider your budget, needed benefits, and preferred doctors and pharmacies when comparing whether to switch to Medicare Advantage. If you still have questions about plans in your area, a licensed agent or broker may be able to help.