The Real Differences Between Original Medicare and Medicare Advantage—Without the Marketing Spin

Key Takeaways

• Original Medicare and Medicare Advantage both offer coverage under Medicare, but they differ dramatically in flexibility, costs, provider access, and rules.

• Your choice can affect everything from how you access specialists to how much you pay annually, so understanding the trade-offs—without the marketing spin—is essential.

What You Get With Original Medicare

Original Medicare consists of two main parts:

• Part A (Hospital Insurance): Covers inpatient care in hospitals, skilled nursing facility care, hospice, and some home health care.

• Part B (Medical Insurance): Covers doctor visits, outpatient care, preventive services, and some home health services.

With Original Medicare:

• You can visit any doctor or facility that accepts Medicare, anywhere in the country.

• You typically pay 20% of the Medicare-approved amount for Part B services after meeting the annual deductible.

• There is no annual out-of-pocket maximum for Part A and B combined, unless you add supplemental coverage.

• You can add a standalone Part D plan for prescription drug coverage.

What Medicare Advantage Plans Provide

Medicare Advantage (MA), also known as Part C, is an alternative to Original Medicare offered by private insurance companies approved by Medicare. In 2025, these plans must cover everything Original Medicare does, but often with added rules and limitations.

Medicare Advantage plans usually:

• Combine Part A, Part B, and often Part D into one plan.

• Have their own provider networks—HMOs and PPOs are most common.

• Include supplemental benefits like dental, vision, hearing, and wellness programs.

• Set annual out-of-pocket maximums for in-network care (in 2025, this can be as high as $9,350).

While these extras may sound appealing, they come with caveats—especially around access and authorizations.

1. Provider Access and Referrals

With Original Medicare, you have freedom to see any provider nationwide who accepts Medicare. There’s no need for referrals to see specialists.

In contrast, most Medicare Advantage plans operate with networks. You may:

• Be required to choose a primary care physician (PCP).

• Need a referral to see a specialist.

• Face higher costs or receive no coverage for care outside your network.

In rural or underserved areas, this network restriction can be particularly limiting.

2. Prior Authorization Requirements

Medicare Advantage plans frequently require prior authorization for many services, including:

• Diagnostic imaging (MRIs, CT scans)

• Home health care

• Durable medical equipment

• Certain surgeries

This means your doctor must get approval from the plan before you receive care. Delays and denials are more common under MA compared to Original Medicare.

Original Medicare typically does not require prior authorization for most services, though a few exceptions exist (like some durable medical equipment).

3. Prescription Drug Coverage

Original Medicare does not include prescription drug coverage. You must enroll in a separate Part D plan. In 2025, Part D features a $590 deductible and a $2,000 annual cap on out-of-pocket costs.

Medicare Advantage plans often include Part D, but with:

• Plan-specific formularies (covered drug lists)

• Varying copayment tiers

• Pharmacy network limitations

If your medications are not covered under your MA plan’s formulary, you may pay the full cost.

4. Costs and Financial Predictability

Original Medicare generally has more predictable costs for those who pair it with Medigap coverage. While premiums and Medigap policies can be higher, the result is fewer surprise charges.

Medicare Advantage plans may offer lower monthly premiums, but:

• You’ll face copays or coinsurance for nearly every service.

• Costs can vary widely based on your usage.

• You might hit a high out-of-pocket maximum.

Also, MA plans reset these charges every calendar year. That means you may start over in January with new deductibles and limits.

5. Coverage When Traveling

Original Medicare covers you across all 50 states and most U.S. territories. You’re not limited by state or plan boundaries, so it’s ideal if you travel frequently within the U.S.

Medicare Advantage plans generally limit coverage to specific geographic service areas. If you’re outside your plan’s area, you may:

• Only receive emergency care

• Pay full cost for non-emergency services

Some PPO MA plans allow out-of-network access, but with higher costs.

6. Supplemental Benefits Aren’t Guaranteed

Medicare Advantage plans often advertise supplemental benefits, such as:

• Dental cleanings

• Eye exams and glasses

• Hearing aids

• Gym memberships

However, these benefits vary widely. In 2025, fewer MA plans are offering over-the-counter items and transportation benefits than in previous years. Availability and value depend heavily on the plan and region.

Original Medicare doesn’t include these services, but you can choose separate coverage or pay out of pocket. The benefit is transparency—you know what’s included and what’s not.

7. Enrollment Periods and Switching

You can enroll in Medicare Advantage or return to Original Medicare during specific times each year:

• Initial Enrollment Period (IEP): Starts 3 months before you turn 65 and ends 3 months after.

• Annual Enrollment Period (AEP): October 15 to December 7. You can switch between Original Medicare and MA or change your Part D plan.

• Medicare Advantage Open Enrollment: January 1 to March 31. Allows one switch between MA plans or a return to Original Medicare with a Part D plan.

You can’t switch plans freely outside these windows unless you qualify for a Special Enrollment Period (SEP).

8. Appeals and Denials

Medicare Advantage enrollees are more likely to face coverage denials and appeals processes due to prior authorization and utilization management.

Original Medicare decisions are generally straightforward and based on national coverage determinations or your doctor’s clinical judgment.

MA plans must follow Medicare rules, but enforcement varies, and resolving disputes can be time-consuming.

9. Plan Stability and Annual Changes

Medicare Advantage plans can change each year. Changes may include:

• Provider network updates

• Changes in benefits or cost-sharing

• Drug formulary adjustments

You receive an Annual Notice of Change (ANOC) in September outlining these changes. It’s your responsibility to review it and determine if your current plan still meets your needs.

Original Medicare benefits are more stable and consistent year to year.

10. Medigap Is Not Available With Advantage Plans

If you choose Medicare Advantage, you cannot use a Medigap (Medicare Supplement) plan. These policies are only for Original Medicare.

Medigap can help cover costs like:

• Part A and B deductibles

• Coinsurance

• Foreign travel emergencies

If you switch from MA to Original Medicare later, you might not be guaranteed Medigap enrollment unless you qualify for special protections. That means you could be denied coverage or charged more based on health history.

The Final Word on Choosing What’s Best for You

There’s no one-size-fits-all answer. What matters most is how you prefer to manage your care:

• Do you value provider choice and flexibility? Original Medicare may suit you better.

• Are you looking for added benefits and can manage a network structure? A Medicare Advantage plan could appeal to you.

But don’t base your decision on commercials or plan perks alone. Carefully consider how each option handles:

• Referrals and authorizations

• Medication access and cost

• Predictability of your out-of-pocket spending

Choosing wisely now helps you avoid unexpected bills and disruptions later. For support in weighing your options, speak with a licensed agent listed on this website who can guide you through the decision.