Once you have Medicare, you choose how to receive your benefits. You can use Original Medicare, run by the federal government, or join a Medicare Advantage plan run by a private insurer. Both cover the same basic hospital and medical services. They differ in cost, flexibility and extras.
Neither option is better for everyone. The right choice depends on your health, your doctors, your budget and how you like to get care.
How the two compare
| Original Medicare | Medicare Advantage | |
|---|---|---|
| Doctors and hospitals | Any provider in the US that accepts Medicare | Usually a network; out-of-network care may cost more or not be covered |
| Referrals | Usually not needed for specialists | Often needed in HMO plans |
| Prior approval | Rarely required | Often required for some services |
| Yearly limit on your costs | None, unless you add Medigap | Yes, set by each plan |
| Drug coverage | Add a separate Part D plan | Usually included |
| Extras such as dental and vision | Not covered | Often included, with limits |
| Monthly premiums | Part B premium, plus Part D and Medigap if you add them | Part B premium, plus the plan premium, which may be $0 |
Questions to ask yourself
Are my doctors and hospitals covered?
If you have doctors you want to keep, check that they are in a plan's network for next year, not just this year. If you live part of the year in another state, ask how the plan covers care there. Original Medicare is accepted nationwide.
Are my prescriptions covered, and at what cost?
Every drug plan has its own list of covered drugs. Enter your exact prescriptions into the Plan Finder at Medicare.gov to compare yearly costs.
How much could I pay in a bad year?
With Original Medicare alone, there is no cap on your 20% share of Part B costs. A Medigap policy can cover most of that gap. With Medicare Advantage, the plan's out-of-pocket maximum caps what you pay for covered medical services, though it can be several thousand dollars.
How do I feel about prior approval?
Medicare Advantage plans often require approval before certain tests, procedures or stays in a skilled nursing facility. Original Medicare rarely does. If you have ongoing health needs, ask how a plan handles approvals.
Do I want extras?
Many Advantage plans include some dental, vision, hearing or fitness benefits. Look closely at the limits: a dental benefit may cover cleanings but only a small amount toward major work.
The Medigap question
If you choose Original Medicare, the best time to buy a Medigap policy is during your Medigap open enrollment period, the six months starting when you are 65 and enrolled in Part B. During that time, insurers must sell you any policy they offer at their best price, regardless of your health.
If you start with Medicare Advantage and later want to switch back, you may not be able to buy a Medigap policy, or it may cost more, because in most states insurers can then review your health. There are some exceptions:
- A trial right: if you join Medicare Advantage when first eligible at 65 and leave within 12 months, you generally have a right to buy Medigap.
- Some states, such as New York and Connecticut, have broader rights to buy Medigap at any time.
When you can switch
- Open enrollment, October 15 to December 7: switch in either direction, with changes starting January 1.
- Medicare Advantage open enrollment, January 1 to March 31: if you are in an Advantage plan, you can switch to another Advantage plan or to Original Medicare once.
- Special situations, such as moving out of your plan's area, can give you other chances.
Get help comparing
Free, unbiased counseling is available from your State Health Insurance Assistance Program. Read how SHIP counseling works. If you speak with an agent or broker, ask which companies they represent and how they are paid, and remember that you never have to decide during the first call.
