What's the difference between Original Medicare and Medicare Advantage?

If you’re enrolling in Medicare for the first time, or thinking about changing plans, you’ve probably come across the two main options: Original Medicare and Medicare Advantage.

Both are types of health coverage you can get under Medicare, the federal health insurance program for aging adults and adults with disabilities, but they work very differently. The costs, access to doctors, drug coverage, and extra benefits can vary significantly between them.

Original Medicare is run by the federal government. Medicare Advantage is private insurance.

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Comparing Original Medicare and Medicare Advantage#comparing-original-medicare-and-medicare-advantage

Here’s a simplified breakdown of how Original Medicare and Medicare Advantage compare, so you can decide what makes sense for you during Annual Enrollment or your special enrollment period.

What is Medicare?#what-is-medicare

Medicare is a federal health insurance program for adults over the age of 65, but you may also be eligible if you have a disability, End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant), or ALS (also called Lou Gehrig’s disease).

Medicare has four main parts:

• Part A (Hospital Insurance) covers inpatient hospital stays, skilled nursing facility care, hospice, and some home health care
• Part B (Medical Insurance) covers outpatient care, doctor visits, preventive services, lab work, and durable medical equipment
• Part C (Medicare Advantage) is another way to receive your Part A and Part B benefits, but through a private insurance plan
• Part D (Prescription Drug Coverage) helps cover the cost of prescription medications

One of the key decisions people face during open enrollment is whether to receive their benefits through Original Medicare (Parts A and B) or through a Medicare Advantage plan (Part C).

What is Original Medicare?#what-is-original-medicare

Original Medicare is the traditional, federal government-run version of the Medicare program. It helps cover the costs of many standard health care services through Part A (hospital insurance) and Part B (medical insurance).

The federal government has rules and minimum standards for what Original Medicare must cover. Generally, Part A and Part B services under Original Medicare cover:

• Hospital stays
• Doctor visits
• Specialist care
• Preventive services
• Lab tests
• Outpatient procedures

Original Medicare does not cover prescriptions, dental care, vision exams or glasses, hearing aids, or most long-term care. To get prescription drug coverage with Original Medicare, you’ll need to enroll in a separate Medicare Part D drug plan for a premium. You will also need to buy a separate dental or vision insurance plan if desired.

If you are low-income you may qualify for Medicaid, which can cover these services for dual enrollees.

What is Medicare Advantage?#what-is-medicare-advantage

Medicare Advantage is another way to receive your Medicare benefits. Instead of using the federal government-run plan, you select from a menu of private insurance plans approved by Medicare.

All Medicare Advantage plans cover what Original Medicare covers, but these plans sometimes offer extra benefits that cover additional services like:

• Part D prescription drug coverage
• Dental benefits
• Vision coverage
• Hearing services
• Over-the-counter allowances
• Gym memberships

Some plans may also offer Special Supplemental Benefits for the Chronically Ill (SSBCI) for eligible members.

When you review Medicare Advantage plans, you may also hear about specific types of Medicare Advantage Plans: MAPD, C-SNP, and D-SNP.

What is MAPD?#what-is-mapd

MAPD stands for Medicare Advantage Prescription Drug plan but is sometimes Medicare Advantage Plus Part D. An MAPD is simply a Medicare Advantage plan that includes Part D, drug coverage. Many Medicare Advantage plans today are MAPDs, meaning your hospital, medical, and drug coverage are bundled into one plan.

What is C-SNP?#what-is-c-snp

A Chronic Condition Special Needs Plan (C-SNP) is a type of Medicare Advantage plan that is specifically designed for people with certain chronic conditions, such as diabetes, heart failure, or chronic lung disease. Enrollment is limited to people with the defined qualifying health condition, and supplemental benefits are usually tailored to that condition.

What is a D-SNP?#what-is-a-d-snp

A D-SNP (Dual Eligible Special Needs Plan) is a type of Medicare Advantage plan designed for people who qualify for both Medicare and Medicaid. D-SNPs are built to help coordinate benefits between the two programs and may offer additional support services.

To be eligible for a D-SNP during open enrollment, you must already be enrolled in Medicaid. Medicaid has different eligibility rules to Medicare and it is a state-run program, so eligibility rules, income limits, and covered populations vary depending on where you live.

If you gain Medicaid coverage during the Medicare plan year, you can request a special enrollment window to change your plan to D-SNP.

How are prescriptions different between Original Medicare and Medicare Advantage?#how-are-prescriptions-different-between-original-medicare-and-medicare-advantage

With Original Medicare, prescription drug coverage is not included automatically. If you want help paying for medications, you have the option to enroll in a separate Medicare Part D Prescription Drug Plan (PDP) and pay an additional monthly premium. The cost varies depending on which plan you choose. The average standalone Part D premium is expected to be $34.50 in 2026. You may pay a higher premium if you make above a certain amount of income.

Your medical coverage (Parts A and B) and your drug coverage (Part D) are run by separate insurers, which means you may have two ID cards and two different companies managing your benefits.

With Medicare Advantage, many plans are MAPD plans, meaning they include prescription drug coverage under the same insurance plan. MAPDs may charge additional premiums for Part D drug coverage, but most do not.

There is no average cost of just the prescription portion of Medicare Advantage Plans, but the average total monthly cost for MAPDs is expected to be $11.50 in 2026. Costs, coverage tiers, and requirements for prior approval can vary widely, so it’s important to check that your specific medications are covered before enrolling.

If you enroll in a Medicare Advantage Plan without drug coverage, you can enroll in Medicare standalone plans or opt-out.

How are provider networks different between Original Medicare and Medicare Advantage?#how-are-provider-networks-different-between-original-medicare-and-medicare-advantage

Your provider network determines what clinics, doctors, hospitals, and pharmacies you can visit.

Original Medicare:

• Any doctor or hospital that accepts Medicare in the whole of the United States
• No geographic boundaries or specific networks to navigate
• Referrals not usually needed to see specialists

Original Medicare’s flexibility can be appealing to people who travel frequently, live in multiple states during the year, or want maximum flexibility in choosing their doctors.

Medicare Advantage:

• Defined provider network
• Referrals usually needed for specialists or medications

Most Medicare Advantage plans use a narrower set of provider networks. If you visit in-network providers for services, costs will usually be kept lower, but if you use out-of-network providers you may see much higher costs. Some plans only cover out-of-network services in special circumstances.

How do costs differ between Original Medicare and Medicare Advantage?#how-do-costs-differ-between-original-medicare-and-medicare-advantage

How much and when you pay for healthcare can look different between the two programs.

With Original Medicare, most people do not pay a monthly premium for Part A. However, you do pay a standardized monthly Part B premium and also pay a Part D premium if you enroll in drug coverage.

• Part A (Hospital Insurance) Premium: $0 per month for most people who paid Medicare taxes for at least 40 quarters. If you don’t meet the tax requirement, you can buy Part A coverage. In 2026, the premium is $311 per month if you have 30-39 quarters of coverage, and $565 per month if you have fewer than 30 quarters.
• Part B (Medical Insurance) Premium: The standard monthly premium is $202.90 in 2026 for Medicare Part B. If your income exceeds certain limits, you may pay more.
• Part D (Optional Prescription Drug Coverage) Premium: The average Medicare standalone Part D premium is expected to be $34.50 in 2026. You may pay a higher premium if you make above a certain amount of income.
• Deductibles and Co-insurance: Medicare requires you to pay a percentage of the cost of your healthcare. For hospital stays (Part A), Original Medicare will pay for up to 90 days of inpatient hospital admission per benefit period (from admission until you are out of inpatient care for at least 60 consecutive days). You will pay $1,736 towards the cost of your stay for the first 60 days, then $434 per day for days 61 to 90, and $868 per day for lifetime reserve days (up to 60 additional hospital days you can use once over your lifetime). Under Part B, when you use outpatient services you pay a $283 annual deductible in 2026, and typically 20% coinsurance for most outpatient services after meeting that deductible.
• Out-of-Pocket Maximum: There is no annual out-of-pocket maximum for Original Medicare. That means if you have serious medical needs, you could experience high out-of-pocket costs or go into medical debt unless you have Medigap. However, Medicare Part D prescription drug plans do include an annual out-of-pocket cap. In 2026, the most you will pay for covered prescription drugs under Part D is $2,100.

With Medicare Advantage, you enroll in a private plan under Part C, which includes your Part A (hospital) and Part B (medical) coverage. Many plans also include Part D prescription drug coverage. Depending on the specific plan you choose, your costs may look slightly different from Original Medicare:

• Part A (Hospital Insurance) Premium: The same Part A eligibility rules apply as Original Medicare. Most people qualify for $0 monthly Part A premium if they worked and paid Medicare taxes for at least 40 quarters.
• Part B (Medical Insurance) Premium: You still pay your Part B premium ($202.90 in 2026). This is required even if your Medicare Advantage plan advertises a $0 premium. Higher-income beneficiaries may pay more.
• Medicare Advantage Plan Premium: Some Medicare Advantage plans charge an additional monthly premium, while many offer $0 plan premiums. The average monthly premium in 2026 is estimated at $14 per month, but many plans with premiums offer extra benefits not included in Original Medicare.
• Part D (Prescription Drug Coverage) Premium: Most Medicare Advantage plans are MAPD plans, meaning prescription drug coverage is included for no extra premium. If you select a Medicare Advantage Plan without prescription coverage, you can purchase an optional standalone Part D plan for an average monthly premium of $34.50 just like Original Medicare.
• Deductibles and Copays: Medicare Advantage plans overall are complex and very different depending on which one you select. Many plans charge fixed copays for services (for example, a set amount for primary care visits or specialist appointments), deductibles, and co-insurance for out-of-network providers. Out-of-pocket costs are expected to be lower upfront than with Original Medicare but could be higher overall if you use health services frequently.
• Out-of-Pocket Maximum: Medicare Advantage plans include an annual out-of-pocket maximum for Part A and Part B services. Once you reach that spending limit, the plan covers 100% of in-network covered medical services for the rest of the year. In 2026, the maximum you will have to pay for out-of-pocket costs for in-network services is $9,350, though many plans set lower limits. If you’re not using an MAPD and you’re enrolled in a Part D plan, the maximum you will have to pay for covered prescription drugs is $2,100. This is one of the biggest cost differences between Medicare Advantage and Original Medicare, which does not have a cap.

What is Medigap?#what-is-medigap

Because Original Medicare does not have an annual out-of-pocket maximum and requires you to pay deductibles and coinsurance, many people choose to purchase additional coverage called Medigap, also known as Medicare Supplement Insurance.

Medigap is sold by private insurance companies and is designed to help cover the “gaps” in Original Medicare. Depending on the plan you choose, Medigap can help pay:

• Part A hospital deductibles
• Part B deductibles (for certain older plans)
• 20% Part B coinsurance
• Copays and other cost-sharing amounts

Medigap works alongside Original Medicare to cover some or most of your health insurance costs. Medicare will pay its share first, and then your Medigap plan kicks in to cover what would normally be out of pocket costs. The monthly cost of Medigap can range from tens to hundreds of dollars a month depending on the plan, but many people opt-in for the predictability of knowing how much they’ll owe in healthcare costs each month.

You cannot use Medigap with Medicare Advantage. If you enroll in a Medicare Advantage plan, you are not eligible to use a Medigap policy.

How to apply for Medicare#how-to-apply-for-medicare

Since Medicare is a federal program, the application process is the same no matter where you live. Generally, you can apply for Medicare in four ways:

• Online: You can apply for Medicare online through the Social Security Administration website. This is probably the easiest way to apply and works for both Medicare Part A (hospital insurance) and Medicare Part B (medical insurance).
• By phone: You can apply for Medicare by calling the Social Security Administration at 1-800-772-1213 (TTY 1-800-325-0778). Assistance by phone is available in most U.S. time zones Monday through Friday, 8 a.m. to 7 p.m., in English, Spanish, and other languages.
• In person: You can apply for Medicare in person at your local Social Security office. Appointments are usually recommended. To find an office near you visit the SSA office locator tool.

By mail: In some cases, you can complete paper forms sent by the Social Security Administration and return them by mail. Call and ask the Social Security Administration for more information about applying by mail.