Home / Original Medicare vs Medicare Advantage: Key Differences
Original Medicare vs Medicare Advantage: Key Differences
Both give you Medicare coverage. They work differently: one is run by the government with no network, the other by private plans with networks, a yearly cap on costs and extra benefits.
Side by side
| Original Medicare | Medicare Advantage | |
|---|---|---|
| Doctor and hospital choice | Any doctor or hospital that takes Medicare, anywhere in the U.S. In most cases no referral is needed to see a specialist. | You may need to use doctors in the plan's network and service area for non-emergency care. Some plans cover out-of-network care at higher cost. You may need a referral. |
| What you pay | Part B premium; for Part B services usually 20% of the Medicare-approved amount after the deductible. Separate Part D premium if you join a drug plan. | The Part B premium, plus the plan's premium if it has one. Costs vary by plan and service. Most plans include drug coverage. |
| Yearly limit on what you pay | None, unless you have supplemental coverage such as Medigap, or employer, union or Medicaid coverage. | Required. In 2026 the limit cannot exceed $9,250 for in-network services (and $13,900 for in-network and out-of-network combined), and plans may set lower limits. |
| Medigap | You can buy Medigap to help pay costs Medicare does not, like the 20% coinsurance. | You cannot use Medigap to cover Medicare Advantage costs. |
| Prior authorization | In most cases not needed. | You may need your plan's approval before it covers certain services or supplies. |
| Extra benefits | Does not cover routine physical exams, eye exams or most dental care. | Must cover everything Original Medicare covers. May add benefits such as some vision, hearing and dental. |
| Outside the U.S. | Generally not covered. Some Medigap policies cover emergency care abroad. | Generally not covered. Some plans add emergency coverage when traveling. |
Sources
Two numbers that explain the trade-off
- Cost cap. KFF reports that in 2026 the average out-of-pocket limit for Medicare Advantage enrollees is $5,421 for in-network services. About 1 in 10 enrollees (9%) are in plans at the $9,250 maximum.
- Network size. KFF reports that Medicare Advantage enrollees have access, on average, to about half of the physicians available to people in traditional Medicare in their area. It varies a lot by county and plan.
Part D prescription drugs have their own separate out-of-pocket limit, $2,100 in 2026, which does not count toward the Medicare Advantage limit. Source: KFF.
What people often overlook
- You can usually switch into Medicare Advantage more easily than back out. A Medicare Advantage plan cannot refuse you for health reasons, but a Medigap insurer generally can, outside protected periods. See the underwriting trap.
- Plans can change every year, including networks, drug lists and costs. Check your doctors and drugs each fall during Annual Open Enrollment.
- You still pay Part B in either option.
How to decide
List your current doctors and drugs, how much risk of a very large bill you can absorb, and whether you travel. Then call a SHIP counselor: it is free and unbiased. We do not recommend one option over the other, because the right answer depends on your health, your doctors and your state.
Sources
- Medicare.gov: Compare Original Medicare & Medicare Advantage
- Medicare.gov: Medicare costs (2026)
- KFF: Medicare Advantage Out-of-Pocket Limits: Variation and Trends
- KFF: Medicare Advantage in 2026: Premiums, Out-of-Pocket Limits, Supplemental Benefits, and Prior Authorization
- SHIP National Technical Assistance Center: find your State Health Insurance Assistance Program
Common questions
Can I have Medigap and Medicare Advantage at the same time?
No. Medigap only works with Original Medicare, and you cannot use it to pay Medicare Advantage copayments, deductibles or premiums.
Does Medicare Advantage cover everything Original Medicare covers?
Plans must cover all medically necessary services that Original Medicare covers, and may add other benefits. The rules for getting care, such as networks and prior authorization, can differ.
Is there a yearly limit on costs in Original Medicare?
Not by itself. Medigap or other coverage can fill the gap. Medicare Advantage plans must have a yearly limit on Part A and Part B costs.