Medicare vs. Medicare Advantage | Health Insurance Guru

Posted on by Neal Shanske | Category: Uncategorized

 

Medicare vs. Medicare Advantage: What’s the Difference?

If you’ve just turned 65 or are helping a parent figure out coverage, you’ve probably discovered that “Medicare” isn’t one simple plan — it’s a whole set of options.
At Health Insurance Guru, we’re here to untangle those choices so you can see what’s what, without getting lost in acronyms.

Medicare in a Nutshell

Medicare is the federal health insurance program primarily for people 65 and older, though certain younger people with disabilities also qualify.
It’s funded by payroll taxes and run by the federal government through the Centers for Medicare & Medicaid Services (CMS).

Original Medicare has two main parts:

  • Part A (Hospital Insurance) – Covers inpatient hospital stays, skilled nursing, hospice, and some home health care.
    Most people don’t pay a premium for Part A if they’ve worked and paid Medicare taxes long enough.
  • Part B (Medical Insurance) – Covers doctor visits, outpatient care, lab work, and preventive services.
    There’s a monthly premium for Part B (usually deducted from Social Security).

Together, Parts A and B form what’s called Original Medicare.

What Original Medicare Covers — and What It Doesn’t

Original Medicare does a solid job covering hospital and medical services, but it doesn’t pay for everything.
Notably, it does not include:

  • Prescription drugs
  • Routine dental, vision, or hearing
  • Long-term care (like nursing homes beyond short rehab stays)

To fill those gaps, many people buy Medigap (supplemental insurance) and/or a Part D prescription plan.

Medicare Advantage (Part C): The All-in-One Option

Medicare Advantage, sometimes called Part C, is an alternative way to get your Medicare benefits.
It’s offered by private insurance companies that contract with Medicare to provide Parts A and B coverage — often bundled with extras.

Key features:

  • You still have Medicare, just managed by a private insurer.
  • Plans usually include prescription drug coverage (built-in Part D).
  • Many offer extras Original Medicare doesn’t, like dental, vision, and hearing.
  • You typically use the plan’s provider network (HMO or PPO).

In short, Medicare Advantage combines your hospital, medical, and drug coverage into one plan, with one insurance card.

The Main Differences at a Glance

Feature Original Medicare Medicare Advantage
Provider choice Any doctor or hospital that accepts Medicare nationwide Usually limited to in-network providers
Referrals required No Often yes (for HMOs)
Prescription coverage Must add Part D separately Usually included
Out-of-pocket limit No annual maximum Has an annual cap (set by plan)
Extras (dental, vision, etc.) Not included Often included
Monthly costs Part B premium + Medigap + Part D (if chosen) Part B premium + plan premium (if any)
Billing Medicare pays providers directly Insurer manages payments

How Medigap Fits In

If you choose Original Medicare, you can buy a Medigap policy (also called a Medicare Supplement).
It helps pay your share of costs like deductibles and coinsurance.
There are several standardized Medigap plans — labeled A through N — sold by private insurers.

Important note:
You can’t have both Medigap and Medicare Advantage at the same time.
It’s one or the other.

Costs and Premiums

Everyone pays the standard Part B premium (about $175/month in 2025, though that can vary).
If you choose a Medicare Advantage plan, that premium still applies — plus any extra the plan charges.
Some Advantage plans advertise “$0 premiums,” but they may have higher copays or smaller networks.

With Original Medicare, costs depend on whether you buy Medigap and a Part D plan.
It’s often a bit more expensive monthly but more flexible if you travel or see many specialists.

How to Enroll or Switch

Your first chance to sign up is your Initial Enrollment Period — a seven-month window starting three months before your 65th birthday.

After that, you can make changes during Open Enrollment each year (October 15–December 7).
During that time, you can:

  • Switch between Original Medicare and Medicare Advantage
  • Change or add a Part D plan
  • Move to a different Advantage plan

Changes take effect on January 1.

How to Choose Between Original Medicare and Medicare Advantage

There’s no one right answer — it depends on your lifestyle and health needs.

Choose Original Medicare if you:

  • Want the broadest choice of doctors nationwide
  • Travel frequently or live in multiple states
  • Don’t mind paying for Medigap and Part D for extra coverage

Choose Medicare Advantage if you:

  • Prefer having everything under one plan
  • Want added benefits like dental and vision
  • Are comfortable using a local provider network

Common Misconceptions About Medicare and Medicare Advantage

  • “Medicare Advantage replaces Medicare.”
    Not true — it’s just a different way of getting the same core benefits.
  • “Original Medicare covers prescriptions.”
    Only if you add a Part D plan.
  • “I can switch anytime.”
    Usually you have to wait for open enrollment unless you qualify for a special enrollment period.

The Bottom Line

Both Medicare and Medicare Advantage are valuable — they just take different paths to the same destination.
Original Medicare offers flexibility and simplicity; Medicare Advantage offers convenience and extras.

The key is to think about how you use healthcare: your doctors, prescriptions, and travel habits.
Once you know what matters most, the right choice becomes clearer.

At Health Insurance Guru, we’ll keep explaining these choices in plain language, so you can feel confident choosing the coverage that fits you best.