When it comes to choosing Medicare coverage, there are two main options: Original Medicare and Medicare Advantage (Part C). Each option comes with its own rules for doctors, costs, and additional benefits. This guide will walk you through the key differences to help you make an informed decision about your healthcare coverage.

1. Doctor and Hospital Access

Original Medicare

With Original Medicare, you have broad flexibility in choosing your healthcare providers. You can visit any doctor or hospital across the U.S. that accepts Medicare. Referrals are generally not required to see specialists, making it easier to get the care you need without going through additional steps.

Medicare Advantage

Medicare Advantage plans usually require you to use doctors and healthcare facilities within a specific network and geographic area for non-emergency care. Depending on the plan, you may also need a referral to see a specialist. This can limit your provider options but may result in more coordinated care.

2. Out-of-Pocket Costs

Original Medicare

Under Original Medicare, after meeting your deductible, you typically pay 20% of the Medicare-approved amount for services (coinsurance). You'll also pay a monthly premium for Part B and, if you choose to add drug coverage (Part D), a separate premium for that plan.

There’s no annual out-of-pocket limit, but you can buy a Medigap policy to help cover costs that Medicare doesn’t pay. Alternatively, coverage from an employer, union, or Medicaid may assist with these expenses.

Medicare Advantage

Out-of-pocket costs in Medicare Advantage plans vary by provider. You still pay the monthly Part B premium and possibly an additional premium for the plan itself. Some plans offer $0 premiums and may contribute toward your Part B premium.

Unlike Original Medicare, Medicare Advantage has an annual limit on out-of-pocket costs for Part A and Part B services. Once you reach that limit, you won’t pay for covered services for the rest of the year. However, you cannot purchase a Medigap policy with Medicare Advantage.

3. Coverage and Benefits

Original Medicare

Original Medicare covers most medically necessary services in hospitals, doctor’s offices, and other healthcare settings. It doesn’t include routine dental, vision, or hearing care. You typically don’t need prior authorization for services, and you can enroll in a separate Part D plan for prescription drug coverage.

Medicare Advantage

Medicare Advantage plans are required to cover all the services that Original Medicare covers, but they may apply their own rules for determining medical necessity. Many plans include extra benefits, such as dental, vision, hearing, and wellness programs. Most plans also bundle Part D drug coverage into the same policy.

Some services may require prior authorization, meaning you’ll need approval from the plan before receiving certain treatments or supplies.

4. Coverage While Traveling Abroad

Original Medicare

Original Medicare generally doesn’t cover care outside the United States. However, you may be able to purchase a Medigap policy that includes coverage for emergency care while traveling internationally.

Medicare Advantage

Most Medicare Advantage plans don’t offer coverage outside the U.S., but some may include limited emergency or urgent care benefits for foreign travel.

How to Set Up Your Medicare Coverage

Setting up Medicare typically involves two steps:

Enroll in Part A (Hospital Insurance) and Part B (Medical Insurance).

Choose how to get your Medicare coverage:

1. Stick with Original Medicare and optionally add Part D and Medigap.
2. Enroll in a Medicare Advantage Plan (Part C), which often includes drug coverage.

You’re automatically enrolled in Original Medicare unless you choose a Medicare Advantage plan. Medicare is individual coverage, so your spouse will need to make their own decisions — there are no family plans.

How Original Medicare Works

Original Medicare includes:

1. Part A (Hospital Insurance): Covers inpatient care in hospitals, skilled nursing facilities, hospice, and some home health care.
2. Part B (Medical Insurance): Covers outpatient care, doctor visits, preventive services, and some home health care.

Once you meet your deductibles, you pay your share of the approved service cost. There's no annual cap on out-of-pocket expenses unless you have additional coverage like Medigap.

Preventive care, such as screenings and vaccines, is included. You can also:

1. Visit any provider nationwide that accepts Medicare.
2. Add Part D for prescription drug coverage.
3. Purchase a Medigap plan to reduce your share of costs.

Keep in mind: if you're not lawfully present in the U.S., you won’t be eligible for Medicare benefits.

How Medicare Advantage Works

Medicare Advantage plans bundle Part A, Part B, and usually Part D into a single plan. These plans are offered by Medicare-approved private insurers and follow federal rules. Coverage and costs may differ based on the specific plan.

Some plans provide additional benefits, especially for people with certain health conditions. However, these plans typically require using in-network providers and may require referrals.

To enroll, you must already have both Part A and Part B. Supplemental insurance (Medigap) is not allowed with Medicare Advantage.

Medicare and Other Health Insurance

If you have Medicare along with other insurance, such as coverage from an employer or Medicaid, each policy is considered a "payer."

1. The primary payer covers costs up to its limits.
2. The secondary payer may cover some or all of the remaining balance.

If a claim isn’t paid within a reasonable time (typically 120 days), Medicare may issue a conditional payment and later recover it from the appropriate insurer. This process is known as coordination of benefits.

Final Thoughts

Choosing between Original Medicare and Medicare Advantage depends on your healthcare needs, budget, and provider preferences. While Original Medicare offers flexibility, Medicare Advantage may provide extra benefits and protection against high out-of-pocket costs.

Take time to review your options annually during Medicare Open Enrollment and make adjustments based on any changes in your health or financial situation.