Should you get original Medicare or an Advantage plan? Here’s what to know
Open enrollment for Medicare starts soon, so it’s time to start thinking about what’s next for your healthcare. The public insurance is for people 65 and older, although some younger people who have certain disabilities or conditions may also be eligible.
There are two main ways to get coverage: either through original Medicare or Medicare Advantage. Open enrollment for traditional Medicare is Oct. 15 though Dec. 7. For people who have a Medicare Advantage plan, open enrollment is Jan. 1 through March. 31.
Here’s what to know:
What’s the difference between original Medicare and Medicare Advantage plans?
Original Medicare:
Traditional Medicare, also known as original Medicare, covers inpatient care in hospitals, skilled nursing facilities care, hospice care and home health care, according to the Centers for Medicare and Medicaid Services. It also covers services from doctors, outpatient care, “durable medical equipment” such as wheelchairs and walkers, as well as preventive services such as screenings, an annual wellness visit and certain vaccines.
Medicare has four parts and traditional Medicare is what’s considered to be Part A (hospital insurance) and Part B (medical insurance), according to the agency. Part C is Medicare Advantage plans and Part D is drug coverage.
“People with Medicare can go to any doctor or hospital, anywhere in the United States that accepts Medicare. If they have traditional Medicare, they can also buy Medicare Supplement Insurance (Medigap) policy from a private insurance company,” the federal agency previously told the Miami Herald in an email. “Traditional Medicare pays for much, but not all, of the cost for covered healthcare services and supplies. A Medigap policy can help pay some of the remaining healthcare costs, such as co-payments, coinsurance and deductibles.”
The federal agency recommends people who get traditional Medicare should also enroll in Part D, which provides prescription drug coverage. This way you’ll get hospital, medical and prescription drug benefits.
To learn more about what is and is not covered by traditional Medicare, visit Medicare.gov
Medicare Advantage:
A Medicare Advantage plan typically “bundles” original Medicare — hospital insurance and medical insurance — with Medicare prescription drug coverage into “one health insurance plan,” according to the agency.
“If someone selects Medicare Advantage coverage, they join a plan offered by Medicare-approved private companies. Each plan can have different rules for how someone gets services — like referrals to see a specialist,” the agency said. “All plans must cover emergency and urgent care, as well as all medically necessary services covered by traditional Medicare.
However, while most Medicare Advantage plans include hospital, medical and prescription drug coverage, you can’t go to any doctor you want. Medicare Advantage plans usually require you to use doctors and other providers who are in a plan’s network and service area.
“Costs for monthly premiums and services vary depending on which plan you join. Some plans may offer some extra benefits that traditional Medicare doesn’t cover — like vision, hearing and dental services,” the agency said.
What documents do you need to apply for Medicare?
If you want to enroll in Medicare Part A (hospital insurance) and Part B (medical insurance), you’ll need to contact the Social Security Administration. This is the information the Centers for Medicare and Medicaid Services says you should have available:
- Your Social Security number
- Where you were born (city, state, country)
- The start and end dates of any group health plans in which you’re enrolled. If you’ve enrolled for a 65-plus group health plan ahead of time, make sure to have the start and end date.
- A valid email address and your existing Medicare number, although the federal agency notes this information is only needed for people who want to enroll in Part B (medical insurance.)
Does traditional Medicare require pre-authorization? What about Medicare Advantage plans?
People with Medicare Advantage plans will often find themselves needing to get approval through pre-authorization from their plan before having certain services or supplies covered.
One of the perks of traditional Medicare is that in most cases, you don’t need approval to have services and supplies covered. However, it’s worth noting that this will change in some states — but not Florida — in 2026.
That’s because the federal government is launching a new program that will require pre-authorization for certain items and services, including skin and tissue substitutes, epidural steroid injection for pain management, and deep brain stimulation for Parkinson’s disease. The goal is to “root out waste on Original Medicare,” streamline the preauthorization process and protect “Medicare beneficiaries from being given unnecessary and often costly procedures,” according to the Centers for Medicare and Medicaid Services.
The program, at least for now, only applies to providers and patients in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington, according to Axios.
Can I keep my doctors if I enroll in Medicare?
Most likely, you can keep the doctors you see if you enroll in Medicare.
People with traditional Medicare can go to any doctor, hospital, facility or other healthcare provider that accepts Medicare. The good news is that many providers accept Medicare. You also don’t need to choose a primary care doctor, and in most cases, you also don’t need a referral to see a specialist, according to the Centers for Medicare and Medicaid Services.
For people with Medicare Advantage plans, take note: You can only use doctors and other providers who are in your plan’s network. Keep in mind that “costs for monthly premiums and services vary depending on which plan you join” and “some plans may offer some extra benefits that traditional Medicare doesn’t cover — like vision, hearing and dental services,” according to the federal agency.
If you want to make sure your doctors accept Medicare and Medicare Advantage plans, call and ask. The federal government also has an online Medicare provider database you can use to find and compare providers near you. The website lets you filter by location, provider type (doctors, hospitals, nursing homes) and you can also search for your doctor by name.
How does the Medicare Prescription Payment plan work. Do I need to renew?
People with a Medicare Part D plan can choose to pay their out-of-pocket costs for drugs covered by their plans throughout the calendar year, via monthly capped payments, instead of all at once at the pharmacy, according to the federal agency. This is done through the Medicare Prescription Payment plan.
The federal agency says your payments could change every month due to various reasons, including if you’re adding or refilling a prescription. Still, it won’t cost you more than what you would have paid out of pocket at the pharmacy originally. You also won’t pay more than the out-of-pocket maximum for prescription drugs covered by your plan.
The program isn’t meant to make medication cheaper, but to help manage monthly expenses. The federal agency says people who have high drug costs earlier in the calendar year will likely benefit the most from the program. You can sign up for it via your health or drug plan. Starting in 2026, anyone who signs up for the prescription payment plan will be automatically re-enrolled for the following year unless you opt out, according to Kiplinger.
To learn more about the program, including a questionnaire meant to help determine if the program would help you, visit Medicare.gov.
For people who have Medicare A and B, how much does it usually cost to add Plan D for drugs?
Medicare Part D, drug coverage, is an optional and recommended Medicare benefit people can enroll in to help cover the cost of prescription drugs.
“In Medicare Part D, prescription drug plans may charge a monthly premium. Premiums vary by plan. People enrolled in a Part D plan may pay this premium in addition to the Part B premium,” according to the Centers for Medicare and Medicaid Services. “If someone is in a Medicare Advantage plan with prescription drug coverage, the monthly premium may include an amount for drug coverage.”
Actual premiums for Part D plans available in 2026 won’t be released until September, but, plan costs are expected to be pricier. Premiums for Part D are expected to increase in 2026 by an estimated 6% from $36.78 to $38.99, according to Investopedia.
In 2026, the cap on how much Medicare enrollees can pay out-of-pocket for prescription drugs is also expected to rise from $2,000 to $2,100.
It’s recommended that people with traditional Medicare enroll in Part D to get drug coverage. Most Medicare Advantage plans include prescription drug coverage, but it’s important to make sure your plan of choice has it.
If you already have Medicare, is it worth switching to a Medicare Advantage plan?
Switching from Medicare to a Medicare Advantage plan depends on what you need. Here are some of the differences:
- Doctors and hospital choice:
Original Medicare lets you visit any doctor or hospital in the U.S. that accepts Medicare, and you usually don’t need a referral to see a specialist.
Medicare Advantage requires you to use doctors and other providers who are in the plan’s network and service area. You may also need to get a referral to see a specialist.
- Coverage:
Original Medicare covers most medically necessary services and supplies although it doesn’t cover some benefits like eye exams, most dental care and routine physical exams.
Medicare Advantage plans are required to cover all medically necessary services, just like traditional Medicare, but depending on the plan, may also offer extra benefits including vision, hearing and dental services.
Original Medicare needs you to enroll in Part D to get prescription drug coverage.
Medicare Advantage plans typically include drug coverage, and won’t let you join a separate Medicare drug plan.
In most cases, traditional Medicare doesn’t require you to get approval to have most drugs and services covered. This will change in 2026 in some states – but not Florida – due to a new program the federal government is launching that will require pre-authorization for certain items and services as part of a plan to reduce fraud and waste.
People with Medicare Advantage plans may need to get approval (pre authorization) before having many services or supplies covered.
- Cost:
Original Medicare patients usually pay 20% of the Medicare-approved amount for Part B (medical) services after meeting their deductible.
Medicare Advantage out-of-pocket costs will vary for certain services depending on the plan.
Original Medicare doesn’t have a yearly limit on out-of-pocket costs for Part A or Part B, unless you have supplemental coverage. In 2026, there will be a $2,100 out of pocket cap for Part D prescriptiong drugs for everyone with Medicare Part D.
Medicare Advantage plans have a limit for Part A (hospital) and Part B (medical) services. This means that once you hit the plan limits, you don’t have to worry about paying out-of-pocket anymore for hospital and medical services for the rest of the year.
Original Medicare also lets you buy Medigap, a supplemental insurance, to pay for remaining out-of-pocket costs.
Medicare Advantage does not allow Medicap coverage.
To learn more about the differences and to compare plans, visit https://www.medicare.gov/basics/get-started-with-medicare/get-more-coverage/your-coverage-options/compare-original-medicare-medicare-advantage
How to enroll in Medicare, Medicare Advantage? Who can you contact for help?
People who apply for retirement or disability benefits from Social Security or the Railroad Retirement Board and start getting benefits at least four months before turning 65 are automatically enrolled in Original Medicare (Part A and B) once they turn 65, according to the Centers for Medicare and Medicaid Services. People who live in Puerto Rico or outside the U.S. would still need to sign up for Part B.
Everyone else has to enroll in Medicare through Social Security, either at your local Social Security office, calling Social Security at 800-772-1213, or using the online portal, which is the easiest and fastest way to sign up. TTY users can also call 800-325-0778. If you have questions about Medicare, call 800-MEDICARE (800-633-4227). TTY users can call 877-486-2048. You can also contact the Florida Department of Elder Affairs SHINE program, which provides free Medicare and health insurance counseling and information to Medicare beneficiaries, their families and caregivers. Call 800-96-ELDER or email information@elderaffairs.org. For TTY, call 800-955-8770.
This story was originally published August 29, 2025 at 5:00 AM.
