Original Medicare is the federal program that lets you use any doctor or hospital in the U.S. that accepts Medicare. Medicare Advantage (Part C) is a plan from a private insurer that delivers your Part A and Part B benefits instead, usually with a provider network, prior authorization rules and a yearly out-of-pocket limit, plus extras such as drug coverage and dental. Neither is better for everyone, and this guide recommends no plan or insurer.
What is the difference between Medicare and Medicare Advantage?
Medicare.gov has a side-by-side comparison. According to KFF, 55% of eligible beneficiaries (35.2 million of 64.2 million with Parts A and B) are in Medicare Advantage, a common choice.
| Topic | Original Medicare | Medicare Advantage |
|---|---|---|
| Doctors and hospitals | Any that accept Medicare, anywhere in the U.S. | Usually the plan’s network and service area for non-emergency care |
| Referrals and prior authorization | In most cases not needed | May be needed |
| Yearly out-of-pocket limit | None, unless you have Medigap, Medicaid or employer or union coverage | Yes, set by the plan within a federal maximum |
| Prescription drugs | Separate Part D plan | Most plans include Part D |
| Dental, vision, hearing | Routine eye exams and most dental care not covered | Many plans offer some of these as extras |
| Medigap | Can be bought to cover your share of costs | Cannot be used with the plan |
In both, you pay the Part B premium ($202.90 a month in 2026 for most people). In Original Medicare you typically pay a $283 Part B deductible, then 20% of most Part B services, and a $1,736 Part A deductible for each hospital benefit period (2026 figures). In Medicare Advantage, costs vary by plan.
Why do people say Medicare Advantage plans are bad?
The complaints concern specific features, and some have documented numbers behind them. So do the features people like.
| What was found | Source |
|---|---|
| 99% of Medicare Advantage enrollees are in plans that require prior authorization for some services, including inpatient hospital stays (97% of enrollees), skilled nursing facility stays (95%) and home health (90%) | KFF, June 2026 |
| In 2024, insurers received nearly 53 million prior authorization requests and denied 4.1 million (7.7%). About 11.5% of denials were appealed, and 80.7% of appeals were partly or fully overturned. For comparison, Traditional Medicare had about 625,000 requests in fiscal 2024, with 22.9% denied | KFF, January 2026 |
| In a 2019 sample from 15 large insurers, 13% of prior authorization denials met Medicare coverage rules, and 18% of payment denials met coverage and billing rules | HHS Inspector General, 2022 |
| On average, enrollees can reach about half of the physicians available to Traditional Medicare beneficiaries in their area | KFF, June 2026 |
| Under federal rules, outside a trial period, Medigap insurers may use health history when someone leaves Medicare Advantage for Original Medicare. New York is one of four states that require insurers to offer Medigap to people 65 and over regardless of medical conditions | KFF, October 2026 |
On the other side, KFF reports that 75% of people in individual plans with drug coverage pay no premium beyond Part B, plans have a yearly cap on covered costs, and nearly all enrollees are in plans offering dental (98%, including preventive-only), vision (more than 99%) and hearing (95%) benefits.
Rules have changed too. A 2024 CMS rule requires plans to follow Medicare’s national and local coverage decisions, and the Inspector General’s three recommendations to CMS are listed as closed and implemented. How much each point matters depends on your doctors, health and budget.
How do networks and prior authorization work in Medicare Advantage?
In an HMO, you generally must use the plan’s doctors and hospitals except for emergencies, urgent care away from home and temporary out-of-area dialysis. PPOs cover out-of-network care for more. Per KFF, 61% of individual plan enrollees with drug coverage are in HMOs and 38% in local PPOs.
Medicare.gov says a treatment’s approval must stay valid as long as it is medically necessary, and if you switch plans mid-treatment you get at least 90 days before the new plan can ask for new prior approval. If a plan denies something, you can appeal within 65 days of the denial notice, and a fast appeal decision is due within 72 hours when waiting could seriously harm your health.
What are the 2026 and 2027 out-of-pocket limits?
For 2026, CMS allows Medicare Advantage plans a maximum of $9,250 for in-network services and $13,900 for in-network and out-of-network services combined in a PPO. Plans may set lower limits, and KFF found the average is $5,421 in-network. For plan year 2027, the maximum CMS set in April 2026 is $9,850 in-network and $14,800 combined.
The limit covers Part A and Part B services only. Drugs have a separate cap, $2,100 in 2026 per Medicare.gov.
What extra benefits do plans cover: dental, vision, hearing, OTC?
Scope varies. KFF notes a dental benefit may be preventive only (cleanings, X-rays) or include crowns and dentures, and many plans cap what they pay each year. Prior authorization applies to some extras too, including preventive dental and hearing and eye exams.
In 2026, 68% of individual plan enrollees were in plans with over-the-counter benefits, down from 79% in 2025. Plans with transportation (22%) and bathroom safety devices (21%) also became less common. Ask any plan for its Summary of Benefits and read the limits before counting on an extra.
What changes for home health and skilled nursing after a hospital stay?
Plans must cover what Original Medicare covers, but how you get it can differ. See our guides to the home health benefit and skilled nursing facility days.
| Situation | Original Medicare | Medicare Advantage |
|---|---|---|
| Home health (homebound, skilled need, provider’s order) | $0 for covered services; agency must be Medicare-certified | Check the plan’s home health benefit and agency network; 90% of enrollees are in plans requiring prior authorization |
| Skilled nursing facility (SNF) stay | Needs a 3-day inpatient stay first; after the Part A deductible, $0 for days 1 to 20 and $217 a day for days 21 to 100 (2026) | Plans may waive the 3-day stay and may charge copays in the first 20 days; 95% of enrollees are in plans requiring prior authorization |
| Care ending too soon | Fast appeal to an independent reviewer (the BFCC-QIO), using the notice from the provider | Medicare.gov’s fast-appeal rules also cover Medicare health plan members, with some plan-specific differences; follow the notice you receive |
Medicare.gov adds that a plan cannot charge more than Original Medicare for skilled nursing facility care. A practical question for the discharge planner is whether the facility or agency is in your plan’s network and whether approval is already in place. Our appeal guide covers what to do when coverage ends.
Medicare does not pay for long-term care, such as help with bathing and dressing. Only some Medicare Advantage plans offer in-home support as an extra (10% of individual plan enrollees and 38% of special needs plan enrollees, per KFF). See home health versus home care and what home care costs in New York.
When can you switch? Enrollment dates
Medicare.gov lists the windows below. Medicare calls the fall window Open Enrollment; you will also see it called the Annual Enrollment Period. This year it runs from 15 October to 7 December 2026 for 2027 coverage, per CMS.
| Window | Dates | What you can do |
|---|---|---|
| Open Enrollment | 15 October to 7 December | Join, switch or drop a Medicare Advantage plan; move between Original Medicare and Medicare Advantage; change drug plans. Coverage starts 1 January |
| Medicare Advantage Open Enrollment | 1 January to 31 March | Only if already in a Medicare Advantage plan: switch plans or return to Original Medicare |
| Initial Enrollment Period | 7 months around turning 65 | Join a plan (Medicare Advantage needs both Parts A and B). If you join Medicare Advantage then, you can change within the first 3 months you have both parts |
| Special Enrollment Period | Varies | Life events such as moving, losing coverage or getting Medicaid |
People who keep their current coverage generally do not need to re-enroll, CMS says. If your plan leaves Medicare, a Special Enrollment Period applies.
How does Medigap fit in?
Medigap is extra insurance that pays part of your out-of-pocket costs in Original Medicare. Per Medicare.gov, you cannot have both Medigap and Medicare Advantage, and Medigap cannot pay a Medicare Advantage plan’s copayments, deductibles or premiums. If you drop Medigap to join Medicare Advantage for the first time, you have one 12-month trial period to get it back.
New York has its own protection. The state’s HIICAP training notebook (2026) says a New York resident with Parts A and B may buy a Medigap policy at any time, and insurers may not consider health status or age, with limited exceptions. KFF’s state overview lists New York as one of four states with this kind of protection.
What if you have Medicare and Medicaid: D-SNP, MAP and PACE?
A Dual Eligible Special Needs Plan (D-SNP) is a Medicare Advantage plan for people with both Medicare and Medicaid. Medicare.gov says D-SNPs help coordinate the two programs, and “integrated” D-SNPs combine Medicare and most or all Medicaid benefits in one plan with one ID card, care coordinator and appeals process. People with full Medicaid can join or switch to an integrated D-SNP once a calendar month. KFF reports that 23% of Medicare Advantage enrollees are in special needs plans, 78% of them in D-SNPs.
New York’s Medicaid long-term care options connect here. According to the Department of Health, Medicaid Advantage Plus (MAP) requires Medicaid, Medicare Parts A and B, and enrolling in the plan’s aligned Medicare Advantage D-SNP, plus an assessed need for community-based long-term care for more than 120 days. PACE is separate: Medicare.gov says it is for people 55 and over who need a nursing home level of care, and joining a separate drug plan disenrolls you. Our PACE versus MLTC guide, Medicare versus Medicaid and Medicaid home care pages explain each.
How do you compare plans, and where is free help?
Medicare.gov’s steps use the Plan Finder:
- Enter your drugs. Add every regular prescription for accurate cost estimates.
- Check doctors and pharmacies. Ask whether each is in the plan’s network.
- Read the costs and benefits. Look at premiums, deductibles, the out-of-pocket limit and the extras you would use. If you live elsewhere part of the year, check where it covers you.
- Join through Plan Finder, the plan, or 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048), which CMS says answers 24 hours a day.
For free, one-on-one help, New York’s HIICAP program offers free and confidential appointments at 1-800-701-0501. Medicare.gov says State Health Insurance Assistance Programs like HIICAP are not connected to any insurance company or health plan.
Medicare, Medicaid and what you qualify for: advice from our nurse director
Anna Klyauzova, RN, MSN, MPA, Director of Patient Services at ProLife Home Care, on what she sees in practice:
Families often haven’t heard of the Medicare Savings Programs, Extra Help with prescription costs, SNAP, or HEAP for heating bills. Many never check Medicaid or home care eligibility because they assume their income is too high. If you don’t know what you qualify for, start with what is on the table: insurance, income, benefits already received and the person’s care needs. You don’t have to fill out a dozen applications this week. First find out which programs fit. NYC Aging, NY Connects and Medicaid specialists are good places to ask, and hospital Medical Social Services can help in tricky situations. Our financial help guide lists programs to check.
We are a licensed home care agency in Brooklyn and Queens, licence #2572L001, New York State Department of Health. We can talk through what home care a plan may cover and what needs another solution, such as post-surgery home care. Call (718) 232-2777 or use our contact page.
Medicare rules, plan benefits and prices change every year. Everything above was checked on 14 October 2026 against medicare.gov, cms.gov, oig.hhs.gov, health.ny.gov, aging.ny.gov and kff.org. Confirm your own situation with your plan, HIICAP (1-800-701-0501) or 1-800-MEDICARE. This page is general information, not insurance, medical or legal advice, and it does not recommend any plan or insurer.
Frequently asked questions
What is the difference between Medicare and Medicare Advantage?
Original Medicare is run by the federal government and lets you see any provider that accepts Medicare. Medicare Advantage is offered by private companies, usually has a network and prior authorization, includes a yearly out-of-pocket limit, and often adds drug coverage and extra benefits.
Why do some people say Medicare Advantage plans are bad?
The concerns documented by KFF and the Inspector General include prior authorization, denials that were later overturned on appeal, and narrower networks. The documented advantages include an out-of-pocket cap, low premiums and extra benefits such as dental, vision and hearing. Which matters more depends on your situation.
Is Medicare Advantage cheaper than Original Medicare?
It depends. In 2026, 75% of people in individual plans with drug coverage pay no premium beyond Part B, but copayments, networks and limits vary. Original Medicare has no yearly cap unless you add other coverage. Compare total expected costs in Plan Finder.
Can I switch from Medicare Advantage back to Original Medicare?
Yes, during Open Enrollment (15 October to 7 December) or, if you are already in Medicare Advantage, from 1 January to 31 March. Special Enrollment Periods also exist. Medicare.gov says to contact your plan before disenrolling if you want to buy Medigap.
Can I have Medigap and Medicare Advantage at the same time?
No. Medicare.gov says you can have one or the other, and Medigap cannot pay a Medicare Advantage plan’s costs. In New York, a person with Parts A and B may buy Medigap at any time, according to the state’s HIICAP notebook.
Does Medicare Advantage cover home health and nursing home care after the hospital?
Plans must cover what Original Medicare covers, including home health and skilled nursing facility care, but may require prior authorization, use networks and charge copays in the first 20 SNF days. Medicare does not pay for long-term custodial care.
What is a D-SNP and how does it work with New York Medicaid?
A D-SNP is a Medicare Advantage plan for people with both Medicare and Medicaid that coordinates the two. Integrated plans combine Medicare and most or all Medicaid benefits. In New York, Medicaid Advantage Plus requires enrollment in the plan’s aligned D-SNP.
