Parts A and B are the government-run program. Medicare Advantage is a private plan replacing them. Every client is really choosing between these two structures — everything else is detail underneath one of them.
| Original Medicare | Medicare Advantage | |
|---|---|---|
| Run by | The federal government directly | Private insurers, under CMS rules |
| Provider network | Any provider nationwide that accepts Medicare | Plan-specific network — usually local/regional |
| Referrals | Never required | Often required for specialists (HMO); usually not for PPO |
| Extra benefits | None built in | Often includes dental, vision, hearing, OTC, transportation |
| Annual out-of-pocket cap | None on its own — costs are uncapped without a supplement | Required MOOP cap, set by the plan each year |
| Drug coverage | Requires a separate Part D plan | Usually bundled in (MAPD) |
| Medigap compatible | Yes — can add a supplement to cover the gaps | No — cannot be paired with a Medigap policy |
| Plan stability | Rules are consistent nationwide, year to year | Benefits, costs, and networks can change annually |
Compliance note
This is a real trade-off, not a one-sided upgrade. A client giving up Original Medicare's open, nationwide access is not automatically the wrong call — but it's a choice they need to understand they're making. Never present Medicare Advantage as strictly "better" — present it as a structurally different fit.
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