During Annual Enrollment Period (Oct 15 - Dec 7), families face a critical choice: stick with Original Medicare or switch to Medicare Advantage. There's no universally "better" option—it depends entirely on your parent's health, finances, and preferences.
The Quick Answer
Understanding the Basics
Original Medicare (Parts A & B)
The government-run program that's been around since 1965. Part A covers hospital stays, Part B covers doctors and outpatient care. You can go to any doctor that accepts Medicare—and 93% do.
What's missing: No cap on out-of-pocket costs, no prescription drug coverage (need Part D separately), no dental/vision/hearing. Most people add a Medigap supplement for protection.
Medicare Advantage (Part C)
Private insurance plans (from companies like Humana, UnitedHealthcare, Aetna) that contract with Medicare to provide all Part A and B benefits. Most include prescription drugs and extras like dental, vision, gym memberships.
The trade-off: You must use network doctors and hospitals, often need referrals for specialists, and may face prior authorization requirements.
Side-by-Side Comparison
| Feature | Original Medicare | Medicare Advantage |
|---|---|---|
| Monthly Premium | Part B: $185/mo (2026) + Medigap: $100-350/mo + Part D: $25-100/mo |
Part B: $185/mo (2026) + Plan: $0-150/mo (Many $0 premium plans) |
| Deductibles | Part A: $1,676/stay Part B: $257/year |
Varies by plan Often $0 for in-network |
| Out-of-Pocket Maximum | None (unlimited liability) | $8,850 max (2026) |
| Doctor Choice | Any doctor accepting Medicare | Network doctors only (HMO) or penalty for out-of-network (PPO) |
| Specialist Access | No referral needed | Often need referral (HMO) |
| Prior Authorization | Rarely required | Common for tests, procedures, specialists |
| Prescription Drugs | Must add Part D separately | Usually included |
| Dental/Vision/Hearing | Not covered | Usually included (varying coverage) |
| Coverage While Traveling | Works nationwide Limited foreign coverage |
Often limited outside service area Emergency only when traveling |
| Nursing Home Care | Any Medicare-certified facility | In-network facilities only |
The Real Costs: Original Medicare
Let's break down what Original Medicare actually costs with a Medigap supplement:
Medigap Plan G: $150-300 (varies by age, state, company)
Part D drug plan: $40-80
Total: $375-565/month
With Medigap Plan G, there's virtually no additional cost for covered services except the $257 Part B deductible once per year.
Why People Choose Original Medicare + Medigap
- Financial predictability - Know exactly what you'll pay each month
- No surprise bills - Medigap covers the 20% that Medicare doesn't
- See any doctor - Never worry about networks
- No prior authorization - Doctor decides treatment, not insurance
- Travel freely - Coverage works anywhere in the US
The Real Costs: Medicare Advantage
Medicare Advantage looks cheaper on paper, but costs depend heavily on how much care your parent needs:
MA plan premium: $0-50 (many $0 plans)
Monthly baseline: $185-235
But add copays for each doctor visit, test, and procedure. Heavy users can hit the $8,850 max.
The Hidden Costs of Medicare Advantage
- Copays add up - $35 for specialist, $295 for ER, $385/day hospital
- Prior authorization delays - Care can be denied or delayed
- Network limitations - May not include preferred doctors or hospitals
- SNF coverage - Some plans have limited nursing facility networks
- Travel restrictions - Coverage problems outside service area
Original Medicare: Pros and Cons
✓ Advantages
- See any Medicare-accepting doctor
- No referrals needed
- Works nationwide
- No prior authorization
- Choose any Medicare-certified hospital/SNF
- Predictable costs with Medigap
✗ Disadvantages
- Higher monthly premiums (with Medigap)
- Must manage multiple policies
- No out-of-pocket maximum without Medigap
- No dental/vision/hearing
- Need separate Part D plan
Medicare Advantage: Pros and Cons
✓ Advantages
- Lower monthly premiums (often $0)
- Out-of-pocket maximum ($8,850)
- Dental, vision, hearing included
- Drug coverage usually included
- One card simplicity
- Extra perks (gym, OTC allowances)
✗ Disadvantages
- Network restrictions
- Prior authorization requirements
- May need referrals
- Limited when traveling
- Networks change yearly
- Harder to switch back
Who Should Choose Original Medicare
Parents with Chronic Conditions
Diabetes, heart disease, cancer, COPD, kidney disease. These require frequent specialists, tests, and procedures. Prior authorization delays with MA can be dangerous.
Frequent Travelers or Snowbirds
Spend winters in Florida, summers up north? Original Medicare works anywhere in the US. Medicare Advantage often restricts care outside the service area.
People Who Value Doctor Choice
Want to see the best specialist regardless of network? Need specific doctors for complex conditions? Original Medicare lets you choose freely.
Those Who Can Afford Medigap
If your parent can afford $150-300/month for a Medigap plan, the predictability and freedom are worth it for peace of mind.
Who Should Choose Medicare Advantage
Generally Healthy Seniors
Few health issues, rarely see doctors, mainly need preventive care. The lower premiums make sense, and they're unlikely to hit cost-sharing limits.
Budget-Conscious Beneficiaries
Can't afford Medigap premiums. The $0-premium plans with out-of-pocket caps provide protection Original Medicare alone doesn't offer.
Those Who Want Dental/Vision
Need hearing aids, glasses, or dental work? Many MA plans include meaningful coverage. Original Medicare covers none of these.
People Comfortable with Networks
Already using doctors in the plan's network? Don't mind getting referrals? Happy staying local? MA's limitations won't matter.
The Prior Authorization Problem
This is the biggest complaint about Medicare Advantage and something many people don't understand until they're enrolled:
Real examples of prior authorization requirements:
- MRI or CT scans
- Physical therapy beyond initial visits
- Specialist referrals
- Certain prescription drugs
- Post-hospital skilled nursing care
- Home health services
- Durable medical equipment (wheelchairs, hospital beds)
A 2023 OIG report found that 13% of prior authorization denials by Medicare Advantage plans were inappropriate—the care should have been approved. These denials and delays can have serious consequences for seniors who need timely care.
The "Medigap Gap" Warning
Here's something critical that many people don't understand:
When you CAN get guaranteed-issue Medigap:
- Within 6 months of turning 65 and enrolling in Part B (the "Medigap Open Enrollment Period")
- Within 12 months of your first MA plan if you disenroll (limited)
- When an MA plan leaves your area or stops covering your doctors
- Some states have additional protections (NY, CT, ME, MA)
Checking If Current Doctors Are In Network
Before choosing any Medicare Advantage plan, verify that your parent's doctors participate:
- Get a list of all doctors, specialists, and hospitals your parent uses
- Check the plan's directory - available on the plan's website or Medicare.gov
- Call each provider - Networks change yearly; verify they'll be in-network next year
- Check hospital networks - Especially important if there's a preferred hospital
- Verify pharmacy coverage - Is their pharmacy in-network? Are their drugs covered?
Understanding Star Ratings
Medicare rates Advantage plans on a 5-star scale. Look for 4-star or higher plans:
- 5 stars - Excellent
- 4 stars - Above average
- 3 stars - Average
- 2 stars - Below average
- 1 star - Poor
Star ratings consider: Preventive care quality, chronic disease management, member experience, customer service, and timely access to care.
Questions to Ask Before Choosing
For Original Medicare + Medigap:
- Can we afford $300-500/month for Medigap + Part D?
- Do we value maximum doctor choice?
- Will we travel or split time between states?
- Are multiple chronic conditions involved?
- Do we want to avoid prior authorization hassles?
For Medicare Advantage:
- Are current doctors in the plan's network?
- Is the preferred hospital in-network?
- Are current medications on the formulary?
- What's the out-of-pocket maximum?
- What dental, vision, and hearing benefits are included?
- What prior authorization requirements exist?
How to Compare Plans
- Visit Medicare.gov/plan-compare - The official comparison tool
- Enter medications - See which plans cover your parent's drugs
- Check doctor networks - Verify all current providers
- Compare total costs - Premiums + deductibles + typical copays
- Read the fine print - Especially prior authorization and limitations
- Check star ratings - 4 stars or above is recommended
Enrollment Periods
| Period | Dates | What You Can Do |
|---|---|---|
| Annual Enrollment | Oct 15 - Dec 7 | Switch between Original Medicare and MA, change MA plans, add/drop Part D |
| Open Enrollment | Jan 1 - March 31 | MA enrollees only: Switch to different MA plan or return to Original Medicare |
| Special Enrollment | Various triggers | Move, lose coverage, plan leaves area, etc. |
The Bottom Line
For healthy seniors on a tight budget who are comfortable with network restrictions, a well-rated Medicare Advantage plan can work well—but understand the trade-offs and the difficulty of switching later.
Whatever you choose, review the decision annually during open enrollment. Health needs change, and so should your Medicare coverage.
Need Help Comparing Coverage Options?
Our Medicare Guide helps you evaluate plans, understand benefits, and make the right choice for your family.
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