Medicare 2026

Original Medicare + Medigap or Advantage? How to Decide

If you're turning 65 in Miami — or helping a parent sort through the mail piling up before the Annual Enrollment Period — the biggest choice usually comes down to two paths: Original Medicare paired with a Medigap policy, or a Medicare Advantage plan. They're built very differently, and understanding that structure upfront saves a lot of second-guessing later.

Two different structures, not two flavors of the same thing

Original Medicare is the federal program itself — Part A (hospital) and Part B (medical). You can visit any doctor or hospital in the country that accepts Medicare, and there is no network. Medicare pays its share, and you're responsible for the rest, which is where a Medigap (Medicare Supplement) policy comes in. Medigap is sold by private insurers and helps cover things like the Part A deductible and Part B coinsurance. With Original Medicare, you also usually add a stand-alone Part D plan for prescriptions.

Medicare Advantage (Part C) is different. It's a private plan, approved by Medicare, that delivers your Part A and Part B benefits — and almost always Part D — in one bundled package. These plans use provider networks (HMOs, PPOs) and set their own copays and rules, within limits Medicare sets. Instead of a Medigap policy, your out-of-pocket exposure is controlled by an annual maximum built into the plan.

How choice of provider works

This is often the deciding factor. With Original Medicare + Medigap, you don't need referrals and you're not tied to a network. If you spend part of the year outside Florida, or travel often to see family, that flexibility matters.

Medicare Advantage plans usually ask you to stay in-network for full coverage, and some require referrals to see specialists. Miami is in Miami-Dade County, where a large number of Advantage plans and carriers compete, so networks here tend to be substantial — but they still vary plan by plan. Always check that your doctors, hospitals, and preferred pharmacies are in a plan's network before enrolling.

How costs are structured

Under Original Medicare + Medigap, you typically pay:

• Your Part B premium (paid to Medicare)
• A Medigap premium (paid to the private insurer)
• A Part D premium if you add drug coverage

In exchange, your cost-sharing at the doctor or hospital is usually very predictable, depending on which Medigap plan letter you chose.

Under Medicare Advantage, you still pay your Part B premium, plus any premium the plan charges. You then pay copays or coinsurance as you use services, up to the plan's annual out-of-pocket maximum. Lower monthly costs can mean higher costs when you actually need care — or vice versa. Neither structure is automatically cheaper; it depends on your health, your providers, and how you like to budget.

Prescription drugs in 2027

Drug coverage rules are the same regardless of which path you take. For 2027:

• The Part D out-of-pocket cap is $2,400.
• The Part D maximum deductible is $700.
• The old "donut hole" coverage gap was eliminated in 2025, so Part D now has three phases instead of four.
• The Medicare Prescription Payment Plan is available if you'd like to spread your drug costs into level monthly payments instead of paying large amounts at the pharmacy counter.

Higher-income beneficiaries may also owe an IRMAA surcharge on Part B and Part D. In 2026, IRMAA begins above $109,000 in income for a single filer (based on your tax return from two years earlier).

The Medigap timing rule most people miss

When you first enroll in Part B at 65, you get a one-time, six-month Medigap Open Enrollment window. During that window, insurers must sell you any Medigap policy they offer at their best available rate, regardless of your health history.

Outside that window, in most states, Medigap insurers can use medical underwriting — meaning they can charge more or decline coverage based on your health. This is why the choice between Original Medicare + Medigap and Medicare Advantage isn't purely a "this year" decision. If you start on Advantage and later want to switch to Original Medicare + Medigap, that Medigap policy may not be guaranteed. It's worth asking a licensed counselor about before you decide.

When you can make changes

• Annual Enrollment Period: Oct. 15 – Dec. 7. You can join, switch, or drop a Medicare Advantage or Part D plan for the following year.
• Medicare Advantage Open Enrollment Period: Jan. 1 – March 31. If you're already in an Advantage plan, you can switch to a different Advantage plan or return to Original Medicare (and add a Part D plan).

Miami-Dade residents have a lot of options during these windows, so give yourself time to compare.