Medicare 2026

How Medicare and Medigap differ from Advantage in Kailua

KAILUA, Hawaii — When people first sign up for Medicare, they face a fork in the road that shapes how they get care for years to come. On one side is Original Medicare, often paired with a Medigap policy and a stand-alone Part D drug plan. On the other is Medicare Advantage, a private plan that bundles coverage together. The two paths work very differently, and switching between them later is not always easy. Understanding the structure now can help Kailua residents avoid a costly mistake.

Path one: Original Medicare plus Medigap

Original Medicare is the federal program itself — Part A (hospital) and Part B (doctor and outpatient). You can generally see any doctor or hospital in the U.S. that accepts Medicare, without needing a network or referral.

But Original Medicare does not cap what you pay out of pocket. That is where Medigap (also called Medicare Supplement Insurance) comes in. Sold by private companies, Medigap policies help pay some of the deductibles, coinsurance, and copays that Original Medicare leaves you owing. Medigap does not include drug coverage, so people on this path usually add a stand-alone Part D plan.

One important rule: your best window to buy Medigap is the six-month Medigap Open Enrollment Period that starts when you are 65 or older and enrolled in Part B. During that window, insurers cannot turn you away or charge more because of your health. Outside that window, in most states, they can.

Path two: Medicare Advantage

Medicare Advantage (Part C) is a way to get your Part A and Part B coverage through a private plan approved by Medicare. Most Advantage plans also include Part D drug coverage and sometimes extras that Original Medicare does not cover, such as routine dental, vision, or hearing benefits.

Advantage plans typically use networks — HMOs, PPOs, and similar structures — so where you go for care and whether you need referrals depends on the plan. Unlike Original Medicare, Advantage plans have an annual out-of-pocket maximum for Part A and B services, which gives some cost protection.

Kailua is in Honolulu County, where a number of Medicare Advantage plans from several carriers are offered each year. The exact list changes annually, which is one reason it pays to review your options during enrollment season.

What is the same on both paths

No matter which path you choose, some rules apply to everyone with Medicare in 2027:

• Part D drug cap: Out-of-pocket spending on covered prescriptions is capped at $2,400 for the year.
• Part D deductible: No plan can charge more than $700 as its annual deductible.
• No more donut hole: As of 2025, the old coverage gap is gone. Part D now has three phases.
• Payment smoothing: The Medicare Prescription Payment Plan lets you spread drug costs across the year in monthly installments, if that helps your budget.
• IRMAA: Higher-income enrollees pay surcharges on Part B and Part D premiums. For a single filer in 2026, IRMAA begins above $109,000 in income.

The mistake to avoid

The trickiest part of the two-path choice is what happens if you want to switch later. You can generally move between Original Medicare and Medicare Advantage during the Annual Enrollment Period (Oct. 15 – Dec. 7) or, if you are already on an Advantage plan, during Medicare Advantage Open Enrollment (Jan. 1 – March 31).

But adding a Medigap policy after your initial six-month window is a different story. In most states, insurers can use medical underwriting — meaning they can deny you or charge more based on your health. People who choose Medicare Advantage at 65 sometimes find, years later, that they cannot easily get a Medigap policy when their health has changed. That is not a reason to avoid Advantage; it is a reason to go in with your eyes open.

How to think it through

Ask yourself a few questions before deciding:

• Do you travel often or split time between states? Original Medicare with Medigap tends to travel well.
• Do you prefer predictable monthly premiums with fewer surprise bills, or lower premiums with cost-sharing as you use care?
• Are the doctors and hospitals you already use in the networks of the Advantage plans offered where you live?
• Do you take prescription drugs that need specific coverage?

There is no single right answer. The best fit depends on your health, budget, providers, and how much you value flexibility versus bundled convenience.