Medicare 2026

Two Medicare structures compared for Westbrook, Maine

In Westbrook, Maine, one of the biggest decisions new Medicare enrollees face isn't which plan to pick — it's which path to take. Medicare offers two very different structures, and they work in almost opposite ways. Understanding the difference before you enroll can save you a lot of second-guessing later.

The two paths, in plain English

When you become eligible for Medicare, you can go one of two ways.

Path 1: Original Medicare + Medigap (+ usually a stand-alone Part D drug plan). Original Medicare is the federal program — Part A (hospital) and Part B (doctor and outpatient). It pays most of your covered care, but it leaves deductibles and coinsurance for you. A Medigap policy (also called Medicare Supplement Insurance) is private insurance designed to fill in some or most of those gaps. Because Original Medicare doesn't include drug coverage, most people on this path also add a stand-alone Part D plan.

Path 2: Medicare Advantage (Part C). Medicare Advantage is a private plan that replaces the way you get your Part A and Part B benefits. The plan is required to cover everything Original Medicare covers, and most Advantage plans also bundle in Part D drug coverage. Instead of Medicare paying providers directly, the private plan does — following its own network rules and cost-sharing.

That's the core structural difference. One path adds on to Original Medicare. The other path routes your benefits through a private plan.

How you see the doctor is different

On the Medigap path, you can generally see any provider in the country who accepts Medicare. There are no networks and usually no referrals. That flexibility is a big reason people choose it.

On the Medicare Advantage path, you typically use the plan's network — HMO, PPO, or another format — and you may need referrals or prior authorization for certain services. In exchange, Advantage plans often include extras that Original Medicare doesn't cover, like routine vision, dental, hearing, or fitness benefits.

Neither structure is "better." They're built differently, and they fit different lives differently.

How the costs are structured differently

This is where the two paths really diverge.

With Original Medicare + Medigap, you generally pay a Part B premium, a Medigap premium, and (if you add drug coverage) a Part D premium. In return, your out-of-pocket costs at the point of care tend to be more predictable, because the Medigap policy absorbs much of the cost-sharing.

With Medicare Advantage, you still pay your Part B premium, plus whatever the plan charges. Cost-sharing usually happens at the point of care — copays for visits, services, and hospital stays — up to the plan's annual out-of-pocket maximum, which is a feature Original Medicare alone does not have.

For prescriptions, the Part D rules are the same no matter which path you're on: the annual out-of-pocket cap on covered drugs is $2,100 in 2026 and $2,400 in 2027, and the maximum Part D deductible is $615 in 2026 and $700 in 2027. The old "donut hole" coverage gap has been gone since 2025. If drug costs hit hard early in the year, the Medicare Prescription Payment Plan lets you spread those costs across monthly payments instead of paying all at once at the pharmacy.

Higher-income enrollees should also know about IRMAA — an income-related surcharge that begins above $109,000 for single filers in 2026 and applies to Part B and Part D premiums on either path.

What's available around Westbrook

Westbrook is in Cumberland County, where Medicare eligibility, enrollment periods, and Part D rules are exactly the same as anywhere else in the country — those are federal. What varies locally is which Medicare Advantage plans and stand-alone Part D plans are offered, and which carriers sell Medigap policies in Maine.

The official plan finder at medicare.gov lets you enter your ZIP code and see the current list of plans available in Cumberland County, along with the specific benefits and costs of each. That's the most reliable way to see your real options, because they update as CMS approves plans each year.

Switching paths later isn't always easy

One thing many people don't realize: moving between the two paths later in life can be harder than choosing between them at the start.

When you first become eligible for Medicare, you have a one-time Medigap Open Enrollment Period — six months starting when you're 65 and enrolled in Part B — during which insurers must sell you a Medigap policy regardless of your health. Outside that window, in most states, Medigap insurers can use medical underwriting, which means they can charge more or decline coverage based on your health history.

Medicare Advantage works differently. You can generally switch Advantage plans, or move back to Original Medicare, during the Annual Enrollment Period (Oct. 15 – Dec. 7) or the Medicare Advantage Open Enrollment Period (Jan. 1 – March 31). But if you drop Advantage and want to add a Medigap policy years later, underwriting may apply.

This is why the first choice matters — not because it's permanent, but because the door back can be narrower than the door in.

Getting help you can trust

You don't have to figure this out alone. In Maine, the State Health Insurance Assistance Program (SHIP) is called Maine SMP/SHIP, and its counselors give free, unbiased Medicare help. You can also call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, or use the plan finder and Medigap comparison tools at medicare.gov.

Take your time. Bring a list of your doctors, your prescriptions, and the way you actually use health care today. The right path is the one that matches how you live — not the one with the flashiest brochure.