Medicare 2026

Two Medicare Structures Compared for Baltimore Readers

# Original Medicare with a Medigap plan vs. Medicare Advantage: how to think it…

BALTIMORE — If you are turning 65 in Baltimore, or thinking about switching coverage during the fall enrollment window, you will run into the same fork in the road every Medicare beneficiary faces. On one side is Original Medicare, often paired with a Medigap (Medicare Supplement) policy and a stand-alone Part D drug plan. On the other side is Medicare Advantage, which bundles your hospital, medical, and usually drug coverage into a single plan from a private insurer.

Both paths are part of the Medicare program. But they are built differently, and that difference is what really shapes your experience — from which doctors you can see to how your bills arrive in the mail.

The two structures, side by side

Original Medicare is the federal program itself — Part A (hospital) and Part B (medical). You can go to any doctor or hospital in the country that accepts Medicare, with no network and no referrals. Medicare pays its share, and you are responsible for the rest: the Part A deductible, the 20% coinsurance under Part B, and so on. There is no annual out-of-pocket cap built into Original Medicare on its own.

That is where Medigap comes in. A Medigap policy is sold by a private insurer and is designed to pay some or all of those leftover costs. You also add a stand-alone Part D plan for prescriptions.

Medicare Advantage (Part C) is different. You are still in Medicare, but a private plan administers your benefits. These plans typically use provider networks (HMO or PPO), may require referrals or prior authorization, and often include drug coverage and extras like dental or vision. In exchange, they must cap your yearly in-network out-of-pocket spending for Part A and B services.

You cannot combine the two. If you enroll in a Medicare Advantage plan, a Medigap policy cannot pay your Advantage cost-sharing.

What this looks like in Baltimore

Baltimore is in Baltimore city, and Medicare plan availability is set at the county level. That means the number of Medicare Advantage plans and stand-alone Part D plans you can pick from depends on your ZIP code and county, not the city name on your mailing address. Residents of Baltimore County (a separate jurisdiction that wraps around the city) may see a different plan list than someone downtown.

For an exact count of plans in your area, the plan finder at medicare.gov is the official source.

How costs are shaped on each path

With Original Medicare + Medigap + Part D, you generally pay:

• Your Part B premium (and any IRMAA surcharge if your income is above $109,000 as a single filer in 2026).
• A Medigap premium.
• A Part D premium.
• Predictable cost-sharing, because Medigap smooths out the surprises.

With Medicare Advantage, you generally pay:

• Your Part B premium (plus IRMAA if it applies).
• Any plan premium the Advantage plan charges.
• Copays or coinsurance as you use services, up to the plan’s annual out-of-pocket maximum for in-network care.

On the drug side, 2027 brings the same program-wide rules no matter which path you pick: a $2,400 annual out-of-pocket cap under Part D, a maximum $700 Part D deductible, and the coverage gap remains eliminated (there are three phases instead of four). If a big drug bill hits early in the year, the Medicare Prescription Payment Plan lets you spread those costs across monthly installments.

How doctor choice actually works

This is the piece many Baltimore-area readers say surprises them most.

Under Original Medicare, you can see any provider in the country that accepts Medicare — a specialist at Johns Hopkins, a cardiologist in Florida during the winter, an urgent care in another state. No referral needed.

Under Medicare Advantage, your plan has a network. Care from in-network providers is typically covered at the plan’s lower cost-sharing; out-of-network care may cost more, need prior approval, or not be covered at all except for emergencies. If keeping a specific hospital system or specialist matters to you, check that provider’s status in any plan you are considering — networks can change from year to year.

One rule that catches people off guard

You can switch into Medicare Advantage during open enrollment fairly easily. Switching back to Original Medicare and picking up a Medigap policy later is not always guaranteed. Outside of your initial Medigap open enrollment window (the six months starting when you are 65 and enrolled in Part B), insurers in most states — including Maryland — can use medical underwriting to decide whether to sell you a Medigap policy and at what price.

That means the choice you make at 65 is worth thinking through carefully, because it can affect your options years down the road.

Key dates to remember

• Annual Enrollment Period: October 15 – December 7. You can join, switch, or drop a Medicare Advantage or Part D plan.
• Medicare Advantage Open Enrollment: January 1 – March 31. If you are already in an Advantage plan, you can switch to another one or go back to Original Medicare (and add a Part D plan).
• Your Initial Enrollment Period: the seven-month window around your 65th birthday.