Medicare 2026

Medicare Advantage or Medigap? How to Choose Your Path

New Yorkers turning 65 quickly discover that Medicare isn't one single product — it's a choice between two very different structures. Understanding that fork in the road is the most important decision most people will make about their health coverage, and it shapes how you see doctors, fill prescriptions, and pay bills for years to come.

Two paths, not two flavors

When you become eligible for Medicare, you're really choosing between two ways to receive your benefits.

Path 1: Original Medicare (Parts A and B), usually paired with a Medigap policy and a stand-alone Part D drug plan. Original Medicare is the federal program itself. Medigap (also called Medicare Supplement Insurance) is a private policy that helps pay the out-of-pocket costs Original Medicare leaves behind, like coinsurance and deductibles. Because Part A and Part B don't cover most prescriptions, people on this path typically add a stand-alone Part D plan.

Path 2: Medicare Advantage (Part C). Medicare Advantage is a private plan approved by Medicare that replaces the way you get your Part A and Part B benefits. Most Advantage plans also include Part D drug coverage and may offer extras Original Medicare doesn't, such as routine dental, vision, or fitness benefits.

Both paths are legitimate. They're just built differently.

How providers and networks work

This is where the two structures feel most different day to day.

With Original Medicare, you can see any doctor, hospital, or specialist in the country that accepts Medicare — and most do. There's no network and usually no referral needed. If you split time between New York City and Florida, or travel often, that flexibility matters.

With Medicare Advantage, plans generally operate through networks (HMOs, PPOs, and similar structures) tied to a specific service area. You may need to use in-network providers, get referrals, or ask for prior authorization for certain services. In exchange, plans often bundle extra benefits and cap your yearly out-of-pocket spending for medical care — something Original Medicare on its own does not do.

New York City is split across five counties (New York, Kings, Queens, Bronx, and Richmond), and plan availability is set at the county level. That means someone in Manhattan (New York County) and someone in Brooklyn (Kings County) may see different lists of Medicare Advantage plans, even though they live in the same city.

How you pay

Under Original Medicare + Medigap + Part D, you typically pay:

• The standard Part B premium
• A monthly premium for your Medigap policy
• A monthly premium for your Part D drug plan

In return, the Medigap policy handles most of the cost-sharing gaps left by Parts A and B, so your medical bills become highly predictable.

Under Medicare Advantage, you still pay the Part B premium, plus any premium the plan itself charges. You then pay copays or coinsurance as you use services, up to the plan's annual out-of-pocket maximum. Costs are lower up front but can vary more based on how much care you use.

Either way, drug coverage follows the same federal rules. The maximum Part D deductible is $615 in 2026 and $700 in 2027, and the annual out-of-pocket cap on covered prescriptions is $2,100 in 2026 and $2,400 in 2027. The old coverage gap (the "donut hole") was eliminated in 2025, leaving three straightforward phases. If cash flow is tight, the Medicare Prescription Payment Plan lets you spread drug costs across the calendar year.

Higher earners should also know about IRMAA — an income-based surcharge that begins above $109,000 for a single filer in 2026 and can raise Part B and Part D premiums.

Switching between the two paths

You can move between Medicare Advantage and Original Medicare during the Annual Enrollment Period, Oct. 15 through Dec. 7, with changes taking effect Jan. 1. If you're already in a Medicare Advantage plan, the Medicare Advantage Open Enrollment Period, Jan. 1 through March 31, lets you switch to a different Advantage plan or return to Original Medicare.

One caution worth knowing before you commit: Medigap policies have their strongest consumer protections when you first sign up for Part B at age 65. After that initial window, insurers in many situations can use medical underwriting to decide whether to sell you a Medigap policy and at what price. New York has some of the more consumer-friendly Medigap rules in the country, but the specifics can change, so confirm current protections before you assume you can move freely between paths later.

How to think about your decision

There's no universally "right" answer. A few honest questions help:

• How much do you travel or live in more than one state? Original Medicare's nationwide access is a strong fit for snowbirds and frequent travelers.
• Are your doctors already in a specific network? Check before assuming.
• Do you want predictable monthly costs or lower monthly costs with more variability? That's the core trade-off between Medigap and Medicare Advantage.
• What prescriptions do you take? Check the drug list (formulary) of any Part D or Advantage plan you're considering.

For personalized help, contact New York's State Health Insurance Assistance Program (SHIP), known locally as HIICAP (Health Insurance Information, Counseling and Assistance Program). Counselors are trained, unbiased, and free.