Medicare 2026

Medigap Letter Plans Explained for Philadelphia

PHILADELPHIA — If you're new to Medicare, or rethinking your coverage during this fall's Annual Enrollment Period, the biggest decision usually isn't which plan to pick. It's which kind of coverage to build around: Original Medicare paired with a Medigap policy, or a Medicare Advantage plan. These two paths are structured very differently, and understanding how they're built makes every other choice easier.

The two paths, in plain terms

Original Medicare is the federal program itself — Part A (hospital) and Part B (doctor and outpatient). You can see any doctor or hospital in the country that accepts Medicare, with no network and no referrals. But Original Medicare has no yearly out-of-pocket limit on its own, which is why many people add a Medigap (Medicare Supplement) policy sold by a private insurer. Medigap helps pay some of the deductibles and coinsurance Original Medicare leaves behind. To get prescription coverage on this path, you also enroll in a standalone Part D drug plan.

Medicare Advantage (Part C) is different. You're still in Medicare, but a private insurer manages your Part A and Part B benefits through its own plan. These plans typically have provider networks (HMO or PPO), often require referrals or prior authorization for certain services, and usually bundle in Part D drug coverage. They must cap your yearly in-network out-of-pocket spending, and many include extras Original Medicare doesn't cover, like routine dental or vision.

You can be in one path or the other — not both at the same time.

How costs are structured

The two paths handle costs in very different ways.

On the Original Medicare + Medigap path, you'll usually pay the standard Part B premium, a Medigap premium, and a Part D premium. In exchange, your share of costs at the doctor or hospital is largely predictable, because Medigap covers a lot of the cost-sharing.

On the Medicare Advantage path, premiums are set by the plan (in addition to your Part B premium), and you pay copays or coinsurance as you use services, up to the plan's annual out-of-pocket maximum. Costs can be lower in a healthy year and higher in a heavy-use year.

Two Part D program-level figures apply to everyone with Part D coverage, no matter which path you choose. The Part D out-of-pocket cap is $2,100 in 2026 and $2,400 in 2027, and the Part D maximum deductible is $615 in 2026 and $700 in 2027. The old "donut hole" coverage gap was eliminated in 2025, so Part D now has just three phases. If drug costs feel lumpy, the Medicare Prescription Payment Plan lets you spread them across the calendar year in monthly installments.

Choice of doctors and hospitals

This is where the structural difference matters most in daily life.

With Original Medicare, the vast majority of U.S. doctors and hospitals participate, and you don't need permission to see a specialist. If you travel a lot, split time between states, or want to keep options open for care at a specific academic medical center, this flexibility can matter.

With Medicare Advantage, your plan has a network and a service area. In and around Philadelphia — Philadelphia is in Philadelphia County — many major health systems participate in multiple Advantage plans, but which doctors and hospitals are in-network depends entirely on the plan. Before enrolling, it's worth checking that your doctors, your preferred hospital, and your regular pharmacy are all in the plan's network.

What's available locally

Plan availability is set at the county level. In Philadelphia County, you'll typically find a broad selection of Medicare Advantage plans and standalone Part D plans from multiple carriers. You can see the full current list — with each plan's own details — using the Plan Finder at Medicare.gov, or by calling 1-800-MEDICARE.

Star Ratings, published each fall by CMS, are one tool for comparing quality across plans. They rate things like customer service, member complaints, and how well plans manage chronic conditions. They're a useful reference point, not a scorecard that tells you which plan fits your life.

A few things to think about before you decide

• Your doctors. Are they in a given Advantage plan's network, or do you want the freedom of Original Medicare?
• Your prescriptions. Check each drug plan's formulary; the same medication can be tiered differently from plan to plan.
• Your travel patterns. Original Medicare travels with you nationwide; Advantage plans generally cover emergencies anywhere but routine care in their service area.
• Medigap timing. In most states, you get your strongest right to buy any Medigap policy during your six-month Medigap Open Enrollment Period, which begins when you're 65 and enrolled in Part B. Outside that window, insurers can use medical underwriting. Pennsylvania has its own rules — worth confirming before you switch.
• Income. If your 2024 income was above $109,000 as a single filer (higher for couples), IRMAA surcharges may raise your Part B and Part D premiums in 2026.

When you can make changes

The Annual Enrollment Period runs October 15 through December 7 each year. During this window, you can join, switch, or drop a Medicare Advantage plan or a Part D plan. Changes take effect January 1.

The Medicare Advantage Open Enrollment Period runs January 1 through March 31. If you're already in an Advantage plan, you can switch to a different Advantage plan or drop back to Original Medicare (and add a Part D plan) once during that window.

Special Enrollment Periods may also apply if you move, lose other coverage, or have certain life changes.