Healthcare is costly, and as we age, we may need more of it. So it's vital to make good decisions regarding healthcare as we approach and enter retirement. One critical decision is whether to choose "original" Medicare or a Medicare Advantage plan.
For many years, I had my decision already planned. I wanted a Medicare Advantage plan. But now I'm thinking I'll reverse that and I'll opt for original Medicare instead. Here's why.
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Original Medicare vs. Medicare Advantage
Let's start with a brief review. Medicare is a health insurance program sponsored by the government and designed mainly for those 65 and older.
When you enroll, you have to select either original Medicare, which features Part A (hospital coverage) and Part B (physician/medical insurance), or a Medicare Advantage plan, sometimes referred to as Part C. (Don't enroll late -- as that can result in a steep penalty.)
Those who sign up for original Medicare typically add Part D, which covers prescription drugs, and they'll often add a "Medigap" supplemental coverage plan, too.
Here are some upsides and downsides to each alternative:
Original Medicare
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Pros |
Cons |
|---|---|
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You often pay only 20% of expenses. |
There is no out-of-pocket spending cap, so you might end up spending many thousands, unless you buy a Medigap plan. |
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It's generally accepted by every provider, anywhere in the U.S. |
Coverage is somewhat limited, with some routine exams not covered. |
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You typically won't need a referral to see a specialist. |
Does not cover hearing, vision, or dental care. |
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You generally won't need to have prior authorization for certain services or supplies. (This may be changing, though.) |
Medicare is testing prior authorization requirements in some states and may roll it out nationwide. |
Source: Author research.
Medicare Advantage
|
Pros |
Cons |
|---|---|
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You can switch out of it to original Medicare at least annually. |
If you switch into original Medicare later, you may have to pay more for a Medigap plan -- or you may be denied that coverage altogether. |
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Every Medicare enrollee pays for Part B coverage (which costs most enrollees $202.90 monthly in 2026), but otherwise, premiums can be as low as $0. |
If you're traveling, you'll likely not have providers in-network near you, though you're covered if you need to go to an emergency room. |
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It typically offers more than original Medicare, such as coverage for hearing, vision, dental, and/or prescription drugs. |
Restricted to a network of providers and facilities, unless you pay more. |
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Your out-of-pocket spending will be capped. The 2026 limit is $9,250 for in-network expenses (excluding drugs) or $14,750 if your plan allows you to see some out-of-network providers. Some plans may feature lower caps. |
You'll likely face co-pays at many appointments. |
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Medicare Advantage plans are rated for quality, so you can shop for the best plans near you. |
You'll often need a referral to see a specialist. |
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Having a Medicare Advantage plan can be simpler than having Original Medicare, plus Plan D, plus a supplemental plan. |
Your plan may deny you some care that original Medicare might have covered. (About 7.7% of prior authorization requests in 2024 were denied, though many decisions were reversed on appeal, per a Kaiser Family Foundation report.) |
Source: Author research.
Why am I choosing original Medicare?
I had been leaning toward a Medicare Advantage plan because of many of the upsides above. I liked that they typically include dental, vision, and hearing coverage and that they cap out-of-pocket spending.
It's true that original Medicare generally covers the lion's share of expenses, typically paying 80% and leaving members paying just 20%. But what if you're looking at a massive $400,000 hospital bill, which isn't unheard of? If you have to cough up 20% of that, that's $80,000!
That's a known concern, though, which is why "Medigap," or supplemental, plans exist, offered by private insurance companies to cover and pay for things that original Medicare doesn't. There are a variety of them, offering different degrees of coverage at different costs -- generally from around $100 to $300 per month.
I had originally been thinking I'd start with a Medicare Advantage plan and then switch to original Medicare later if I wanted, getting a Medigap plan then. But then I learned that it's not so simple:
If you don't sign up for original Medicare at the outset, choosing a Medigap plan then, you won't necessarily be able to do so later. If you try to buy a Medigap plan later, you may not be able to buy one, or you might have to pay a lot more for it.
The best time to buy a Medigap plan is right when you enroll in Medicare -- and you'd have to be enrolling in original Medicare to get a Medigap plan. At that time, you can't be refused due to any pre-existing condition.
So that's why I'm planning on starting out with original Medicare -- and sticking with it. To keep my retirement healthcare costs in check. Do your own research and thinking on the topic, to determine what seems best for you.
