Medicare Advantage vs. Original Medicare Budget Seniors, February 26, 2026February 26, 2026 Key Takeaways: 10 Critical Answers You Need Right Now 💡 Is there an out-of-pocket limit for Original Medicare? No. Original Medicare has zero spending cap — a single catastrophic illness can cost you unlimited amounts without supplemental coverage. What’s the 2026 Medicare Advantage out-of-pocket max? The federal cap dropped to $9,250 in-network and $13,900 combined — but most plans set theirs lower. Can I have both Medigap and Medicare Advantage? Absolutely not. They are mutually exclusive — choosing one means forfeiting the other. Which covers more doctors? Original Medicare + Medigap lets you see any provider nationwide who accepts Medicare. Advantage plans restrict you to a network. Is Plan F or Plan G better? Plan G saves most people $800–$2,500/year in premiums versus Plan F, with only a $283 deductible difference. What new drug benefits arrive in 2026? Negotiated prices on 10 high-cost medications and $50/month GLP-1 access starting July 2026. What’s the biggest hidden risk of Medicare Advantage? Prior authorization denials — over 15% of people who left Advantage plans in 2025 cited payment disputes. Can I switch from Advantage back to Medigap? Technically yes, but insurers can deny you or charge more based on health conditions outside your initial enrollment window. What does ValuePenguin rank as best Advantage plan? AARP/UnitedHealthcare for overall coverage, Kaiser Permanente for $0-premium quality, and Devoted Health for affordability. What is IRMAA and could it affect me? If your 2024 income exceeded $109,000 (single) or $218,000 (joint), you’re paying surcharges up to $487/month extra on Part B alone. 💰 1. Original Medicare Has No Spending Cap — and That’s the Scariest Thing Nobody Mentions Here’s the detail that should terrify every retiree relying solely on Parts A and B: Original Medicare has no annual out-of-pocket maximum. If you’re hospitalized for 90 days, you’re responsible for the deductible, daily coinsurance, and eventually $868 per day for lifetime reserve days in 2026. There is no ceiling. No safety net. No stopping point. In 2026, beneficiaries must pay a coinsurance amount of $434 per day for the 61st through 90th day of a hospitalization in a benefit period and $868 per day for lifetime reserve days. Meanwhile, Medicare Advantage plans have a maximum out-of-pocket limit — in 2026, your maximum expenses are $9,250 for in-network services and $13,900 for out-of-network services, which is actually a decrease from $9,350 and $14,000 in 2025. This is precisely why 81% of Original Medicare enrollees carry some form of supplemental coverage. Without it, you’re gambling your retirement savings on staying healthy. 📊 Feature🏛️ Original Medicare (A+B)🏢 Medicare Advantage (Part C)💡 Insider TipOut-of-pocket cap❌ None — unlimited exposure✅ $9,250 in-network / $13,900 combinedThe “free” nature of Original Medicare becomes expensive fast without Medigap 🚨Monthly premium (Part B)$202.90 for everyone$202.90 Part B + avg. $27 plan premiumMany MA plans are $0 extra, but copays add up during actual care 💸Part A deductible$1,736 per benefit periodVaries by plan (often $0–$500)Original Medicare charges this each time you’re admitted, not annually 😰Part B deductible$283 annuallyOften $0 with MA plansMedigap Plan G is the only supplement that still requires you to pay this 📝 💡 Pro Tip: Ask yourself this brutally honest question: “Can I afford a $50,000+ hospital bill if something catastrophic happens?” If the answer is no, you must have either a Medigap policy or a Medicare Advantage plan. Bare Original Medicare is a financial gamble that gets worse with age. Discover 10 Best Clear Caption Phones for Seniors 🏥 2. Medicare Advantage Plans Offer Flashy Extras — But the Prior Authorization Problem Is Getting Worse, Not Better Medicare Advantage plans lure seniors with benefits Original Medicare doesn’t touch: dental, vision, hearing, gym memberships, meal delivery, even grocery allowances. Some plans offer flex cards loaded with hundreds of dollars for over-the-counter health products. It sounds like a dream. But the industry’s dirty secret? More than 15% of people who left their Medicare Advantage plans in 2025 said it was because of problems getting their plan to pay for medical care. Doctors and hospitals increasingly report frustration with insurers denying or delaying necessary treatments through prior authorization — a process where the insurance company decides whether your doctor’s recommended care is “medically necessary” before they’ll pay for it. The Department of Justice has even launched investigations. Several groups have brought class-action lawsuits against UnitedHealthcare relating to its billing practices, its use of AI in handling claims, and the DOJ has launched a criminal probe over concerns the company may have been overcharging the government for Medicare services. 📊 Advantage Perk✅ The Upside⚠️ The Hidden Downside💡 What to WatchDental, vision, hearingBundled coverage Original Medicare lacks entirelyCoverage is often limited (e.g., $1,000–$2,500 annual dental max)Check if your specific dentist/optometrist is in-network before enrolling 🦷$0 monthly premiumsLower upfront cost than MedigapHigher copays, coinsurance, and deductibles when you actually use careA “$0 plan” can cost $9,250 in a bad health year 💸Gym memberships (SilverSneakers)Free fitness access promotes wellnessSome plans dropped SilverSneakers for inferior programsConfirm the specific gym benefit before enrolling 🏋️Flex cards / OTC allowancesMoney for health products and groceriesUnused amounts expire monthly or quarterly — use it or lose itSet calendar reminders to spend your allowance each period ⏰ 💡 Pro Tip: Before choosing any Medicare Advantage plan for its extra perks, call your three most important doctors and ask: “Do you accept this specific plan, and have you had issues with their prior authorization process?” The answer may shock you. Some top specialists are dropping Advantage plans entirely because of payment disputes. 🔒 3. The Medigap Lock-Out: Why Switching from Medicare Advantage Back to Medigap Could Be Impossible This is arguably the most critical and least discussed aspect of the entire Medicare decision. During your Medigap Open Enrollment Period — the six months after you first enroll in Medicare Part B at age 65 — every Medigap insurer must accept you regardless of health conditions, at the best available rate. No medical underwriting. No denials. Period. But if you choose Medicare Advantage first, and then later decide you want to switch to Original Medicare with a Medigap supplement, insurers in most states can subject you to full medical underwriting. That means if you’ve developed diabetes, had a heart attack, or been diagnosed with cancer while on your Advantage plan, a Medigap insurer can deny your application entirely or charge dramatically higher premiums. The inability to return to Medigap due to medical underwriting can lock you into Medicare Advantage for life. 📊 Enrollment Scenario🔓 Medigap Access⚠️ Risk Level💡 Critical ActionAge 65, first enrolling✅ Guaranteed issue — no health questions🟢 LowThis is your golden window — don’t waste it without careful analysis 🪟Switching from MA after 1+ years⚠️ Medical underwriting in most states🔴 HighYou may be denied coverage if you’ve developed health conditions 🚫Lost MA plan (insurer left your area)✅ Guaranteed issue right triggered🟢 LowFederal rules protect you — but only for specific qualifying events ✅State birthday rule (select states)✅ Annual switch window with no health questions🟡 MediumOnly available in states like Nevada, Oregon, California — check your state 🗺️ 💡 Pro Tip: If you’re even slightly uncertain about Medicare Advantage, enroll in a Medigap plan during your initial open enrollment period. You can always drop Medigap for Advantage later with no consequences. But going the other direction? That door may slam shut permanently. This is a one-way trap that insurance agents rarely emphasize because Advantage plans pay them higher commissions. Discover Free Legal Services 📊 4. The 2026 Part B Premium Increase Chart: Why Your Income from Two Years Ago Is Hitting Your Wallet Today Most seniors know their Part B premium went up. What most don’t realize is that the IRMAA income brackets and surcharges increased by approximately 3% and 9%, respectively, for 2026, and the determination is based on your 2024 tax return — income you earned nearly two years ago. IRMAA does not function like a progressive tax bracket. Once income exceeds a threshold, the entire surcharge applies. A single retiree earning $137,001 pays the same surcharge as someone earning $171,000. Even one dollar over the line triggers the full penalty. 💵 2024 Income (Single / Joint)📋 Monthly Part B Premium💊 Part D Surcharge💡 Total Monthly Impact≤ $109,000 / ≤ $218,000$202.90 (standard)$0Baseline — no surcharge 🟢$109,001–$137,000 / $218,001–$274,000$284.10$14.50Extra $95.70/month = ~$1,148/year 🟡$137,001–$171,000 / $274,001–$342,000$405.80$37.50Extra $240.40/month = ~$2,885/year 🟠$171,001–$205,000 / $342,001–$410,000$527.50$60.60Extra $385.20/month = ~$4,622/year 🔴$205,001–$500,000 / $410,001–$750,000$649.20$83.50Extra $529.80/month = ~$6,358/year 🔴> $500,000 / > $750,000$689.90$91.00Extra $578.00/month = ~$6,936/year 🔴🔴 💡 Pro Tip: If you recently retired and your 2024 income was higher because you were still working, file SSA Form 44 to appeal your IRMAA determination based on a “life-changing event” like work stoppage. The SSA can use your current lower income instead — potentially saving you thousands. This is the single most underutilized Medicare savings strategy in existence. 🆚 5. Medigap vs. Medicare Advantage: The Brutally Honest Side-by-Side That Insurance Agents Don’t Want You to See Let’s cut through the marketing noise and lay out what actually matters when your health is on the line. 📊 Decision Factor🏛️ Original Medicare + Medigap🏢 Medicare Advantage🏆 WinnerMonthly costPart B ($202.90) + Medigap ($100–$300) + Part D ($35–$60) = $338–$563Part B ($202.90) + Plan ($0–$27 avg) = $203–$230💰 MA wins on priceDoctor accessAny Medicare-accepting provider nationwideNetwork-restricted — out-of-network costs dramatically more🩺 Medigap wins on freedomAnnual spending cap❌ None without Medigap (Medigap essentially makes it near-$0)✅ $9,250 in-network max🛡️ Tie — Medigap effectively eliminates costs; MA caps themPrior authorization❌ Rarely required (new WISeR pilot in 6 states only)✅ Commonly required for procedures, imaging, specialists🏥 Medigap wins on autonomyExtra benefits❌ No dental, vision, hearing, gym, or flex cards✅ Often includes all of these bundled🎁 MA wins on extrasDrug coverageRequires separate Part D plan purchaseUsually bundled into the plan💊 MA wins on convenienceTravel coverage✅ Most Medigap plans cover foreign emergencies⚠️ Limited or none outside the network/service area✈️ Medigap wins for travelersSwitching flexibilityCan drop anytime for MASwitching back to Medigap requires medical underwriting🔄 Medigap wins on future flexibilityBest forSeniors who value freedom, predictability, and travelSeniors who are healthy, budget-conscious, and stay local🎯 Depends on your situation 💡 Pro Tip: Here’s the financial reality check most people miss — a healthy 65-year-old paying $150/month for Medigap Plan G will spend roughly $1,800/year on premiums plus the $283 Part B deductible = approximately $2,083/year in predictable costs, with virtually zero surprise bills. A Medicare Advantage enrollee paying $0/month can face up to $9,250 in a year of serious illness. The “expensive” option is often cheaper when you actually need healthcare. Discover Feeling Lonely? How to Find Senior Social Clubs in Your ZIP Code 💊 6. New 2026 Medicare Benefits: Negotiated Drug Prices, $50 GLP-1s, and the Inflation Reduction Act Payoff 2026 marks a historic turning point in Medicare drug coverage. For the first time, the federal government negotiated prices directly with pharmaceutical manufacturers — and the savings are real. CMS selected ten drugs covered under Medicare Part D for the first cycle of negotiations, and when the negotiated prices go into effect in 2026, people enrolled in Medicare prescription drug coverage would save an estimated $1.5 billion. The 10 medications with negotiated lower prices include treatments for diabetes, blood clots, heart failure, cancer, and autoimmune conditions — drugs that nearly 9 million Part D enrollees use. And the headline grabber: Under the GLP-1 payment demonstration, eligible Medicare beneficiaries will pay $50 for a month of GLP-1 medications, covering injectables like Mounjaro, Ozempic, Wegovy, and Zepbound starting July 2026. Part D plans would cover the medications priced at $245 per month, with copayments capped at $50 per month. 💊 2026 Drug Benefit📋 What Changed💰 Your Savings💡 Who Benefits MostNegotiated prices (10 drugs)Government-set maximum fair prices~50% average reduction in out-of-pocket costsSeniors taking Eliquis, Jardiance, Xarelto, Entresto, Enbrel, Januvia, Farxiga, Fiasp, NovoLog, Imbruvica 💊Part D out-of-pocket capIncreased from $2,000 to $2,100After $2,100 spent, you pay $0 for the rest of the yearAnyone with high prescription costs 🛡️GLP-1 coverage (July 2026)New demonstration program — first-ever Medicare weight-loss drug coverage$50/month copay (was $1,000+ out-of-pocket)Seniors with BMI >30 + qualifying conditions like heart disease, diabetes 💉Part D payment planSpread out-of-pocket drug costs monthlyNo upfront pharmacy shock — budget monthlySeniors on fixed incomes who can’t absorb large pharmacy bills 📆15 more drugs selected for 2027Second round of negotiations announcedPrices negotiated in 2025, effective January 2027Even more savings coming next year ⏳ 💡 Pro Tip: The GLP-1 coverage requires meeting specific clinical criteria — this isn’t a blanket weight-loss benefit. You’ll need a BMI over 30 with conditions like uncontrolled hypertension, heart failure, or advanced kidney disease, or a BMI over 27 with prediabetes or established cardiovascular disease. Ask your doctor to document your qualifying conditions now so you’re ready when the program launches in July. 📑 7. Medicare Plan F vs. Plan G: The $283 Question That Costs Plan F Holders Thousands This is one of the most misunderstood comparisons in all of Medicare. Plan F covers everything — every deductible, every copay, every coinsurance amount. Plan G covers everything except the annual Part B deductible, which is $283 in 2026. So the only coverage difference is $283 per year. But the premium difference? That’s where the math gets devastating for Plan F holders. On average, a Plan F will cost $800 to $2,500 more per year in premiums at the age of 65, and this premium difference increases as you get older. Why? Because Plan F is no longer available to anyone who became eligible for Medicare on or after January 1, 2020. This means the Plan F risk pool is aging and shrinking — no healthy new enrollees are joining. Insurers respond by raising premiums faster on Plan F than Plan G, creating a financial death spiral for those who hang on. 📊 Comparison📋 Plan F📋 Plan G💡 The VerdictPart B deductible covered?✅ Yes❌ No ($283 out-of-pocket in 2026)The only coverage difference between the two plans 📝Availability❌ Only for those eligible before Jan. 1, 2020✅ Available to all Medicare beneficiariesPlan G has a larger, healthier risk pool = more stable premiums 📈Average monthly premium$140–$200+/month$100–$180/monthPlan G typically saves $40–$100+/month 💰Annual premium savings (Plan G vs F)—$480–$2,500+ depending on age and locationThe $283 deductible is dwarfed by premium savings 🏆Premium trajectory📈 Rising faster (shrinking risk pool)📉 More stable (growing, younger enrollee base)Plan G premiums are projected to stay more competitive long-term 📊High-deductible version$2,950 deductible before coverage starts$2,950 deductible before coverage startsBoth available, ideal for very healthy budget-conscious seniors 🏥 💡 Pro Tip: In 2026, if Plan F costs less than $23.58 per month more than Plan G, it could save you money. If the monthly premium for Plan F is more expensive than Plan G by $23.58 or more, then Plan G is the better deal. Do this simple math with your actual quoted premiums. In the vast majority of cases, Plan G wins decisively. 🏆 8. What ValuePenguin and Industry Experts Say About the Best Medicare Plans in 2026 According to ValuePenguin’s Medicare experts, AARP/UnitedHealthcare sells the best Medicare Advantage plans in 2026, with excellent coverage, low rates, and good service. But that rating comes with asterisks. UnitedHealthcare faces ongoing lawsuits and DOJ investigations into its claims practices, and the company’s quality ratings vary significantly by location. For $0-premium plans, the best options in 2026 are from Kaiser Permanente, AARP/UnitedHealthcare, and Humana, though Kaiser is only available in eight states plus Washington, D.C. For 2026, only about 3% of Medicare Advantage contracts got a 5-star rating from CMS. The highest-rated plans are from Anthem, Devoted Health, and UnitedHealthcare — but 5-star availability is limited to just 19 states and Puerto Rico. 🏆 Category🥇 Top Pick⭐ Why⚠️ Watch Out ForBest overall MA planAARP/UnitedHealthcareLow rates, wide availability, strong extrasDOJ probe + class-action lawsuits on billing/AI claims 🚨Best $0 premium MAKaiser PermanenteExcellent quality, high satisfactionOnly in 8 states + D.C. — very limited availability 🗺️Best budget MADevoted HealthAffordable with 5-star ratings in select statesLimited to a handful of states (FL, TX, NC, IA) 📍Best Medigap planPlan G from any insurerMost comprehensive coverage available to new enrolleesCompare quotes from multiple carriers — premiums vary wildly for identical coverage 🔍Best for veteransHumana Honor plansDesigned for VA + civilian provider flexibilityMust verify VA coordination works smoothly with your specific plan ⚔️ 💡 Pro Tip: Don’t choose a Medicare Advantage plan based on TV advertisements. The Centers for Medicare & Medicaid Services put more restrictions on Medicare Advantage ads to help cut down on misleading or confusing marketing, but the problem hasn’t disappeared. Always verify benefits, networks, and drug formularies directly on Medicare.gov’s Plan Finder — not through a 1-800 number you saw during a commercial break. ❓ Frequently Asked Questions Can I have Medicare Advantage and Medigap at the same time? No. Federal law prohibits holding both simultaneously. If you enroll in Medicare Advantage, any existing Medigap policy becomes essentially unusable. You must choose one path. What happens if my Medicare Advantage plan leaves my area? You receive a Special Enrollment Period with guaranteed-issue rights to purchase a Medigap policy — meaning no health questions or denials. This is one of the few protected pathways back. Does Original Medicare cover dental, vision, or hearing? No. These services require either a standalone plan, a Medicare Advantage plan with these benefits bundled, or paying entirely out of pocket. Is the $2,100 Part D cap the same for Advantage and Original Medicare? Yes. In 2026, annual out-of-pocket Part D costs increased from $2,000 to $2,100, and this applies to both standalone Part D plans and drug coverage through Medicare Advantage. What is the WISeR program? A new 2026 pilot in six states (Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington) that introduces prior authorization requirements to Original Medicare for certain procedures. It’s designed to reduce fraud and unnecessary treatments, using both AI and human reviewers. Can I get Ozempic or Wegovy through Medicare in 2026? Starting July 2026, eligible Part D enrollees can access GLP-1 medications at $50/month through a new CMS demonstration program. You’ll need to meet specific clinical criteria related to BMI and qualifying health conditions. What is the best Medicare plan that covers everything? No single plan covers literally everything. The closest combination is Original Medicare + Medigap Plan G + a standalone Part D plan + a separate dental/vision/hearing plan. This provides virtually complete medical coverage nationwide with minimal out-of-pocket costs — but it comes at a higher monthly premium than Medicare Advantage. This article reflects 2026 Medicare costs, premiums, and policy changes as published by the Centers for Medicare & Medicaid Services (CMS), the Social Security Administration, and verified through government sources. Medicare plans, premiums, and benefits change annually. Consult a licensed Medicare counselor or your State Health Insurance Assistance Program (SHIP) before making enrollment decisions. This content is for educational purposes and does not constitute financial, legal, or medical advice. Recommended Reads Medicare Advantage vs. Medigap Medicare Advantage vs. Medicare Supplement Is Medicare Actually for Seniors? Humana Medicare Advantage Plans for Seniors Blog