Two Doors

I’m not an insurance agent, an attorney or a financial advisor, and I don’t know your health, your doctors or your state’s rules. This is a way to think about the choice, not a recommendation for your situation. Confirm details on Medicare.gov and, ideally, with a free SHIP counselor before you decide.*

On Monday we covered the checklist. Today is the question underneath it, the one the whole season is really about.

When you get Medicare, you are quietly handed a choice that most people don’t realize is a choice. You can stay with Original Medicare, the government program, and add other coverage around it. Or you can hand the whole thing to a private insurer through Medicare Advantage. Both are Medicare. They do not work the same way.

How each one works, in two paragraphs

Original Medicare is Part A (hospital) and Part B (doctors and outpatient). You can see any doctor or hospital in the country that accepts Medicare, and you generally don’t need permission first. The catch: it has no out-of-pocket maximum. If you have a bad year, the 20 percent you owe on Part B services can keep adding up. That’s why most people who choose it add either a Medigap supplement policy or other coverage to fill the gaps, plus a separate Part D drug plan.

Medicare Advantage bundles Parts A and B, usually drug coverage and often extras into one private plan. In exchange for the bundle, you accept a network, and the plan can require prior authorization, meaning approval before certain services. It does come with a yearly cap on what you pay out of pocket.

What the data says, not the ads

The Kaiser Family Foundation tracks this every year. For 2026, among people in individual Medicare Advantage plans with drug coverage:

– 75 percent pay no premium beyond the Part B premium. That is a real draw. The other 25 percent pay about $59 a month on average.

– The average in-network out-of-pocket limit is about $5,400, and the legal maximum is $9,250. Original Medicare has none.

– Nearly all plans include vision, dental, hearing and fitness benefits. But some extras shrank this year: over-the-counter benefits fell from 79 to 68 percent of enrollees, and meals and transportation also dipped.

– 99 percent of enrollees are in plans that require prior authorization for some services.

That last one deserves a closer look, because it’s where the trade is made.

The number nobody advertises

In 2024, Medicare Advantage insurers made about 53 million prior authorization decisions. They denied 7.7 percent, around 4.1 million requests. Here is the part that stays with me: only about 11.5 percent of those denials were appealed, and of those appeals, about 81 percent were overturned in whole or part.

Read that twice. When people pushed back, they usually won. Most people never pushed back.

I’m not telling you Advantage plans are bad. For plenty of people they are a smart, affordable choice. I am telling you the cost of a plan like this isn’t only the premium. It’s also whether you or a family member will have the energy to fight a denial in a bad week.

The door that’s harder to walk back through

This is the part to read slowly.

If you pick Original Medicare and later decide you want Advantage, you can generally switch. But if you pick Advantage and later want to go back to Original Medicare with a Medigap policy, in most states the insurance company can look at your health history and decline you or charge more, unless you’re in a protected window or live in a state with extra protections. A few states give more room. Most don’t.

So the choice is not symmetrical. One door swings both ways. The other swings one way for many people, and it’s most likely to stick when you’re sick, which is exactly when you’d want to use it.

(Verify against Medicare.gov and your state’s insurance department before publishing, see the note at the bottom.)

My pick

If you can comfortably afford a Medigap premium and you want the freest choice of doctors, the order I’d put them in is:

1. Original Medicare plus a Medigap policy plus a standalone Part D plan. It costs more each month. In exchange you get the widest choice of providers, you generally don’t need prior authorization for covered services, and your costs are predictable. If you travel, or you split time between states, or you already see specialists at a major academic center, this is where I’d start.

2. A Medicare Advantage plan that your actual doctors and hospital accept, and that you’ve checked in Plan Finder with your real drugs. If the monthly budget is tight and you’re relatively healthy, this can be the right call. Treat the first year as a test, and know your appeal rights.

3. Original Medicare alone, with no supplement. I’d rank it last for most people, because the missing out-of-pocket cap is the one genuine risk.

And here is the strongest argument against my pick, left standing: a Medigap policy costs real money every month, and for a person who is healthy, on a fixed income and in a plan that includes their doctors, paying extra to avoid problems that may never happen can be the worse financial bet. Millions of people choose Advantage for exactly that reason, and many are happy. If that’s you, the checklist from Monday is how you stay safe.

Questions to ask before you pick

1. Are my specific doctors and my hospital in this plan’s network for 2027? Call the offices.

2. What happens if I get sick away from home?

3. Which of my drugs need prior authorization or step therapy?

4. What is the maximum I could owe in a bad year?

5. If I choose Advantage and change my mind, could I get a Medigap policy in my state?

What to do this week

1. Do Monday’s three-question test on your current plan.

2. Ask a SHIP counselor (free, no commission) about the Medigap rules in your state.

3. If you’re in Advantage and not sure it fits, write down your reasons now, so that in January you aren’t deciding from a hospital bed.

4. Hold the line at December 7.

Go be bold!

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