FREE NEWSLETTER
Go to main Forum page »
Healthcare can be one of the biggest expenses you’ll face in retirement. That’s why it’s so important to make the right Medicare decision when you turn 65.
Medicare’s open enrollment for 2026 is October 15 to December 7, 2025 or 3 months before you turn 65. If you’re approaching 65 — or helping a loved one — here’s what you need to know before making a choice.
When you sign up for Medicare, you’ll choose between:
I want to be upfront about this because too many people only learn these things when it’s too late:
With Medicare Advantage, your insurance company — not your doctor or Medicare — decides what care you can have. And sadly, they sometimes deny or delay care you need.
Before you can get certain tests, treatments, or medications, your doctor has to get approval from the insurance company. This is called Prior Authorization and it’s a way to control costs — often at the patient’s expense by denying or delaying expensive care.
Original Medicare doesn’t do this. If your doctor says you need it, Medicare covers it. There is no Prior Authorization with Original Medicare.
Most Medicare Advantage plans have a list of doctors and hospitals you’re allowed to use. Top hospitals like Memorial Sloan Kettering and Mayo Clinic and top specialists usually won’t accept most Medicare Advantage plans because they pay less and require extra approvals that deny or delay care.
With Original Medicare, you can see almost any doctor or hospital in the country that takes Medicare. And most do.
Insurance companies receive a fixed amount from the government for each person enrolled in a Medicare Advantage plan — over $12,000 a year (in 2019). The less care they approve, the more money they keep. That’s not a system built to put you first.
Sadly, many Medicare “consultants” make 3 times the commissions selling Medicare Advantage plans than Medicare Supplement plans. I always recommend working with someone who will honestly prioritize your needs, not their paycheck and recommend Original Medicare plus a Supplement G plan.
Some workplace and school district retiree plans promise you can see any doctor — but if you read the fine print, it often says, “as long as the provider accepts this .” Many top providers won’t.
Unlike all Medicare Advantage plans, Original Medicare allows you to be treated at any Hospital in the United States.
Unlike Original Medicare, all Employer- sponsored Medicare Advantage plans require Prior Approval for most treatments.
When you first enroll at 65, you have a guaranteed right to buy a Medicare Supplement policy — no health questions asked. But after 65, in most states you could be turned down or charged triple because of Pre-existing conditions.
A few states — Connecticut, New York, Maine, and Massachusetts — allow you to switch any time, but most don’t.
I’ve seen too many people regret their Medicare choices simply because no one explained how important that decision is at 65. Watch Medicare: What the Insurance companies won’t tell you.
Advantage plans are captivated in that the md provider gets a check for X number of pts on a steady basis if he sees you or not. I saw this in NJ Dental Medicaid and its a vv poor system leading to prioritizing pts
That may be true in a few cases, but capitation payments are not common. It was tried in HMOs decades ago and didn’t work. The provider would need a large number of such patients. The criticism was there would be disincentive to spend time with such patients.
Several observations after talking to many people about Medicare:
Medicare Advantage is a local issue, agreed. That’s one of the problems with it. I have a rare eye disease which eventually requires surgery. Many, if not most, patients have to go out of state for the latest techniques. Less skilled surgeons can produce unfortunate outcomes.
Are you saying there are no surgeons at Duke or UNC-Chapel Hill who use the latest techniques for this surgery or that they don’t participate in most MA plans in your area? Duke’s opthamology program is ranked 7th in the country which is where I had my cataract surgery done by Terry Kim who is currently president of the American Association of Cataract and Refractive Surgery.
My wife and I saw several physicians at Duke and UNC during the 4 years we lived in Raleigh and never encountered one who didn’t take our Aetna MA advantage plan. We have been on this plan for six years now because it part of my wife’s retiree benefits. We have yet to have any problems with authorizations and our combined surgeries are well over $500,000 since we retired.
When I first looked for a surgeon using the latest technique, in the early 2010s, none of the Duke surgeons performed it. Fortunately, I was able to wait a few years until one of them developed expertise in it. I still read posts to the relevant online support group, and many people still have to travel out of state. There is now an even newer, less invasive technique, but I haven’t heard that the Duke surgeons offer it. Most people wanting it go to a pioneering doctor in Florida.
I’m not a fan of insurance companies and we would almost certainly opt for traditional Medicare if our MA plan wasn’t paid for by my wife’s retirement plan. Nevertheless, our experience with Aetna MA has been excellent.
As I’m sure you know, newly developed procedures to treat complex diseases take time before there are a sufficient number of competent surgeons who can perform them. And, unfortunately, if the disease is extremely rare, it may not be cost effective to have a large number of surgeons go through the time and expenses of learning the new technique. Thus the need to travel out of state for a new procedure may have nothing to do with the type of insurance a person has.
I suspect the point you may be trying to make is that MA plans are more likely to deny coverage of new procedures because they view them as experimental and/or lacking sufficient evidence that they are superior to more established procedures.
The issue is that the surgeon(s) are out of network. Would treatment by out of network doctors be covered?
In any case, with Medicare plus Medigap the whole issue is moot. I can see any doctor willing to see me.
I can relate to that. Connie’s eye injury required several surgeries. The first at a major trauma center. Then she needed retina surgery which could be done there, but we did some research and found Wills Eye Hospital in Philadelphia listed as the best for eye care. She had the surgeon who was head of the department.
Subsequent to the surgery when more care was required we got a second opinion on what had been done at Wills and were told it was an excellent job.
All this while on standard Medicare. No issues, no questions, no limitations on our choices and with Medigap, no bills either. From the date of the injury to Wills procedure we had incurred over $200,000 in charges according to the EOBs.
We are now experiencing the same freedom and level of care with Connie’s cancer treatment. Our cost is the annual Part B deductible.
I would never use a MA plan because of lack of choice. They may get good doctors to participate, but networks are still limiting as to where you can go and sometimes when as well. And your out of pocket costs can often be higher.
In the end, we are going to find that MA plans cannot be sustained, at least not at current cost levels for beneficiaries. Medicare is paying more for MA plans than for traditional. That can’t last much longer.
This is not an accurate understanding of the Medicare Advantage plan’s primary disadvantage: denial of coverage. I can tell you from the standpoint of seeing first hand the provider side of the equation, it is not uncommon for treatment recommendations to be denied even when very experienced specialist physicians advise that treatment to be the best plan for the patient. Much of the misunderstanding stems from the very typical “off-label” treatments and advanced treatment protocols, which cover most of medicine. In short, the choice of Medicare Advantage is trading the risk of an insurance company and its conflicted “peer review” panels’ coverage decisions for the “benefit” of lower premiums. Most people do not encounter the risk because it is largely associated with serious illness and expensive treatments, so Advantage plans capture a growing market share due to the cost of insurance.
With Medicare’s annual open enrollment period underway, a new KFF analysis finds that Medicare Advantage enrollees, on average, had access to just under half (48%) of the physicians in their area who were available to people enrolled in traditional Medicare.
The study found that PCPs had the lowest access compared to tradional Medicare while specialists had higher rates. MA access was also much higher in urban areas.
Thank you all for continuing this important conversation, and especially to Lucrecia for getting the conversation started.
when I was in practice I had far too many payients forced to go to inferior specialists or hospitals because of Medicare Advantage, and this was in central Ct where tgere was generally good care. If you need a bone marrow transplant dont you want Yale vs a community hospital? Massachusetts General Hospital just dropped all MA plans!
What criteria determine an inferior specialist? Even the evaluation of hospitals is largely subjective except perhaps infection rates or readmission rates.
I recently read the reviews by patients on my wife’s new oncologist. Many very critical. We spent a half hour with her asking all types of detailed questions. We were very pleased how she handled them all and more and no hint of behavior some of the reviews complained about. She showed us the guidelines for the care already provided and to be provided. I find it hard to believe any major healthcare organization would keep an inferior physician on staff.
For that matter how does a patient have the objective ability to evaluate the quality of their care provider!
In some cases it’s easy. Either the surgeon in question does a lot of the latest surgery for my eye disease or they do it infrequently or do an older version. They also get good reports from patients posting to the relevant support group.
Mass General is only dropping two MA plans: Blue Cross and United Healthcare. And, based on my experience, one can’t assume the two sides won’t reach a last minute agreement until the hospital actually stops accepting the insurance.
When we lived in NC we were informed twice that Duke Hospitals and Aetna were parting ways only to have them reach an agreement before the deadline. The same thing recently happened with NY Presbyterian-Colmbia and our Aetna MA plan. We’ve had Aetna MA since we retired 6 years ago because it is one of my wife’s NYC employee retirement benefits. During that time we have yet to have coverage denied and have been able to see top specialists at Duke, UNC-Chapel Hill, Columbia-NYP, NYU, Montefiore and Mt. Sinai.
That happens all the time. It’s a negotiating strategy to try and get the public to put pressure on the insurer. Which, of course results in higher fees to the hospital and ultimately higher premiums to the patient.
It’s like people who insist teachers are underpaid and deserve more while complaining about property tax levels and increases.
Good article, but it’s too generic to apply to everyone.
In certain large cities, Medicare Advantage can be much better. In my county alone, there are over 60 Advantage plans. Around 90% of them are garbage — but the top plans from Aetna and Humana are excellent.
I’ve been on Humana PFFS for three years now — it’s the only one available in the county. With this plan, I can see any provider or get any procedure anywhere in the U.S., with the same cost whether in or out of network.
Here’s what my plan looks like:
Now compare that to Original Medicare + Plan G:
Three years ago, low-deductible Plan G was $145/month. In 2026, it’ll be $206 — a 33% increase. Add the annual deductible ($257) and Plan D, and you’re looking at around $250/month.
In my case, annual prescriptions would cost about $2,100, bringing the total to roughly $5,000 out-of-pocket per year.
If you’re lucky and your prescriptions are cheap, it’s still around $3,500–$3,800 per year.
Now let’s do the math for 2025:
This year, I paid nothing for all the benefits listed above.
Total out-of-pocket for 2025: roughly $900
So, compared with Original Medicare, I’m ahead by:
Add in the extra plan benefits (OTC $1,000 + Dental $2,500 + Gym $500 = $4,000), and we’re talking at least $6,000 in total value.
That extra $6,000, when invested at 8% annually, becomes more than $150,000 over time. I’ll take that deal any day.
Bonus tip:
If your Advantage plan is canceled, you can return to Original Medicare without underwriting — a nice loophole most people don’t know about. The best plans may get cancelled; the worst stay.
Many people I know have been on one of the top 2–3 Advantage plans in our county for years. They all use the same broker, who manages close to 1,000 Advantage clients. According to him, the highest out-of-pocket cost any of them ever paid was about $2,000.
My wife is on the same plan. Together, we’ve probably saved around $300,000 over 15 years.
So yes, there are plenty of scary stories out there — and some are true — but not all Advantage plans are bad or inferior. The key is finding one of the good ones. In our case, it’s been absolutely worth it.
BTW, the savings, including making money already, are over $25K.
You realize that is not possible except for over subsidizing by Medicare which is now under scrutiny.
What you describe is just not sustainable even for a younger population.
What is your annual deductible?
There is no deductible. There are certain things that cost more.
Primary dr = $0
Specialists are a flat $20
Surgery=$415 flat
CT/MRI from $190 to $325
Cancer is the big one; you pay 20% of the cost for chemo, radiology, and others. I know several who had cancer and only paid the MOOP.
MOOP = max out of pocket
Since I don’t know the plan my comment is based on my years of managing many different health plans. What you describe is just not sustainable. It just doesn’t add up, unless as I said the Medicare payments are way too high.
I agree from the standpoint they can work for YOU. However, it is not just about the money. You seem to be in the minority based on your comments about being careful of what Medical Advantage plan is available in your area, note you indicated 90% are garbage, my belief also maybe even a higher percentage. The key is, you have to be fully aware of your Hospitals and Drs available, and your plan. One BMT, that is bone marrow transplant, could eat up that $300,000 in one year. The best to you, and more imortantly stay healthy.
Also know if your Medical Advantage plan is NOT cancelled and you want to change back to Medicare, you have to meet the criteria from a medical standpoint as shown below. Switching from Advantage → Original Medicare is always allowed during open periods. ✅
Buying a Medigap plan after that may require health underwriting unless you’re in a guaranteed issue situation
Garbage was a relative term.
HMOs have limited providers, and that’s why I never look at them.
PPOs are the ones you look for. Then, I added all my doctors, who are the best in our town…and only several plans remained.
The chances you will find great Advantage plans in small cities are much lower.
How can I spend $300K in one year? If a procedure falls under Medicare, it is available under Original and Advantage.
My MOOP (max out of pocket) is $6700.
I know a couple that switched to Original after their Advantage was cancelled without underwriting for Medigap. The county 20 miles from us doesn’t include our Advantage. Use your imagination.
All excellent points to consider. However, clarification on point 1. Not all health insurance plans are for profit. For example, Kaiser is a nonprofit. In my experience Kaiser , though certainly not perfect, provided us excellent seamless care to specialists. There are big drawbacks to any Advantage plan, but I urge people to look at the options carefully and not paint them all with the same bad brush.
Kaiser is my city has limited and not great choices for specialists and hospitals. We had couple of friends on Kaiser and all switched.
Kaiser is not available everywhere. I have also read about people wanting a specific eye surgery and not finding a Kaiser doctor that offered it (they offered an older, inferior, version instead).
I’m glad you’ve had positive experience with Kaiser Medicare Advantage. However the key things to keep in mind is that may not be everyone’s experience. Kaiser as with any Medicare Advantage plan you need prior authorization for many procedures. In addition even though your plan may be a PPO you may only be able to see the doctors and hospitals in the Kaiser network. Even if your Kaiser plan says you can go out of network, that is only if the out of network provider is willing to take the out of network plan. Many top hospitals and specialist won’t. For me, if I’m sick I want to be able to go to the top hospital, see the top specialist, without any prior authorization any where in the country to improve my healthcare outcome. If you’re not too sick, Medicare advantage plans may work out fine. But I like to go with the higher odds of Original Medicare and a G Supplement.
Important article for sure. Read the above very carefully, there is a BIG difference between Medical Advantage Part C and Medicare Part A, B, D.
Note clearly you want your doctors to make medical decisions not your Insurance companies. Look at all the BIG cities in the USA, almost all those tall buildings downtown, are owned by Insurance companies, because they know how to earn your money for THEM, not you. Buyer beware!
A bit overstated. If you were at risk for and paying someone else’s bills wouldn’t you ask questions?
Not overstated at all. A doctor should make the decisions, not someone who is paid to increase profits for insurance companies. I’m surprised you say this
That is not accurate. That’s not done to increase profits. Doctors estimate 25% of all care is unnecessary. 60% of all workers are in employer plans that are self-insured meaning there is no profit motive for the insurance company processing claims and those plans do the same things
If you think doctors should make all the decisions without oversight of any kind, then never complain about the premiums you pay. Insurers do not deny necessary and appropriate care to increase profits.
I would love to see more not-for-profit-healthcare, where companies care more for their customers than themselves.
During my working life the best health care I ever experienced was from Blue Cross Blue Shield of Illinois when they were not-for-profit. They had to spend any money above their expenses for health care. I never had anything denied and they were very generous with their coverage.
Then they installed a new CEO, the first thing he did was to go for-profit, probably because he could pay himself more money. After the change they became cheap, and things they had covered before they started denying.
What has the insurance company to do with your health care? It does not provide care. More care is not necessarily better care, nor is more expensive care. 60% of American workers are in self-funded (self-insured) employer plans. There is no profit motive involved and they use the same processes to control costs and avoid unnecessary care on occasion. The beneficiaries are the employer and the workers.
When I retired, I made the fateful and fortunate decision to opt for Medicare Classic, plus a Medicare supplement policy and Plan D drug coverage. After 10+ years of retirement an several expensive trips to the hospital, I have paid virtually nothing out of pocket, other than my policy premiums.
However, for anyone who is about to retire and trying to make a decision as to which plan to opt for, I have only sympathy as both the decision making and sign up process are not simple. And, as the author notes, there are consequences if you later decide you have made the wrong choice and want to change coverage.
Getting professional advice (and not from whichever ex-pro football player is touting Medicare Advantage this year) is a good idea. For do it yourselfers, buying a copy of Medicare For Dummies would be a good idea. Whichever route you plan to take, start the education process well in advance of your target retirement date as you will have much to learn in order to make the best choice for your situation.
I would add reason #8: Be a patriot and help reduce the federal deficit by choosing traditional Medicare. According to medicarerights.org Medicare Advantage is now costing the U.S. taxpayer 20% more per user than traditional Medicare. That adds up to an additional $84 billion per year. My simple engineer’s brain cannot fathom how a program that only existed to save costs was allowed to be gamed by the health insurance providers. My simple engineer’s solution would be to immediately cap the payments per user to the insurance companies at no more than what traditional Medicare costs.
It has nothing to do with being a patriot. The quote ‘patriots’ running the government are getting donations for their campaigns from insurance companies to continue the status quo. So much for patriotism. The also do not care about the federal deficit based on their recent actions
The payment to an MA plan from Medicare to an insurance company to cover an individual that chooses an MA plan is actuarily driven, not contractually driven. The illness burden for many in MA plans is higher, (that is, more expensive,) than those in traditional Medicare, especially for the Special Needs plans.
I should have stated that the total payments to a Medicare Advantage insurance company for N users should be capped at no greater than the cost for N traditional Medicare users; not capping the benefits for individuals. The one and only reason to have the Medicare Advantage program is that it was promised to cost less than traditional Medicare since, after all, private enterprise always functions more efficiently than government, right?
And why would the “illness burden” for Medicare Advantage be greater than traditional Medicare? Could it be due to “up coding” by the Medicare Advantage insurance companies to increase profit? This problem is very well documented.
I hate to come off sounding so adversarial but I am absolutely certain that the Medicare system, Medicare users, and U.S. taxpayers would be better served if Medicare Advantage never existed.
But this discussion branch is off-topic anyway since the article was about making individual Medicare enrollment choices and not about fixing the system. And I am sure that for some a Medicare Advantage plan could be the right choice.
Let’s be fair to the Medicare Advantage programs. Here are two situations, where a Medicare Advantage plan could be a good choice.
1. Large metropolitan vs. rural areas – Access to care is directly proportional to the abundance of hospitals and providers, access is available. In a rural area, such as here in northern Iowa, you might have to travel as much as 100 miles for specialist care, or to find an appointment less than 90 days out. There are several nearby counties where there is no hospital. That is not abundant care and for that reason, a Medicare Advantage plan is not a good choice. Compare that to any of the five boroughs of New York City where the number of hospitals and providers is abundant. A Medicare Advantage plan could be a good choice.
2. Special needs – There is a class of Medicare advantage plans available for people that either have a specific medical issue or are on Medicaid. Most have a $-0- premium that allow people to access care. Some provide a buy down of the Medicare Part B premium, increasing the Social Security check of the plan participant. These plans must provide all Medicare Part A and Part B health care and services as well as Medicare prescription drug coverage (Part D). Generally, they offer extra benefits and have lower copayments than Original Medicare. Medicare Special Needs Plans offer services through a network of contracted hospitals, doctors, and other providers. If the plan is a PPO, participants may be able to go outside of the plan’s network to receive care. For many, this is the only access to healthcare, except through charity.
Maybe your second statement about special needs makes sense, but not you first one where you reference abundance of hospitals. The problem is that even with all this abundance, you still are relying on approval for procedures by actuaries, not doctors. Medicare Advantage can cost more for those with serious illnesses due to higher out-of-pocket costs, network restrictions, and prior authorization requirements. While premiums are not higher based on health, costs increase when you need more care, such as frequent specialist visits, hospital stays, or certain medications, which plans may have higher copayments or coinsurance for.
In rural areas, an insurance company might not need to fight since a procedure might not be available due to limited practitioners or facilities. Personally, I traveled 75 miles for my cancer treatment for these access issues.
By cost, you mean the amount the patient pays, not the cost of care. The choice between traditional Medicare with a supplement and Medicare Advantage is when you pay for treatment and how much you actually pay. If you select traditional Medicare with a G plan supplement, you pay up front with a monthly premium and a Part B deductible. There are thousands of people with an F plan supplement that never see a bill from a provider. With an MA plan, you typically do not pay premiums or deductibles, but copayments when care is received and there is typically an out-of-pocket maximum. It is a choice that must be made when you enroll in Medicare.
Also, let’s be clear, it is not actuaries making the rules or treatment decisions at insurance companies, but the medical staff of the companies – trained medical professionals turned bureaucrats.
These days it is probably AI making the decisions.
The biggest problem is choice itself. Choice in health care is not good and not necessary. We only have it because of insurance company lobbying.
It does not benefit beneficiaries and sometimes harms them.
For example, If we had one Part D plan covering all approved medication with the same deductible and copays we would be better off. The insurance companies could compete on their efficiency and hence prices.
Beneficiaries would have less to worry about and no need to predict what drugs they may take in the future. It’s nuts.
In Massachusetts: With the help of a computer algorithm, the state’s biggest health insurer says it will scrutinize doctors who frequently bill it for the most expensive patient visits. It will then unilaterally cut payments to physicians it concludes charged too much.
Targeting what it described as a small percentage of “outliers,” blue cross blue shield plans to roll out a new program around Nov. 3. The insurer says health care costs at their fastest rate in more than 20 years and that it has a duty to help control them for its 3 million members.
But the move has angered some doctors, particularly those who often see older patients in need of more care and time. They say Blue Cross’s initiative fails to recognize a simple fact of medicine: Patients and treatments don’t fit neatly into categories used by insurers and software developers.
The dispute represents another front in the battle over spiraling health care costs and who — insurers, providers, or patients — should bear the brunt of efforts to control them.
Yup, everyone wants what they want, but no understanding of the consequences. We could pay for everything no questions asked, but then there would be even more screaming about premiums. Many people think the insurance company motive to do such controls is profit. That is not the case.
Although none of you will find my opinion popular, I think the biggest problem is the US system itself. Among first world developed nations, the US profit-driven medical system that treats health as a commodity is an outlier. Every other developed nation treats healthcare as a basic civil right. Taxes might be higher because of this, but health outcomes, the primary and only reason for a health system, are better on every metric outside the US. This is true even though US health spending is nearly double that of other comparable countries. On the higher tax front, comparative studies have shown that when you include US private medical insurance, out-of-pocket costs, and co-pays, the total financial burden of healthcare per person is highest in the US. It’s bizarre that the most advanced and powerful nation on earth has such a poor health system.
It’s not actually correct that health care outcomes are worse because of our payment system. There is nothing wrong with our healthcare other than cost and for many access.
You have to account for population differences, lack of homogenous population, age, lifestyle differences, obesity rates, even poverty differences when evaluating care outcomes.
For Americans with the ability to pay one way or the other, good quality care is easily accessible by most standards and promptly available. Needless to say access in some rural areas is lacking.
In most cases the delay in care is measured in days, perhaps a couple of weeks, but rarely in months.
All of Connie’s current doctors and needed care are in one modern building. That includes lab work, scans, infusion, radiology, some surgery and a pharmacy.
Every system is profit driven in one way or another. Nobody works for free or manufactures equipment for free.
We need a single payer insurance system covering every person, but it’s not a matter of quality.
Dick, just because Connie gets great timely care doesn’t make you are right. Unlike you, many Americans do not have the ability to pay ‘one way or the other’. I live near Boston, and I cannot get a general practitioner from the biggest hospital system we have here. Many appointments are booked out months in advance over many medical specialties. So, regarding quality, if you have to wait months to see a podiatrist for foot pain, that is a quality issue.
That is a different issue. Not a quality issue. My friend in England waited for nine months for a hip replay
Your healthcare outcomes are worse because of the design of the whole system. There’s pockets of excellence, and I’m glad you have access to those. But the figures don’t lie. Lifespan is lower, preventable death and infant mortality are higher than comparable first world nations.
That’s right, but as I said, not because of the health care system. Infant mortality is a good example, it has to do with poverty, age of those having babies, irresponsible behavior, not the care. Obesity affects many of those things as well.
Our problem is the payment system and lack of universal insurance, not the healthcare delivery system. And, to some extent lifestyle too.
Other countries provide pre-natal and post-natal care that is sadly lacking in the US. Obesity is increasing in Europe – the UK is not that far behind the US. Blaming the patients is the wrong answer.
Wrong again Dick. The healthcare system is a problem if you cannot get timely treatment. You can be in great health, but incur an injury. It is because of the health care system we have. My doctors have told me their hospitals (biggest and best in Boston) cannot afford to hire more doctors, leading to big delays.
I agree on the part D plans. Unlike the supplement plans, they are not standardized. Change that, so it is a “fair” choice based on unknown futures.
Further on your example, Farxiga is in the formularies of many Part D plans as well as it’s generic, dapagliflozin. However, the generic is more expensive than the brand. Since doctors and pharmacies have been trained to fill the generic, we spend more.
During 2025, the brand Synthroid was not in most formularies from the Part D insurers, only the generic levothyroxine. For 2026, the opposite is true.
It’s not just prediction of one’s own health, it is consistency, reliability and a focus on the patient by the Part D insurers that we need.
An even bigger problem is the fact that the formulary can change during the plan year. If you signed up because a given drug was covered, you may find it dropped part way through the year. That is just ridiculous.
Regarding the last paragraph about medicare choices, this informative article may be of interest to readers.
https://www.statnews.com/2025/10/15/medicare-open-enrollment-choice-help/
From the article:
Theories of rational choice say that having more options should be better. It should allow everyone to select the plan they like the most given their health care needs and preferences. If all Medicare beneficiaries selected their preferred plan every year, then insurers would be incentivized to improve their plans to give beneficiaries what they want.
But in reality, most beneficiaries can rarely predict exactly what prescription drugs or health care they will need the following year. One beneficiary we interviewed for an ongoing USC Schaeffer Institute study said, “I have no basis, none whatsoever, on which to base a decision.”
Not quite so simple in Maine in regards to switching plans. Mainers do have a right to change plans so long as the new plan has the same or lesser benefits.
For me with a Plan G High Deductible, I likely couldn’t switch to a regular Plan G. But that doesn’t worry me. This year, I save a minimum of $2348 a year (over a normal plan G) and the additional annual deductible is $2513. I liken the difference in premium cost in healthy years to a form of a health savings account.
We’ve seen horrible situations with Medicare Advantage thru a friend who has rheumatoid arthritis and fell hard after tripping, breaking bones made more brittle by her R.A.
She retired before age 65 with Medicare Advantage when her teaching career ended suddenly through disability after injuries from a classroom incident. Her insurer was denying reasonable claims and it took constant battling to get treatment like needed rehab after surgery for her fall.
But when you turn 65 you can switch to traditional Medicare if you started on MA before age 65 due to disability. The healthcare outcomes on traditional Medicare have been like night and day for her.
I learned the hard way, but not too hard! Shortly after 65, my PSA came back high and my primary care suggested I either get a urologist or go ahead and do an mpMRI. It made sense to do the MRI–cheaper, faster, and better science than waiting. My medicare advantage plan wouldn’t pay for it! I went ahead and paid cash, but used their in-network provider who charged a higher cash price and had older equipment, as I later found out.
BUT I was still in the free-look first six months, so I changed to original medicare and a high-deductible plan G supplement (cheaper, but a better deal!), got a best of class mpMRI and biopsy out of state from a research urologist, and went on from there.
My moral–medicare advantage is good while you’re healthy, but the whole point of buying insurance is for coverage when you’re not, and everyone agrees it’s either the same or worse when you’re sick.
[And not only is the insurance company rewarded for delaying and denying coverage, but they are rewarded when sick people switch away from their plan and choose something else.]
Even if you can’t qualify for a supplement plan, original medicare can be a good choice if you can afford the copays in the event you need to. For people likely to be visiting this forum, that is often the case.
This is very likely a stupid question, but I’m hoping some savvy HD readers can explain it to me.
We both turned 65 and just started Medicare. Because of my husband’s previous 20 years working for the state of California, we get a Medicare supplement as part of his retirement package. Per instructions from CalPERS (the retirement system), we both signed up for Medicare Parts A and B and then the supplement kicked in (also includes enrollment in Part D). We got our hefty IRMAA surcharge letters (my husband is still working, so $$$), and we also get a partial reimbursement for IRMAA added to his pension checks from CalPERS. We’re enrolled in the same Blue Shield PPO that we were before Medicare—it’s just paid for differently now. The card says “PERS Platinum Supplemental.”
I assume this scenario is still traditional Medicare and not Medicare Advantage, because we signed up for Parts A & B? The supplement from CalPERS is a type of Medigap plan?
I’ve never quite understood how all of this works. I mean, now that we’re in it, I know what our monthly costs and reimbursements are, but not the terminology.
I just went through the same exercise with CalPERS given I retired in August of this year. My spouse is over 65 and Medicare eligible. She signed up for Part A on her 65 birthday and just signed up for Part B since my former employer no longer pays the full premium and CalPERS requires all Medicare eligible participants to be in Part B. I am not 65, so we have a combination plan. I am not sure if CalPERS still has open enrollment but you should look into PERS Gold Supplemental. It will save you on monthly premiums and I believe the coverage is equal with the Medicare component.
Yes, that’s traditional Medicare with a supplemental plan aka “Medigap”.
Thank you!
Great summary and it reflects how I have approached Medicare for my wife and myself. I would go so far as to say that before you consider early retirement, make sure you will have enough money when you reach Medicare age to fund Traditional Medicare plus Medigap plus Part D.
But beware: Pre Authorization is coming to traditional Medicare in the form of a pilot program involving 6 states and 17 procedures. See Prior Authorization Coming to Traditional Medicare Starting in 2026 | Kiplinger
My wife is likely to be a test case of this since we live in Ohio. Last week she had a total right knee replacement. The decision was made by her and her doctor; insurance considerations did not enter into it. With our Medigap policy on top of traditional Medicare, we are not expecting any bills.
She and the doctor have already discussed having a left knee replacement in late 2026. What hoops will we have to jump through to get that approved?
I see preparing a HD article comparing the two approaches in my future. Stay tuned.
Thank you. Thanks for pointing out how the current administration is bringing prior authorization to Original Medicare. The federal government (CMS) will choose and pay companies a percentage of the healthcare that they deny using AI
https://www.financialfreedomforwomen.org/healthcare/a-major-medicare-protection-just-vanished
However it there is still no comparison to the thousands of procedures that require prior authorization in Medicare Advantage
I agree: “no comparison.” The other rule is to ALWAYS appeal a denial. First level appeals have a high reversal rate.
How important is it to have a Medigap policy? I know this is really unanswerable, but for a reasonably healthy person (easy for me to say at 62), I pay some out-of-pocket costs now, for my Health Connector coverage (I’m retired). If I decide to just have Medicare cover what it covers and pay the rest out of pocket, and invest the money I’d have spent on a Medigap policy, am I being foolish?
Risky in my opinion. Remember straight Medicare has no out of pocket limit. And medical treatment cost has no upper limit. You are always responsible for 20%. So, if the medical costs are $500,000 you are responsible for $100,000.
I think it is risky. You’re better off getting a High Deductable G plan and investing the difference. Also unless you live in New York, Mass, Maine or Conn you may not be able to find an insurance company that will sell you a supplement because of pre existing conditions, https://www.financialfreedomforwomen.org/healthcare/surprise-your-medicare-coverage-isnt-guaranteedheres-what-you-need-to-know
Sounds like a plan! A minimal amount of research suggests a high deductible plan isn’t expensive. When the time comes (I still have three years to think about it), I’ll probably do something along those lines.
Could be quite foolish. One, there then is no limit on your medical costs. What if you are seriously injured or get cancer? The costs will quickly skyrocket. Two, depending on your state, if you want a supplement later, you may have to go through medical underwriting and could be denied.
I chose original Medicare plus Medigap & Part D. No regrets. The Medigap plan increases in price every year but it is worth it to me to have freedom to choose any doctor and quickly get an appointment.
This is a great overview and a very important topic for those needing to make the decision between Original vs. Advantage Medicare. The Original (+ Medigap plan) of course costs more, but invaluable for those with lots of heath needs and/or who want peace of mind.
To add to the overview – if a mistake is made in selecting a plan, you have a 6-month window to get a Medigap policy without discrimination.
Also consider the risk pool and history in your state for Medigap providers, if they pull plan from the state my understanding is you may be discriminated against with either higher premiums or declined from coverage.
Worst case, move to 1 of 4 states mentioned above 🙂
P.S. I learned lots after being misled by a broker to an Advantage plan, fortunately, I was able to make switch before 6 months expired.
Lucretia, excellent article and very good advice. Regular Medicare is the way to go!