Medicare 2026

The structural split between Medicare paths in Shawnee

SHAWNEE, Kan. — If you're turning 65 soon, or helping a parent sort through Medicare mail, you've probably run into a fork in the road. On one side is Original Medicare, often paired with a Medigap policy. On the other is Medicare Advantage. They can look similar in a brochure, but structurally, they work in very different ways — and switching between them later isn't always easy.

Here's a plain-language walk-through of how the two paths are built, so you can ask better questions before you sign anything.

Path 1: Original Medicare, sometimes with Medigap

Original Medicare is the federal program run directly by the government. It comes in two parts:

• Part A helps pay for hospital stays, skilled nursing, and some home health care.
• Part B helps pay for doctor visits, outpatient care, lab work, and durable medical equipment.

Original Medicare generally covers about 80% of approved costs for Part B services, and there is no annual out-of-pocket limit built into it. That's where Medigap (also called Medicare Supplement Insurance) comes in. Medigap is a private policy that helps pay some of the costs Original Medicare leaves behind — things like coinsurance and deductibles.

Two important structural points about this path:

1. You can generally see any doctor or hospital in the country that accepts Medicare. There's no network. 2. Original Medicare does not include prescription drug coverage. If you want drug coverage, you add a stand-alone Part D plan.

Path 2: Medicare Advantage (Part C)

Medicare Advantage is different. Instead of getting your benefits directly from the federal government, you get them through a private insurance company that Medicare pays to run your coverage.

By law, a Medicare Advantage plan must cover everything Original Medicare covers (except hospice, which stays with Part A). Most Medicare Advantage plans also bundle in Part D drug coverage, and many include extras like routine dental, vision, or hearing benefits.

The trade-off is structural:

• Plans typically use networks of doctors and hospitals (HMOs, PPOs, and others).
• Plans set their own copays, coinsurance, and yearly out-of-pocket maximum.
• Referrals or prior authorization may be required for certain services.

Shawnee is in Johnson County, where 29 Medicare Advantage plans from 7 carriers are offered for 2027. You can see the full current list on Medicare.gov's Plan Finder.

The mistake people make most often

The single biggest mistake we hear about is assuming you can freely jump between the two paths later. You often can switch from Medigap to Medicare Advantage. But going the other direction — leaving a Medicare Advantage plan and picking up a Medigap policy later — can be harder.

Here's why: when you first become eligible for Medicare, you have a Medigap Open Enrollment Period (six months starting when you're 65 and enrolled in Part B). During that window, insurance companies must sell you a Medigap policy at their standard rate, regardless of your health.

Outside that window, in most states, Medigap insurers can use medical underwriting. That means they can charge more, or decline to sell you a policy, based on your health history. So the decision you make at 65 can quietly shape your options for years.

If you're weighing this choice, it's worth asking a licensed agent or your local SHIP counselor directly: "If I try to switch back later, what would that look like for me?"

What's the same on both paths

No matter which path you choose, some Medicare rules apply across the board:

• Part D out-of-pocket cap: $2,100 in 2026 and $2,400 in 2027. Once your drug spending hits that cap, you pay nothing for covered drugs the rest of the year.
• Part D maximum deductible: $615 in 2026 and $700 in 2027.
• The old "donut hole" coverage gap is gone as of 2025. Part D now has three phases.
• Medicare Prescription Payment Plan: an optional program that lets you spread your drug costs across the year in monthly payments instead of paying big amounts at the pharmacy counter.
• IRMAA: higher-income beneficiaries pay extra for Part B and Part D. In 2026, IRMAA surcharges start above $109,000 in income for a single filer.

These figures come from Medicare.gov and apply whether you're on Original Medicare or a Medicare Advantage plan.

Enrollment windows to circle on the calendar

• Annual Enrollment Period: Oct. 15 – Dec. 7. You can join, switch, or drop a Medicare Advantage or Part D plan for the following year.
• Medicare Advantage Open Enrollment: Jan. 1 – March 31. If you're already in a Medicare Advantage plan, you get one chance to switch to another Medicare Advantage plan or return to Original Medicare (and add a Part D plan).
• Medigap Open Enrollment: the six months starting the month you're 65 and enrolled in Part B. This is a one-time federal protection.

Missing these windows can lock you out of changes for a year — or, in the case of Medigap, potentially longer.