Choosing the right Medicare coverage is one of the most important decisions retirees will make. Should you stick with Original Medicare (Parts A & B) and add a Medigap policy, or join Medicare Part C (Medicare Advantage)?
For some, Medicare Advantage offers cost savings and convenience. For others — especially those who want nationwide access to doctors and hospitals — it can become a frustrating limitation.
Let’s break down the pros, cons, and real-life implications, using a practical case study: Megan, a retiree in California, who wanted cancer treatment in Texas but faced coverage challenges.
What Is Medicare Part C (Medicare Advantage)?
Medicare Advantage (MA) is an all-in-one alternative to Original Medicare, offered by private insurance companies approved by Medicare. These plans bundle hospital (Part A) and medical (Part B) coverage, and often include prescription drugs (Part D), dental, vision, hearing, and wellness perks — all under one plan.
Pros of Medicare Advantage
- Lower Monthly Premiums – Many MA plans have $0 or low monthly premiums (beyond your Part B premium).
- Annual Out-of-Pocket Maximum – Unlike Original Medicare, MA plans cap your yearly costs for in-network services. Once you hit the limit, you pay nothing more for covered care.
- One-Card Convenience – Hospital, medical, and drug coverage are all combined in one plan, reducing paperwork.
- Extra Perks – Many plans include dental cleanings, eye exams, hearing aids, transportation, or even fitness memberships.
Cons of Medicare Advantage
- Limited Provider Network – You must use in-network doctors and hospitals for non-emergency care. Out-of-network care may not be covered (or could cost much more).
- Prior Authorization Required – Many plans require approvals before surgeries, rehab stays, or specialty treatments — potentially delaying care.
- Geographic Restrictions – Plans are regional. If you spend time out of state, your access to routine care may be limited.
- Yearly Changes – Your plan’s premiums, network, and benefits can change every January — meaning your doctor could leave the network next year.
Real-Life Example: Megan’s Cancer Treatment Dilemma
Megan, a California retiree, enrolled in a Medicare Advantage HMO plan. After being diagnosed with cancer, she wanted treatment at MD Anderson Cancer Center in Houston, Texas, one of the nation’s top cancer hospitals.
Her MA plan denied coverage because MD Anderson is outside the plan’s network. Megan faced two choices:
- Pay 100% out of pocket for MD Anderson treatment, or
- Stay in California and use an in-network facility.
This scenario highlights a major risk of MA plans: restricted access to out-of-network, out-of-state specialty care.
Comparison Table: Original Medicare + Medigap vs. Medicare Advantage
| Feature / Factor | Original Medicare (A & B) + Medigap + Part D | Medicare Advantage (Part C) |
|---|---|---|
| Provider Choice | See any doctor or hospital in the U.S. that accepts Medicare | Limited to plan’s in-network providers (except emergencies) |
| Referrals / Authorizations | Rarely required | Often required for specialists, tests, and procedures |
| Out-of-Pocket Limit | None (but Medigap can cover most costs) | Has an annual spending cap for in-network services |
| Monthly Premiums | Part B premium + Medigap premium + Part D premium | Part B premium + plan premium (some $0) |
| Extra Benefits | Usually none (buy separately if needed) | Often includes dental, vision, hearing, fitness |
| Drug Coverage | Must enroll in standalone Part D plan | Usually included (MA-PD) |
| Out-of-State Access | Nationwide access to any Medicare-accepting provider | Restricted — out-of-state non-emergency care may not be covered |
| Stability | Medigap benefits are standardized and renewable annually | Plan benefits, costs, and networks can change yearly |
California-to-Texas Scenario: Access & Cost Considerations
| Feature | California-Based MA Plan | Original Medicare + Medigap |
|---|---|---|
| Non-Emergency Out-of-State Care | Usually not covered unless pre-approved; may be denied (as with Megan) | Covered at any Medicare-participating facility |
| Emergency Care Out-of-State | Covered (federal requirement) | Covered |
| Cancer Treatment at MD Anderson | Likely denied or full-cost out-of-pocket | Covered if MD Anderson accepts Medicare |
| Annual OOP Limit | Up to $9,350 (for in-network care) — out-of-network costs may not count | No limit with Original Medicare, but Medigap covers most or all cost sharing |
| Plan Changes | Network may change yearly | Stable as long as you pay premiums |
Key Takeaways for Retirees
- If you rarely travel and prioritize low premiums, Medicare Advantage may work — just stick with in-network doctors.
- If you value nationwide freedom and top-tier care options, Original Medicare + Medigap is often the safer long-term choice.
- Switching Later Can Be Hard – If you wait until you get sick to switch back to Original Medicare, you may face medical underwriting for Medigap coverage in most states (premiums could rise or you could be denied).
Bottom Line
Megan’s story underscores the importance of thinking ahead. Medicare Advantage plans can save money when you stay local, but can also limit your options if you need specialized, out-of-state care.
For retirees who want maximum choice and peace of mind, especially those who might seek treatment at nationally ranked hospitals (like MD Anderson, Mayo Clinic, or Cleveland Clinic), Original Medicare with a good Medigap plan may be the better fit — even if monthly premiums are higher.
-Lê Nguyên Vũ-
Further Reading & Resources