LA Castle Brokers Group

Educational content only. Not legal advice or a recommendation for any specific plan. Amounts and rules can vary by state and change over time. Verify on Medicare.gov and with a licensed advisor before making decisions.

At a Glance

• Medicare Original (Parts A & B): See any provider nationwide who accepts Medicare. No annual out-of-pocket maximum; you can add Medigap for deductibles/coinsurance and Part D for prescriptions.
• Medicare Advantage (Part C): Private plans that must cover what A & B cover, often include extra benefits, and have an annual out-of-pocket limit (MOOP). They use networks (HMO/PPO, etc.), and rules vary by county and plan.

How Each Option Works

Medicare Original (Parts A & B)

• Federal, fee-for-service.
• Any doctor or hospital that accepts Medicare.
• No network and generally no referrals for specialists.
• Standard cost sharing; no annual out-of-pocket maximum.
• Add-ons:
  • Medigap (Supplement) to help with deductibles/coinsurance.
  • Part D (PDP) for prescription drugs.

Medicare Advantage (Part C)

• Private plans managing A & B benefits.
• Common types: HMO, PPO, PFFS, MSA, SNP.
• MOOP: once reached, the plan pays 100% of covered A & B services for the rest of the year.
• May include Part D and extra benefits (varies by plan/area).
• Networks and rules may require referrals/prior authorization.

Quick Comparison

• Providers
  • Original: Any provider nationwide that accepts Medicare.
  • Advantage: In-network providers; out-of-network rules/costs depend on plan.
• Referrals
  • Original: Generally not required.
  • Advantage: Common in HMO; less common in PPO.
• Annual Limit on A & B Costs (MOOP)
  • Original: None.
  • Advantage: Yes, amount varies by plan/year.
• Prescription Drugs (Part D)
  • Original: Add a standalone PDP.
  • Advantage: Often included (MA-PD), but not always.
• Extra Benefits (routine dental/vision, etc.)
  • Original: Not included by default.
  • Advantage: Often included, varies by plan.
• Medigap Compatibility
  • Original: Yes.
  • Advantage: Not compatible.
• Travel and Service Area
  • Original: Easier nationwide if provider accepts Medicare.
  • Advantage: Service-area rules apply; emergency/urgent care typically covered anywhere.
• Authorizations/Management
  • Original: Less administrative management.
  • Advantage: Prior authorization and care management more common, especially in HMO.

Who Might Prefer Each Option?

• Original if you value nationwide freedom of choice, travel frequently in the U.S., and want predictability by pairing Original + Medigap + Part D.
• Advantage if your doctors are in-network locally, you want an annual spending cap and extra benefits, and you’re comfortable following network/authorization rules.

Key Questions Before You Decide

1. Do my doctors/hospitals accept Medicare (Original) or are they in-network for the MA plan I’m considering?
2. Are my medications on the plan’s formulary (Part D or MA-PD), and at what tiers?
3. What is the MOOP in my county, and what’s my estimated annual cost based on my usage?
4. Will I need referrals or prior authorization for specialists/procedures?
5. How often do I travel, and what happens outside the plan’s service area?

Review Appointment Checklist

• List of preferred doctors/specialists and hospitals
• Current prescriptions (name, dosage, preferred pharmacy)
• Recent utilization: hospitalizations, therapies, DME
• Monthly budget and tolerance for unexpected costs
• Preferences for extra benefits (e.g., routine dental/vision)

Practical Tips

• Original + Medigap: Compare standardized benefits and state underwriting rules.
• Medicare Advantage: Confirm network, MOOP, copays, and the formulary (if Part D is included). Review the Evidence of Coverage (EOC).
• For MA and Part D, preferred pharmacies often reduce costs.
• Expect referrals/prior authorization more often with HMO than with PPO.

2026 Update — Prescription Drugs (Part D)

Recent law changes set a yearly cap on your out-of-pocket spending for Part D-covered medications (the 2025 cap was $2,000; in 2026 it adjusts by law). The cap applies to both standalone PDP and MA-PD. Each year, verify the current amount, premiums, deductibles, copay tiers, and preferred pharmacies in your plan materials and on Medicare.gov.

Useful Enrollment Dates

• Annual Enrollment Period (AEP): October 15 – December 7 (changes typically effective January 1)
• Medicare Advantage Open Enrollment Period (MA-OEP): January 1 – March 31 (if you’re already in MA, you can switch to another MA or return to Original + PDP)

FAQs

Can I have Medigap and Medicare Advantage at the same time?
No. Medigap works with Original Medicare and is not used with Medicare Advantage plans.

Does Original Medicare cover prescription drugs?
Not by default. You need a separate Part D (PDP) plan.

Do all MA plans include drug coverage?
No. Many are MA-PD, but some MA plans do not include Part D (e.g., certain PFFS or MSA). Check your plan.

Do MA plans always require referrals?
Common in HMO. In PPO they may not be required, though out-of-network care usually costs more.

Does the MOOP also apply to drugs?
No. MOOP applies to A & B services within MA. Part D drugs have a separate annual cap set by law; check the current amount each year.

Next Steps

1. Gather your checklist.
2. Schedule an educational session (virtual or in-person) to review networks, costs, and medications.
3. Decide based on your actual usage and preferred doctors.

Book an Educational Session

LA Castle Brokers Group — “Bienestar con Sentido”
Address: 1431 Graham Dr, Ste 232, Tomball, TX 77375
Phone: 832-528-3824
Email: info@lacastlebrokers.com

Disclaimer: This article is informational and does not replace the official review on Medicare.gov or a consultation with a licensed advisor. Rules can change by state/date. No specific plans or carriers are promoted in this article.