At 66, He Is Leaving Advantage After Medigap Says No. Original Medicare Has No Annual Out-of-Pocket Limit, and One Bad Year Can Cost $14,000

Insurers are cutting Medicare Advantage plans and counties again for 2027, leading many enrollees to reconsider Original Medicare. A 66-year-old who joined Advantage at 65 sees his plan continuing but its network shrinking. He applies for Medigap Plan G and is denied based on his health history.

He leaves Advantage anyway, assuming his 20% share must stop at some ceiling. Original Medicare has no annual out-of-pocket maximum without supplemental coverage.

This risk affects a narrow group: Advantage members past their first-year trial right whose plans are continuing and who live in states that allow Medigap insurers to screen applicants based on health. If an Advantage plan leaves Medicare or stops serving your area, federal rules generally give you a guaranteed-issue right to buy certain Medigap policies without medical underwriting.

20%, With No Annual Limit

For most Part B services, he pays the $283 annual deductible in 2026 and then 20% of the Medicare-approved amount. Advantage plans must set an annual maximum on covered Part A and Part B cost sharing. Once a member reaches it, the plan pays 100% of covered services for the rest of the year. Original Medicare on its own never reaches that point.

Outpatient bills drive exposure: chemotherapy and other Part B drugs, outpatient surgery, imaging, specialist visits, and physical therapy. One cancer diagnosis can bring all five in the same year.

How One Bad Year Reaches $14,000

Say Medicare approves $70,000 of Part B services during a year of treatment. His 20% share is $14,000. Add the deductible and he owes $14,283. That comes on top of the $202.90 standard monthly Part B premium every enrollee pays in 2026.

A hospital stay adds more. Part A charges a $1,736 deductible per benefit period, and a new benefit period starts after 60 days out of the hospital. So two admissions spaced far enough apart in one year mean two deductibles. Add a single admission to the outpatient year above and his bill reaches $16,019.

With Plan G, his share of that bad year would have shrunk to the $283 Part B deductible. Losing Plan G costs him far more than the network change he was trying to escape.

Why One Denial Should Not Settle It

He joined Advantage when first eligible for Medicare, so his federal trial right generally lasted only the first 12 months. Past that window, Medigap insurers may screen him on health unless another guaranteed-issue right or state protection applies. New York and Connecticut offer guaranteed issue all year; Massachusetts and Maine offer broader rights.

What Original Medicare Alone Still Gives Him

Without Medigap, he still has Part A hospital coverage and Part B outpatient coverage. He can see any provider in the country who takes Medicare, and he can add a standalone Part D plan. What he gives up is the yearly limit on his costs.

A 66-year-old with enough savings may decide that the provider freedom is worth taking on more financial risk. Someone expecting heavy medical use should compare that uncapped exposure with the out-of-pocket maximum and network rules of available Advantage plans. An Advantage plan’s medical out-of-pocket maximum does not include Part D drug spending, and noncovered or out-of-network care may follow different rules (we mapped out the surcharges and coverage gaps that catch retirees off guard in a free Medicare guide, here). But for covered Part A and Part B services subject to the plan’s maximum, there is a ceiling. If he leaves and gets sick later, future Medigap applications may face health screening again.

Three Moves to Make Before You Disenroll

1. Get written decisions from at least two more Medigap insurers before dropping Advantage. Check your state insurance department’s website for protections stronger than federal rules.
2. Cost your worst year. See your plan’s in-network out-of-pocket maximum in its 2027 Annual Notice of Change and compare it with the potential uncapped Part B costs under Original Medicare alone.
3. If the network is your complaint, switch Advantage plans instead. During open enrollment, from October 15 through December 7, look for a PPO covering out-of-network care. Changes take effect January 1.

Advantage limits where he gets care. Original Medicare lets him see almost any doctor, but without Medigap, his costs have no yearly ceiling. One year of chemotherapy is enough to show the price.

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