As the upcoming Annual Enrollment Period approaches, big changes are on the horizon for both Medicare and ACA Marketplace plans. Whether you’re a senior evaluating your Medicare coverage or an individual relying on ACA subsidies, this year’s decisions could have a major impact on your health and finances.
⚠️ Original Medicare Vs Medicare Advantage. Which is better?
Recent reports in, 2025 show approximately 34.1 Million Medicare beneficiaries, or 54% of the 62.8 million people on Medicare A & B are in Medicare Advantage plans. Many of these don’t understand or know the difference between Original Medicare and Medicare Advantage (MA), yet the distinctions are substantial.
Medicare Advantage was codified by Congress in the Balanced Budget Act of 1997 as a cost saving measure for Medicare. When you enroll in Medicare Advantage (MA), Medicare transfers all responsibility for your care to private insurance. Medicare then pays that private insurance company a fixed monthly amount to manage your medical care. The MA then in exchange assumes full responsibility to cover all costs associated with your care. This fundamentally alters how providers are paid, and places insurer oversight over your care and dramatically changes the dynamic between patients, providers, and payers. Because of this, some providers opt out of Medicare Advantage. Original Medicare, by contrast pays providers directly when Medicare approved services are rendered. This gives providers more freedom and less restrictions when developing treatment plans as long as they follow Medicare-approved guidelines.
MA plans have faced scrutiny in recent years for strict preauthorization requirements for treatment which have led to delays, denials, and a burdensome appeals process. Some MA plans have also been found inflating patient diagnoses codes in billing to secure higher compensation from Medicare. Talks between regulators and industry leaders earlier this year, yielded an agreement in which insurers will work to ease preauthorization requirements which they know will raise operating costs. In response, the Centers for Medicare & Medicaid Services (CMS) approved a monthly compensation increase to insurers. But industry experts warn the increased costs for services will likely be passed on to members through increased copays, coinsurance and premiums. They also expect insurers to reduce or eliminate popular perks that have historically aided MA enrollment such as dental, vision, and gym memberships. These changes could prompt many beneficiaries to reconsider a switch back to Original Medicare, which offers nationwide provider access without network restrictions, few preauthorization hurdles, and the option to pair with Medigap for very low and predictable out-of-pocket costs.
This year’s enrollment window is a perfect opportunity to reevaluate coverage and explore whether Original Medicare might offer better protection and peace of mind.
💸 ACA Plans: Subsidy Rollback Ahead
For those enrolled in ACA Marketplace plans, 2026 is expected to bring serious sticker shock. Enhanced subsidies are set to expire, meaning premiums could rise by as much as 75%. Currently, 92% of ACA enrollees receive subsidies that cap premiums at 8.5% of income, even for higher earners. Without these supports, many may be forced to drop coverage or seek alternatives.
One such alternative gaining traction is health sharing plans. While not traditional insurance, these plans offer lower monthly costs and have appealed to healthy individuals looking for budget-friendly options. However, they come with limitations and may not offer the same protections as ACA-compliant plans.
🧠 Need Help Navigating Your Options?
At InsuranceSmart, we specialize in helping Texans make informed decisions about their health coverage. With over 20 years of experience in Medicare, health, life, and long-term care insurance, we’re here to guide you through every step—from comparing plans to understanding your benefits.
Whether you’re considering a switch to Original Medicare or exploring ACA alternatives, we offer free consultations and personalized support to help you get the coverage that fits your needs and budget.
📞 Call us today at 210-972-9035 🌐Visit InsuranceSmart to learn more or schedule your free consultation www.GetInsuranceSmart.Com
by Mike Sosso
management of concerns outside of the primary care physician’s scope of practice. A simple phone call once served as an introductory transfer of the patient from primary to specialty care. Progress notes and polite thank you notes followed upon returning the patient to the primary care setting. Today, insurance regulations and paperwork have become the primary focus, while the actual diagnosis and treatment of the condition(s) have become a distant secondary focus. Medicare starts something and commercial insurers follow their lead, whether the policy is beneficial or harmful to their beneficiaries.
