Medicare Advantage vs Original Medicare for Michigan Seniors in 2026

Every fall, around the time the mailbox starts filling with Medicare brochures, we get a version of the same question from families in Troy. A parent is starting to need help, and someone in the family has been told that picking the right Medicare plan will make paying for that help easier.

We understand why the question comes up. It is also, mostly, the wrong question, and we would rather tell you that at the start than at the end. Nothing about the Medicare Advantage decision changes whether Medicare covers assisted living, because neither option covers it. What the decision does change is how a parent's medical care gets paid for, how much of it a family can predict in advance, and how much freedom they will have later. Those matter enormously. They just are not the same thing.

Here is what actually separates the two in 2026, and where Michigan's own rules come into it.

The Two Structures, Briefly

Original Medicare is the federal program itself. Part A covers hospital stays and short skilled-nursing stays, Part B covers doctors and outpatient care, and a person adds a separate Part D drug plan and usually a Medigap supplement policy to fill the gaps. Any provider in the country who takes Medicare takes it. There is no network and no referral.

Medicare Advantage, or Part C, is a private insurance plan that Medicare pays to deliver those same benefits. It bundles Part A, Part B, and almost always Part D into one card, and typically adds dental, vision, and hearing coverage that Original Medicare simply does not include. In exchange, the plan has a network, and it decides in advance what care it will approve.

Most people are now on the second one. In 2026, 55 percent of eligible Medicare beneficiaries nationally are enrolled in a Medicare Advantage plan, about 35.2 million of the 64.2 million people with both Part A and Part B. Michigan sits above the national average, and it has a wrinkle worth knowing: a third of Michigan's Medicare Advantage enrollees are in employer or union group plans rather than plans they shopped for themselves. In a state with this many auto and building-trades retirees, a lot of families discover that a parent's plan came with the pension and has been renewing quietly for a decade.

The 2026 Numbers

Original Medicare has fixed, published costs. In 2026 the standard Part B premium is $202.90 a month, up from $185.00, with an annual Part B deductible of $283. The Part A hospital deductible is $1,736 per benefit period. If a hospital stay runs long, days 61 through 90 cost $434 a day, and lifetime reserve days cost $868. In a skilled nursing facility, days 1 through 20 cost nothing and days 21 through 100 cost $217 a day.

Those are the numbers people find alarming, and the reason Medigap exists. A supplement policy covers most or all of that cost sharing for a monthly premium, which is why Original Medicare plus Medigap is the predictable option: you pay more every month and almost nothing when something goes wrong.

Medicare Advantage inverts that. About 75 percent of enrollees in individual Medicare Advantage drug plans pay no premium beyond their Part B premium, and across all enrollees the average added premium is about $15 a month. The trade is that costs arrive when care does, in copays, and they are capped rather than covered. For 2026, federal rules cap in-network out-of-pocket spending at $9,250, though most plans set their limits well below that: across enrollees the average in-network limit is $5,421. For enrollees whose plans also cover out-of-network care, which is the PPO structure, the average combined limit is $9,825.

So the honest comparison is not cheaper against costlier. It is a known monthly cost against a known worst case. A family that can absorb a bad year comfortably may do better on Medicare Advantage. A family that cannot afford a surprise usually sleeps better with a supplement.

What Medicare Advantage Adds, and What It Asks

The extra benefits are real and nearly universal. More than 99 percent of Medicare Advantage enrollees have some vision coverage, 98 percent have dental, and 95 percent have hearing coverage including hearing aids. For an 80-year-old who needs hearing aids and a partial denture, that is not a small thing.

Some plans go further in directions that matter for an aging parent. Meal benefits reach about 65 percent of individual plans and 81 percent of Special Needs Plans, and in-home support services appear in about 10 percent of individual plans and 38 percent of Special Needs Plans. Special Needs Plans are worth asking about specifically if a parent has both Medicare and Medicaid, or a qualifying chronic condition, because that is where the supportive benefits concentrate.

What the plan asks in return is permission. Essentially all Medicare Advantage enrollees, 99 percent, are in plans that require prior authorization for at least some services. In 2024 insurers received about 53 million prior authorization requests and denied roughly 4.1 million of them, about 8 percent. Most denials are appealable and many appeals succeed, but appealing takes time and someone to do it.

This is the piece we see land hardest, and not for the reason people expect. It is rarely a denied surgery. It is a parent who has a fall, does well in the hospital, and is ready for a short rehab stay, and the discharge planner has to get the stay authorized and then get each extension authorized while the clock runs. When a family is already stretched thin, that administrative work falls on whoever has the least ability to say no to it. If you are the adult child likely to be doing it from a desk in another state, factor that in honestly.

The Michigan Rule That Is Hard to Undo

This is the part we most want families to understand, because it is the only piece of the decision that is genuinely difficult to reverse.

You cannot hold a Medigap policy and a Medicare Advantage plan at the same time. To move from Medicare Advantage back to Original Medicare with a supplement, you first disenroll from the Advantage plan, then apply for Medigap. And once your Medigap open enrollment window has closed, Michigan insurers are allowed to use medical underwriting. They can look at a health history and decline the application or price it high. Michigan has not adopted a birthday rule or the kind of annual guaranteed-issue window a few other states offer.

There is one important protection. If the Advantage plan was the first one a person ever joined and they disenroll within twelve months, federal trial rights give them guaranteed issue back into a supplement. Certain other situations qualify too, and one of them matters to families more than they expect: the right runs in both directions. It applies when the plan withdraws from the area, and equally when the member moves out of the plan's service area, which is the position a parent relocating to Troy from another state is in. Loss of employer coverage qualifies as well.

The practical effect is that the choice is easiest to make well at 65 and hardest to revisit at 82, which is exactly when a family is most likely to want to revisit it. A parent who has been on an Advantage plan for years and now has a dementia diagnosis and a cardiac history may find that the door back is closed. Knowing that early is worth more than any comparison of copays.

What Neither One Pays For

Both options cover the same core medical care, because Medicare Advantage plans are required to. Neither covers custodial care, and that is the category almost all assisted living falls into. Help with bathing, dressing, medication reminders, meals, and supervision is not medical care in Medicare's definition, and room and board is not covered by Original Medicare or by any Medicare Advantage plan.

Medicare will pay for a short skilled nursing stay after a qualifying hospitalization, which is a genuinely useful benefit and a frequent source of confusion, since families sometimes read the first weeks of a rehab stay as proof that Medicare covers long-term care. It does not. We wrote a longer piece on what Medicare does and does not pay for in assisted living if you want the full picture.

In Michigan, the program that does reach into a residential setting is the MI Choice waiver, which can pay for personal care services delivered in a licensed home. Even then, federal Medicaid rules bar the waiver from paying rent and food, so a resident's own income covers room and board.

How to Decide Without Guessing

Get the current plan documents rather than working from memory. The Evidence of Coverage names the out-of-pocket maximum, the network, and the services requiring prior authorization. If a parent is in a group retiree plan, call the retirement system rather than the insurer, since group plans often have terms an individual plan does not.

Then take it to someone with no commission attached. Michigan runs a free counseling program, the State Health Insurance Assistance Program or SHIP, at 1-800-803-7174. Longtime staff and older handouts still call it MMAP. Their counselors will sit with a specific plan and a specific set of doctors and tell you what it means. The Department of Insurance and Financial Services answers Medigap and underwriting questions at 877-999-6442. Neither sells anything.

Changes happen in defined windows. Annual open enrollment runs October 15 through December 7 for the following year, and there is a Medicare Advantage open enrollment period from January 1 through March 31 for people already in an Advantage plan.

One more thing worth saying out loud. If a parent's care needs are rising, the Medicare question and the housing question are separate, and running them together tends to delay both. Sort out coverage on its own timeline, and sort out where your parent is going to live on its own.

When families reach that second question, we are glad to help think it through. Every resident at our Troy homes begins with an individual assessment so we understand what your loved one needs before they arrive. Reach us at (248) 266-2738 or [email protected].