Original Medicare + Medigap vs. Medicare Advantage: What Pain and Spine Patients Should Know

If you may need an MRI, injections, or an outpatient procedure, your Medicare choice affects your costs, your doctors, and how quickly you get care. This article is general education, not insurance or medical advice.

The two options

Original Medicare (Parts A and B), with optional Medigap

• See any doctor or facility in the U.S. that accepts Medicare.
• Usually no referral needed to see a specialist.
• A Medigap (Medicare Supplement) policy helps pay your 20% share.
• Add a separate Part D plan for drugs.

Medicare Advantage (Part C, “managed Medicare”)

• A private plan approved by Medicare.
• Often a low or $0 premium, often includes drug coverage and extras.
• Usually limited to the plan’s network.
• Referrals and prior approvals are often required.
• Has a yearly out-of-pocket maximum.
• Medigap cannot be used with it.

What you pay at a surgery center (ASC)

Original Medicare

• 2026 Part B deductible: $283.
• Then 20% of the approved amount, for both the surgery center and the doctor.
• No yearly cap unless you have Medigap.
• Medigap Plan G pays the 20% in full (you still pay the $283 deductible).

Medicare Advantage

• The plan sets its own deductibles and copays.
• Compare the yearly out-of-pocket maximum, not just the premium.

Prior approvals

• Original Medicare: In most cases, no prior approval is needed.
  • Exceptions: some hospital outpatient services, such as facet joint procedures and spinal cord stimulators.
  • New Jersey 2026 pilot (WISeR): a short list of services, including epidural steroid injections, may need review first.
• Medicare Advantage: Prior approval is much more common.
  • 99% of Advantage members need approval for some services.
  • In 2024, Advantage plans made 52.8 million approval decisions, compared with about 625,000 in Original Medicare.
  • Ask whether MRI or CT scans, injections, radiofrequency ablation, and implants need approval, and how long decisions take.

Denials

• In 2024, Advantage plans fully or partly denied 7.7% of approval requests (4.1 million).
• Only 11.5% of those denials were appealed, but 80.7% of appeals were overturned. If you’re denied, appeal.
• A 2022 federal review (HHS Inspector General) found that 13% of denied requests met Medicare’s own rules and likely would have been approved under Original Medicare, including MRIs.

Switching back to Medigap can be hard

• You have a guaranteed right to buy Medigap during the 6 months after you first enroll in Part B at 65 or older.
• After that, New Jersey insurers can deny you or charge more based on your health.
• 12-month trial right: if you try Advantage and leave within 12 months, you can usually get Medigap without health questions.
• Talk to New Jersey SHIP (free counseling) before you switch: 1-800-792-8820.

Checklist before you choose

• Are your pain doctor, imaging center, and surgery center in network?
• Which scans and procedures need prior approval?
• What is the total yearly cost: premium, deductible, copays, and out-of-pocket maximum?
• Is drug coverage included?
• Do you still have a right to switch back to Medigap later?
• Key dates: Open Enrollment runs Oct 15 to Dec 7. If you’re already in an Advantage plan, you can switch Jan 1 to Mar 31.

Care at Garden State Medical Center

• GSMC accepts Medicare, Aetna, CHN, Horizon Casualty, and QualCare & Qualynx.
• Manchester Surgery Center accepts Aetna, Clover, Humana, Medicare, and QualCare & Qualynx.
• Coverage varies by plan. We verify your benefits before scheduling procedures.
• Request a consultation: gsmedicalcenter.org/consultation or call 732-202-3000.

Sources

• Medicare.gov: Compare Original Medicare and Medicare Advantage; Medigap plan benefits
• CMS: WISeR Model
• KFF: Medicare Advantage prior authorization, 2024
• HHS OIG: Medicare Advantage prior authorization denials (2022)
• New Jersey SHIP: Important information

This article is general education, not insurance or medical advice.

Request an appointment   Call 732-202-3000