Medigap vs. Medicare Advantage

Which Supplemental Option Is Best For Your Original Medicare Plan

Medigap vs. Medicare Advantage

Which Supplemental Option Is Best For Your Original Medicare Plan

Are you confused about the differences between Medigap and Medicare Advantage?

With so many options available, it’s essential to understand the key distinctions to make informed decisions about your healthcare coverage.

Whether you’re approaching retirement age or already enrolled in Medicare, this article will shed light on the Medigap vs. Medicare Advantage debate and help you navigate the complex world of healthcare options.

In this guide, we will delve into the intricacies of Medigap and Medicare Advantage, exploring their coverage, costs, eligibility requirements, and other vital aspects.

By equipping yourself with this knowledge, you can decide which option best suits your unique healthcare needs during your golden years.

Seniors Wondering the Difference Between Medigap vs Medicare Advantage

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Medicare Advantage Plans

Medicare Advantage plans should cover all of the services covered by Original Medicare with optional benefits included.

Medicare Advantage plans, also known as Part C, are a type of health insurance option offered to individuals who are eligible for Medicare.  These plans are offered by private insurance companies that are contracted by the federal government to provide Medicare beneficiaries.  Medicare Advantage plans offer as good basic health coverage as Original Medicare, which includes hospital insurance (Part A) and medical coverage (Part B), but they may also offer additional benefits, such as prescription drug coverage, dental coverage, vision, hearing benefits, and wellness programs.

One of the key benefits of Medicare Advantage plans is that they often have lower out-of-pocket costs than Original Medicare.  Additionally, Medicare Advantage plans typically have a cap on out-of-pocket spending, which can help individuals budget and plan for their healthcare expenses.  Medicare Advantage plans also often have provider networks, meaning that individuals may need to see healthcare providers within the plan’s network to receive the full coverage benefit.  

Overall, Medicare Advantage plans can be a great option for individuals looking for comprehensive healthcare coverage with additional benefits, lower out-of-pocket prices, and a network of healthcare providers.  

Regardless of which Medicare Advantage plan you choose, know that you are always covered for urgent and emergency care. A majority of Medicare Advantage plans include prescription medicine coverage, and the benefits can change year to year, so it’s important to understand how a plan works before enrolling — also another reason why we’re here! We can help you prepare and review your plan annually as well to ensure you understand any changes in coverage and benefits.

Who Qualifies for Medicare Advantage?

Eligibility for Medicare Advantage is determined by several criteria. You may qualify for a Medicare Advantage plan if:

  1. You reside in the service area of the Medicare Advantage plan: These plans are offered by private insurance companies and may not be available in all areas. It’s important to ensure the plan you’re interested in is offered in your geographic location.

  2. You’re enrolled in Original Medicare (Parts A and B): Before you can sign up for a Medicare Advantage plan, you need to be registered in both Medicare Part A (hospital insurance) and Part B (medical insurance). You should also have a valid Medicare number.

  3. You are not currently enrolled in a Medigap plan: Medigap, or Medicare Supplement Insurance, is not compatible with Medicare Advantage. If you’re already enrolled in a Medigap plan, you would need to drop it before switching to Medicare Advantage.

What Are the Benefits of Medicare Advantage?

  • Additional Coverage: Medicare Advantage plans often offer benefits beyond Original Medicare, such as prescription drug coverage, dental and vision care, hearing aids, and wellness programs.

  • Cost: Many Medicare Advantage plans have low or even $0 monthly premiums, although they typically involve co-pays and deductibles.

  • Out-of-pocket Maximums: Unlike Original Medicare, Medicare Advantage plans have a yearly limit on what you pay out of pocket for medical services.

  • Coordinated Care: Many Medicare Advantage plans are organized as Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs), which encourage and sometimes require coordination of care between your healthcare providers.

  • All-in-One Convenience: With many services covered under one plan, Medicare Advantage can be a simpler, more convenient option for beneficiaries.

  • Prescription Drug Coverage: Most Medicare Advantage plans include Part D prescription drug coverage, so there’s no need to enroll in a separate plan for this.

MediGap Plans

Medigap is Medicare Supplement Insurance that we say helps “fill in the gaps” in Original Medicare. Private companies sell it and pays for close to all of the medical costs for covered health services and supplies. A Medigap policy can help pay for some of the remaining health care costs like copayments, coinsurance, and deductibles.

Some Medigap policies cover services that Original Medicare doesn’t cover like medical care when you travel outside of the U.S. If you have Original Medicare and you purchase a Medigap policy, Medicare will pay its share of the Medicare-Approved Amount for covered health care costs and then your Medigap insurance company pays its share.

Here are some things to know about Medigap Policies:

  • You must have Original Medicare (Part A & B).

  • You are responsible for paying the private insurance company a monthly premium for your Medigap policy, which is in addition to the monthly part B premium you pay to Medicare.

  • A Medicare Supplement Insurance policy covers only one person. If you and your spouse both want Medigap coverage, you’ll each have to buy separate policies.

  • Any standardized Medigap policy is guaranteed renewable, regardless of health condition.

Who Qualifies for Medigap Coverage?

Medigap, also known as Medicare Supplement Insurance, has certain eligibility requirements. Here are the primary criteria to qualify for a Medigap plan:

  1. Enrollment in Original Medicare: To be eligible for Medigap, you must be enrolled in both Medicare Part A (hospital insurance) and Part B (medical insurance). Medigap is designed to supplement Original Medicare by covering certain out-of-pocket costs that Original Medicare does not cover.

  2. Age Requirement: Typically, you must be 65 or older, which is the same age requirement for Medicare. However, certain states require insurance companies to offer at least one type of Medigap policy to people under 65 who have Medicare.

  3. Timing: The best time to buy a Medigap policy is during your 6-month Medigap open enrollment period. This period starts the month you’re 65 or older and enrolled in Part B. During this period, you can buy any Medigap policy sold in your state, even if you have health problems.

  4. Not enrolled in a Medicare Advantage Plan: You cannot have a Medigap policy if you’re enrolled in a Medicare Advantage Plan. These are two different ways to get your Medicare coverage. If you want to switch from a Medicare Advantage Plan to a Medigap policy, you’ll need to leave the Advantage Plan before your Medigap policy begins.

What Are the Benefits of Medigap Plans?

  • Out-of-pocket costs: Medigap policies can help pay some of the health care costs that Original Medicare doesn’t cover, like copayments, coinsurance, and deductibles.

  • Coverage beyond Original Medicare: Some Medigap also cover services that Original Medicare doesn’t cover, like medical care when you travel outside the U.S.

  • No network restrictions: With a  Medigap plan, you can see any doctor or visit any hospital that accepts Medicare. There are no network restrictions.

  • Predictability: Medigap plans often make your health care costs more predictable because they provide coverage for expenses that you would otherwise have to pay out-of-pocket.

  • Flexibility in medical service: Some Medigap covers excess charges. These are fees above the Medicare-approved amount for a service. Currently, they are set at 15%.

  • Extended hospital coverage: Medigap often provides an additional 365 days of hospital coverage after your Medicare benefits are exhausted.

What’s the difference between Medicare Advantage and Medigap plans?

Medicare Advantage vs Medigap refers to two different ways individuals can choose to get their Medicare coverage. 

Medicare Advantage, also known as Medicare part C s is a private, Medicare-approved health insurance plan designed for individuals registered in Parts A & B (Original Medicare). It combines coverage for doctor visits, hospital care, and other medical services in one plan.

Both Medicare Advantage and Medigap are supplemental options to your Original Medicare plan.

Most Medicare Advantage plans to provide similar to an individual or employer HMO or PPO plan, helping lower out-of-pocket costs with predictable copayments, smaller deductibles, and out-of-pocket costs. Medicare Advantage covers out-of-pocket expenses that can save money buy. You can also save money with a Medicare Advantage plan by seeing a doctor within the plan’s network.

On the other hand, a Medigap plan can work with your Original Medicare to help pay for most or all of your out-of-pocket costs that Original Medicare doesn’t cover, like copayments, coinsurance, and deductibles.

A Medigap plan can also give you more flexibility regarding doctor choice because you can go to anyone who accepts Medicare.

Two seniors with Medicare Eligibility

How to choose between Medigap and Medicare Advantage

Choosing between Medigap and Medicare Advantage can be a complex decision, as the right choice depends on your specific healthcare needs, budget, and personal preferences. Here are some considerations to keep in mind:

  1. Understand the difference: Medigap (Medicare Supplement Insurance) and Medicare Advantage (Part C) are two ways to get more coverage beyond Original Medicare (Parts A and B). Medicare Advantage plans are an alternative to Original Medicare, providing all the same coverage and often including extras like prescription drug coverage, vision, dental, and wellness programs. Medigap plans, on the other hand, supplement Original Medicare by covering some or all of the out-of-pocket costs (like deductibles and coinsurance) that Original Medicare doesn’t cover.

  2. Costs: Compare the costs of both options. Medicare Advantage often has lower monthly premiums but higher out-of-pocket fees when you need care. Medigap plans tend to have higher monthly premiums but lower out-of-pocket fees when you use medical services.

  3. Coverage: Medicare Advantage plans often offer additional benefits that Original Medicare doesn’t cover, such as prescription drug coverage, dental, vision, and hearing care. If these extras are important to you, a Medicare Advantage plan may be a good choice. On the other hand, if you’re mainly concerned about out-of-pocket costs for the benefits covered by Original Medicare, a Medigap plan could be a better fit.

  4. Network restrictions: Medicare Advantage plans often have network restrictions, similar to HMOs or PPOs. You may need to see doctors in the plan’s network to get the lowest costs. If you travel frequently or have doctors you want to see who are not in these networks, you might prefer Medigap, which doesn’t have these network restrictions.

  5. Prescription drugs: Most Medicare Advantage plans include prescription drug coverage. If you choose a Medigap plan, you’ll need to buy a separate Part D plan for prescription drugs.

  6. Medical conditions and frequency of doctor visits: Medigap may be a better choice if you have a chronic illness or see the doctor frequently because it covers more of the cost-sharing you would otherwise have to pay under Original Medicare.

  7. Availability: Not all plans are available in all areas. Check to see which Medicare Advantage and Medigap plans are available in your area.

Consider Original Medicare with a Medigap plan if you:

You wish to have the freedom of choosing your healthcare provider:

If it’s important for you to be able to select any doctor or hospital that accepts Medicare, then Original Medicare with a Medigap plan offers this flexibility. This is especially valuable if you have complex health issues that may require specialized care.

You are a frequent traveler:

Medicare Advantage often have service area limitations which could mean out-of-pocket expenses if you require medical attention while traveling outside of this area. In contrast, with Original Medicare and a Medigap plan, you can visit any provider across the nation that accepts Medicare, offering peace of mind for those who travel often.

You have a chronic condition or need regular medical care:

With a Medicare Advantage plan, frequent visits to the doctor could lead to significant out-of-pocket fees, as the maximum limit for in-network doctors or care can be pretty high (up to $8,300 in 2023, for example). Medigap programs, while requiring a monthly premium, cover many of these out-of-pocket fees. If you are enrolled in certain Medigap programs, the premium might be your only expense even if you need frequent medical care.

You prefer to err on the side of caution:

If you’re concerned about the possibility of a serious health diagnosis later in life, and the potential for associated high costs, a Medigap plan can provide added security. It can cover certain out-of-pocket expenses and allow access to a wide range of specialists, regardless of whether they accept Medicare Advantage. As Medicare insurance specialist David Smith suggests, a Medigap policy can be a smart choice for those concerned about the risk of high healthcare costs.

Consider Medicare Advantage if you:


You reside in an area with a comprehensive network:

Medicare Advantage plans often require that you use their network of medical providers. However, if you live in a large metropolitan area, the network of doctors and hospitals available to you may be extensive. You can choose Medicare Advantage if you are content with the providers in your plan’s network and do not plan to relocate.

Medigap is beyond your budget:

Enrolling in Original Medicare without a Medigap plan can lead to substantial medical expenses if you require frequent or extensive care. If the cost of a Medigap plan is prohibitive for you, Medicare Advantage could be a more financially feasible alternative.

You are comfortable with managed care plans:

If you’ve had a history with insurance plans that utilize networks (such as HMOs) and found them to be satisfactory, you might feel at ease with the similar structure of a Medicare Advantage plan. As Smith mentions, those who’ve had positive experiences with HMOs often feel comfortable continuing with a similar setup through Medicare Advantage, provided they were content with their previous plan.


In Conclusion

Both Medicare Advantage and Medicare Supplement Plans(Medigap) are advantageous to seniors in their retirement years.

If you still have a question or would like to get a quote please do not hesitate to contact us at 954-282-6891.

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