by Russell Noga | Updated July 31st, 2023
If you’re a senior, you’re eligible for Medicare in the three months before your 65th birthday. Medicare has four parts, A, B, C, & D, to help you cope with healthcare expenses in your golden years. Medicare Part A involves coverage for hospitalizations, hospice care, and stays at skilled nursing facilities. Part B involves medical care with doctors and other related services. Part D offers coverage for prescriptions.
Medicare Part C, also known as “Medicare Advantage,” replaces Parts A & B with a single policy covering everything. It’s a popular choice due to the more comprehensive coverage available in the 30+ plans from private healthcare insurers. Some MA plans even have $0 monthly premiums and offer drug coverage and fitness perks as well.
Like Medicare Advantage, private healthcare insurers offer Medigap plans. They differ from Medicare Advantage in the sense that Medigap provides coverage for the out-of-pocket expenses not covered by Original Medicare Parts A & B. This post looks at Medigap vs Medicare Advantage. We’ll give you the information you need to make an informed decision on the right policy for your healthcare needs.
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Medigap vs Medicare Advantage – What are the Differences?
What Benefits Do You Get with Medigap Plans?
Medigap plans offer coverage for Original Medicare Part A & B healthcare services. The Federal government (CMS) regulates the benefits in all ten plans, ensuring all providers offer consistent benefits. So, the benefits you get in a Plan N policy from AARP will be the same as those in a Plan N policy from Humana or Blue Cross Blue Shield.
- Part A coinsurance and hospital costs for up to 365 days after using up Medicare benefits.
- Part A hospice care coinsurance or copayment.
- Part B coinsurance or copayment.
- Blood transfusion costs for the first three pints of blood.
Plans F*, G, and N offer additional Medicare Parts A & B benefits.
- Part A deductible.
- Part B excess charges (Plan N doesn’t cover these charges).
- Skilled nursing facility care coinsurance.
- 80% of emergency healthcare costs when traveling outside the US for 60 days. ($250 deductible and $50,000 maximum apply).
- Unlimited coverage for all out-of-pocket costs.
*Plan F is the only Medigap policy offering coverage for the Part B deductible. However, it’s no longer available for seniors qualifying for Medicare after January 1, 2020.
Medigap plans only cover the out-of-pocket expenses not fully covered by Original Medicare Parts A & B. So, that means if Original Medicare Parts A & B don’t cover the service, Medigap won’t cover it either. Medigap doesn’t cover private-duty nursing, long-term care at nursing homes, and preventative services like hearing, dental, and vision.
There are exceptions where Medicare Parts A & B will cover preventative care, but a doctor or surgeon needs to motivate Medicare to cover these services. An example would be jaw reconstructive surgery and dental follow-ups after being involved in an accident when you need hospitalization to recover.
Medigap also won’t cover drug prescriptions. Some Medigap providers offer add-on plans or discounts on dental, hearing, and vision services if you use their partner network providers.
What Benefits Do You Get with Medicare Advantage Plans?
Medicare Advantage plans are also available from private healthcare insurers. Medicare Advantage, also known as “Part C,” replaces your Original Medicare Part A & B policies. MA plans offer coverage for hospitalization and medical services, and some of the plans also cover preventative treatments, vision, hearing, and dental services, or prescription drugs.
Most Medicare Advantage plans operate as a preferred provider organization (PPO) or health maintenance organization (HMO). HMOs require MA beneficiaries to use the hospitals and doctors in their network. PPOs typically let members seek care outside the network, but beneficiaries will pay additional fees for this care or higher monthly premiums on their plan.
Some MA plans require the beneficiary to get pre-authorization for specialist procedures or care, or they must get a referral from their primary care physician. Many MA Plans don’t offer coverage outside a specific geographical area, whereas Medigap beneficiaries can use any provider accepting Medicare in the United States.
What are the Price Differences Between Medigap and Medicare Advantage Plans?
Medicare Advantage Plans are usually cheaper than Medigap policies. However, it depends on the plan and provider. Since private insurers offer Medigap and MA plans, the rates charged for monthly premiums can differ by state and provider.
Using a licensed agent to get you the best deal on monthly premiums is the best way to avoid overpaying for your plan. Medigap and MA consulting firms work with all the insurers in our state, and they’ll get you the best rates on any policy.
When do You Enroll in Medigap or Medicare Advantage Plans?
To avoid gaps in coverage and penalties, sign up for Medicare Part A & B within the seven-month window starting three months before the month of your 65th birthday. You can delay signing up for Part B if you have an existing healthcare plan with a union or employer. You can sign up for Medicare Advantage during this period as well.
You can enroll in Medigap plans in the six months starting from the date of your 65th birthday. The insurer must accept your application for any Medigap policy during this time. They cannot refuse your application, and they can’t force you to undergo medical underwriting.
Underwriting is the process where the insurer asks you about pre-existing health conditions. Suppose you delay enrollment in Medigap plans until after the Open Enrollment window. In that case, the Medigap provider can use medical underwriting to charge you higher-than-average premiums or deny your application.
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Frequently Asked Questions
What is the difference between Medigap and Medicare Advantage?
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Russell Noga is the CEO and Medicare editor of Medisupps.com. His 15 years of experience in the Medicare insurance market includes being a licensed Medicare insurance broker in all 50 states. He is frequently featured as a featured as a keynote Medicare event speaker, has authored hundreds of Medicare content pages, and hosts the very popular Medisupps.com Medicare Youtube channel. His expertise includes Medicare, Medigap insurance, Medicare Advantage plans, and Medicare Part D.