Some Medicare beneficiaries have concerns about their out-of-pocket expenses. In particular, it can be intimidating to face 20% coinsurance after your deductible is met. That can get expensive.
Both Medicare Advantage and Medicare Supplements can address these concerns, in different ways. Understanding the difference between Medicare Advantage vs Medicare Supplements can help you choose the right plan for your needs. This article will help you understand the differences between Original Medicare, Medicare Advantage, and Medigap
Did you know Medicare has the highest rate of satisfaction among Medicare beneficiaries? In fact, they ranked both Original Medicare and Medicare Advantage highly according to a 2019 survey.
Still, it can be a difficult task to pick the best Medicare plan for your needs. Let's simplify the process by looking at Original Medicare, then discussing how Medicare Part C (Medicare Advantage) plans and Medicare Supplement (Medigap plans) work and take a closer look at the difference between Medigap and Medicare Advantage.
Medicare is health insurance with different parts for:
Original Medicare is broken into two parts: Part A (for hospitalization) and Part B (for medical services). In most cases, there is no cost for Medicare Part A.
But you would have to pay a $471 monthly premium for Medicare Part A if you only paid Medicare taxes for 29 quarters or less (about 7.25 years). And if you paid Medicare taxes between 30-39 quarters (7.5 years to 9.75 years), the standard Part A premium is $259.
Medicare Part B premiums are determined by your modified adjusted gross income.
If your income for 2021 was less than or equal to $87,000 for a single or $174,000 for a married couple filing jointly, you will pay the standard Medicare Part B rate, which is $148.50 a month in 2021. Part B premiums rise to a maximum of $504.90 a month if your income exceeds $500,000 for an individual or $750,000 for a couple filing jointly.
Many people are automatically enrolled in Medicare Part A and Part B when they turn 65 and begin to receive Social Security retirement benefits.
But you might be in a situation where you have other health insurance besides Medicare, like a plan through your employer. In this case, you can delay your enrollment in Part B without being penalized and save paying the monthly premium. However, you would have to pay a $458 monthly premium for Medicare Part A if you only paid Medicare taxes for 29 quarters or less (about 7.25 years). And if you paid Medicare taxes between 30-39 quarters (7.5 years to 9.75 years), the standard Part A premium is $252.
If you don’t receive Social Security benefits at age 65, you need to sign up on your own. There are three ways to enroll:
The seven-month Initial Enrollment Period (IEP) for Medicare begins three months before you turn 65, continues during your birthday month, and runs for three months after you turn 65. If you don’t enroll in Medicare during this timeframe, you could face penalties for not complying with Medicare rules.
There’s also a Medicare annual enrollment period each year after your initial enrollment, which allows you to make changes to your coverage for the following year.
So, the big question is: Should you consider Medicare Advantage, or enroll in Original Medicare and get a Medicare Supplement instead? And the short answer is: It depends.
You have to evaluate your healthcare needs and how much you can afford to pay out-of-pocket for health insurance.
Medicare Advantage provides all of your Part A (hospital) and Part B (medical) coverage. A majority of Medicare Advantage plans offer extra coverage, such as vision (78%), hearing, dental care (67%) or wellness programs (72%). Most include Part D prescriptions drug coverage (90%).
As a Medicare beneficiary, you have a choice between selecting Original Medicare or choosing a Medicare Advantage plan (also known as Part C), which is provided by private health insurance companies.
Medicare Part C premiums vary by the plan (many plans have $0 premiums). And each Medicare Advantage plan can charge different out-of-pocket costs and have different rules for how you get medical services.
For example, most insurance companies require Medicare Advantage plan participants to get pre-approved before they can have a procedure done, but another insurance company might not have that requirement.
Yes, your acceptance is guaranteed and you're not required to complete any medical history forms. This includes coverage for people with End State Renal Disease (ESRD), which is a 2021 change to Medicare.
Medicare supplement plans (Medigap) plans provide extra coverage to help pay for some of the healthcare costs and services that Medicare doesn’t pay. These plans can offer protection from large out-of-pocket medical costs that result from numerous doctor or hospital visits.
It’s important to note that you can’t have more than one Medicare supplement plan. And though Medicare supplement plans may have higher monthly premiums than Medicare Advantage plans, you may want to consider buying a Medicare supplement insurance plan if:
A Medicare supplement plan may also be a good fit if you want to visit a specific top-tier medical facility like the Mayo Clinic. You wouldn’t qualify for an in-network check-up with a Medicare Advantage plan, but you’d have the ability to see a Mayo Clinic doctor with a Medicare supplement plan, with coverage for a large chunk of your services.
Pricing for Medicare Supplement plans are based on the plan you select (high/low benefits), your age at time of enrollment, your state of residence, and the health insurance company you select. That’s why it is important to compare when you shop from plan to plan or even between the same company’s plan differences before choosing a Medicare supplement plan.
Medicare Advantage offers more choice and covers more medical services than Medicare, while still following all of Medicare’s rules. One of the biggest differences between the two is the difference in cost. Medigap plans generally have a higher premiums than Medicare Advantage plans, but in some cases, Medicare Advantage can cover less expenses than Medigap. This means that despite a lower initial cost, you may end up paying more in out-of-pocket expenses with Medicare Advantage than with a medicare supplement.
Remember: Medicare Advantage acts as an alternative to original Medicare, while Medicare Supplement plans are additions to Original Medicare coverage.
Choosing between a Medicare Advantage plan or adding a Medicare Supplement plan on to your Original Medicare coverage depends on your situation.
To start, ask yourself these types of questions:
Do I travel outside of the United States regularly? Do I live in a different state for a portion of the year? Do I want to see any doctor and not be limited to a network? Is my budget more important than my health benefits? Are extra benefits like dental and vision coverage important to me?
Answering these questions will help you determine if Medigap or Medicare Advantage is a better fit for you.
Switching from Medicare Advantage to Medigap means you need to go back to Original Medicare. Instead of having coverage under Medicare Part C (Medicare Advantage), you’ll have coverage under Medicare Part A and Part B, with Medigap added on.
This can only be done during open enrollment periods. The Annual Election Period is between October 15th and December 7th of each year. The Medicare Advantage Open Enrollment Period is between January 1st and March 31st each year.
Keep in mind that usually if you switch from Medicare Advantage to Original Medicare with Medigap, you may pay a higher price for your Medigap plan because you won’t have guaranteed issue rights. Guaranteed issue rights give you the ability to buy any Medigap plan without paying more due to your health status.
To switch from Medicare Advantage to Medigap with guaranteed issue, you need to:
These temporary guaranteed issue opportunities may not include all Medigap plans — it will depend on the rules in your state.
The chart below offers a side-by-side comparison of costs and coverage to help you understand the difference between Medigap and Medicare Advantage.
|Medicare Advantage||Medicare Supplement|
|Coverage||In most cases, copayments (a fixed amount of money you pay) are required.||In most cases, it can cover deductibles, copayments, and coinsurance that isn’t covered by Part A and Part B.|
|Cost||Many times $0 or a low monthly cost.||Higher monthly cost based on state, gender, and age.|
|Travel||Many plans may cover emergency care when you’re out of the country, but there’s typically a maximum amount the plan will pay.||Many plans may cover emergency care when you’re out of the country, but there’s typically a maximum amount the plan will pay.|
|Prescription Drugs||Typically included with coverage.||Not covered. You must enroll in a Part D plan for drug coverage.|
|Routine dental, vision, hearing coverage||May be covered depending on the plan selected.||Not covered.|
|Copayments and coinsurance||Usually have copayments and/or coinsurance.||Typically pays for copayments and coinsurance.|
|Network||Medicare Advantage plans have different networks: HMO, PFFS, and PPO. It’s important to understand the rules about going out of network for your healthcare.||No network. See almost any doctor or medical facility that accepts Medicare.|
Medicare Advantage and Medigap plans may provide benefits for the following services (but check your plan details for specific benefits):
Note: Medicare supplement plan benefits are subject to state rules and regulations. Benefits described here encompass common Medigap plans available in the marketplace. Other services may be covered based on the supplemental plan you pick. Please check your insurance policy documents or talk to a customer service representative for more information.
But you don’t have to go it alone: We can answer your questions about Medicare and help you find the best Medicare quotes for your needs. Just try our Medicare Advantage plan comparison tool to get Medicare quotes online, or call 800-620-4519 to get help from a licensed insurance agent.