Medicare Advantage vs. Medigap with Original Medicare: What Are the Differences and How to Choose
Key takeaways:
For many people, the decision between Medicare Advantage versus Medigap with original Medicare comes down to plan benefits and out-of-pocket costs.
Medigap is Medicare supplement insurance that covers certain out-of-pocket costs for people enrolled in original Medicare (Part A and Part B).
Medicare Advantage plans are private alternatives to original Medicare. Sometimes known as Medicare Part C, Medicare Advantage typically offers extra vision, dental, and hearing benefits but is accepted by a narrower network of healthcare professionals and hospitals.
One of the key differences between original Medicare and Medicare Advantage is that the latter typically includes prescription medication coverage, or Medicare Part D. That, among other things, could be a factor in which type of plan you choose.
Table of contents
When enrolling in Medicare, many people opt for original Medicare (Part A and/or Part B). But if you think you need additional coverage, Medicare Advantage and Medigap with original Medicare are two options to consider.
Medicare Advantage plans are private alternatives to original Medicare that bundle Part A and Part B. These plans typically offer extra benefits for vision, dental, and hearing care. Medigap, on the other hand, is supplement insurance plan that covers all or some out-of-pocket costs related to original Medicare.
Knowing the differences between Medicare Advantage and Medigap with original Medicare can help you make the best choice for your health needs.
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What is the main difference between Medicare Advantage and Medigap with original Medicare?
Medigap versus Medicare Advantage is not an apples-to-apples comparison. Medigap is supplement insurance for original Medicare. Medicare Advantage plans are private alternatives to original Medicare.
A Medigap plan may be able to help you cover your out-of-pocket costs once you decide to choose original Medicare for your hospital and medical coverage. Medicare Advantage is a choice you make in lieu of original Medicare.
What are the pros and cons of Medigap with original Medicare and Medicare Advantage?
Here are some pros and cons of Medigap with original Medicare and Medicare Advantage.
Medigap With Original Medicare Pros and Cons
Pros | Cons |
|---|---|
Original Medicare is accepted by most physicians and hospitals in the U.S. And you can see any healthcare professional who accepts original Medicare without a referral. | Original Medicare doesn’t cover prescription medications — or include extra benefits such as coverage for vision, hearing, or dental care. If you want your prescription medications covered, you will need to buy a standalone Part D plan. |
Medigap covers some or all of your out-of-pocket costs related to original Medicare Part A and Part B coverage. | You may face medical underwriting if you miss your 6-month Medigap open enrollment period or want to switch Medigap plans later on. Depending on which state you live in, missing your Medigap open enrollment period could lead to higher premiums or coverage denial. |
Standardized Medigap plan benefits by letter name make comparison shopping simpler, because the only difference between plans with the same letter is price. | Prices vary widely among plans with the same benefits, so it makes sense to shop around. |
Some Medigap plans offer emergency healthcare coverage while traveling abroad. | If you are younger than 65 with end-stage renal disease (kidney failure) or a disability, you may or may not be able to buy a Medigap plan in your state. |
Medicare Advantage Pros and Cons
Pros | Cons |
|---|---|
Medicare Advantage bundles Part A and Part B into private plans. | Medicare Advantage plans require you to use in-network hospitals, physicians, and other healthcare professionals. And those networks are typically more limited than with original Medicare. |
Medicare Advantage often provides extra benefits like coverage for dental, hearing, and vision care. | You may need referrals to see specialists or a prior authorization (advance approval) for services or procedures. |
Most Medicare Advantage plans include Part D prescription medication coverage. | You need to make sure your Medicare Advantage plan’s Part D coverage includes the medications you need in its formulary. If you have a Medicare Advantage plan that doesn’t include Part D coverage, you will have to pay a separate premium for a standalone plan. |
Medicare Advantage has an annual out-of-pocket maximum for out-of-pocket costs for covered services. | Most Medicare Advantage enrollees don’t reach the annual out-of-pocket maximum. |
How do you choose between Medicare Advantage and Medigap with original Medicare?
Whether you choose Medicare Advantage or Medigap with original Medicare depends on your healthcare and financial needs — now and in the future. As of December 2023, Medicare enrollment was split nearly evenly between Medicare Advantage (49%) and original Medicare enrollment (51%).
Most people don’t pay a premium for Part A coverage. And you have to pay a Part B premium whether you have Medicare Advantage or Medigap with original Medicare. So, in that regard, the upfront costs are fairly similar. Though, there are significant differences when it comes to Part D prescription medication coverage.
Part D Coverage Comparison
Medicare Advantage plan that includes Part D | Prescription medication coverage is included in your plan, but you may have to pay an additional premium beyond your Part B premium. |
Medicare Advantage without Part D | If you want your medications covered, you need to buy a standalone Part D plan. That means you will have to pay an additional Part D premium. |
Original Medicare with Medigap | Original Medicare doesn’t include Part D, so you need to buy a standalone plan to have your medications covered. That means you will have an additional Part D premium. Medigap plans sold after 2005 also do not include Part D coverage. |
After upfront costs and options for prescription medication coverage, many people look at benefits such as:
Physician and hospital networks
Medicare Advantage extras such as vision, hearing, and dental coverage
Emergency care coverage outside the U.S., which is available through some Medigap and some Medicare Advantage plans
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It's also wise to consider how your health needs may change over time, since switching plans in the future may lead to higher costs. If you pass your 6-month Medigap open enrollment period, for example, and want to buy a Medigap plan later, you can be charged more or denied coverage because of medical underwriting. And this can make switching from Medicare Advantage to original Medicare unaffordable.
Some older Americans have reported feeling trapped in Medicare Advantage plans as they age and have more healthcare needs, because they can't afford to switch. In fact, a study published in 2023 found that the group with the highest rate of switching from Medicare Advantage to original Medicare were enrollees with high needs and high costs. This is typically least financially painful for those who do so early enough to get a Medigap plan. The switch also happens for those who care was denied or limited by their Medicare Advantage plans.
Quiz: Should you get a Medicare supplement insurance plan?
How do you know if you would benefit more from Medigap with original Medicare versus Medicare Advantage?
If you're happy with the benefits offered by original Medicare and have the opportunity to buy a Medigap plan during your open enrollment period, original Medicare with Medigap may be the right option for you. Having Medicare Advantage could be a good choice if you need the extra benefits and don’t have a lot of resources to cover out-of-pocket costs. Just keep in mind that there’s a chance that your plan will limit or deny you coverage in some cases, which can be particularly burdensome as you get older.
Here are some other questions to consider:
Will your health needs be served better by having access to the wider range of healthcare professionals and hospitals covered by original Medicare?
How many Medicare Advantage plans are available in your area?
If the Medicare Advantage plans in your area include Part D coverage, are the medications you need included in their formularies? If you need to buy a standalone Part D plan that covers your medications, how much is the premium?
Are there Medicare Advantage plans available to you that have extra benefits you want or need?
What are the differences in premiums and out-of-pocket costs between your Medicare Advantage options and original Medicare with Medigap?
How can you switch from Medicare Advantage to Medigap with original Medicare, or vice versa?
You can typically only switch from Medicare Advantage to original Medicare (and vice versa) at certain times of the year.
Medicare open enrollment, which runs from October 15 to December 7, is open to all current and first-time Medicare enrollees. Medicare Advantage open enrollment, which runs from January 1 to March 31, is only open to current Medicare Advantage enrollees.
You also may become eligible for a special enrollment period if you experience a qualifying life event. If so, you would be able to switch plans outside of the open enrollment periods.
You can make changes to your Medicare plan by calling 1-800-MEDICARE (1-800-633-4227). Agents are available 24/7, except during a few federal holidays. If you have additional questions, the State Health Insurance Assistance Program (SHIP) offers free access to trained, unbiased benefits counselors who can help you navigate original Medicare, Medicare Advantage, and Medigap issues.
Medigap trial right and guaranteed issue rights situations
There are certain instances when you can switch from Medicare Advantage to original Medicare with Medigap after the Medigap open enrollment period and not be subject to medical underwriting. These are called “trial right” or “guaranteed issue rights” situations, which are explained in the charts below.
Trial Right Situations
Trial right situation | You have the right to buy | When you must apply for a Medigap policy |
|---|---|---|
You joined a Medicare Advantage or Program of All-Inclusive Care for the Elderly (PACE) plan when you were first eligible for Medicare, and, in the first year of enrollment, you want to switch to original Medicare. | Any Medigap plan that is sold in your state* | You must apply for a Medigap policy 60 days before your coverage ends and no more than 63 days after your coverage ends. Your trial right period may last for an additional 12 months under certain circumstances. Contact your state insurance department for more information. |
You dropped a Medigap policy less than 1 year ago to join a Medicare Advantage plan or to switch to a Medicare SELECT plan for the first time, and you want to switch back to original Medicare with Medigap coverage. | The Medigap plan you previously dropped if the company still sells the policy, or, if that policy isn’t available, a Medigap Plan A, B, C*, D*, F*, G*, K, or L that is sold in your state | You must apply for a Medigap policy 60 days before your coverage ends and no more than 63 days after your coverage ends. Your trial right period may last for an additional 12 months under certain circumstances. Contact your state insurance department for more information. |
Common Guaranteed Issue Rights Situations
Guaranteed issue rights situations | You have the right to buy | When you must apply for a Medigap policy |
|---|---|---|
You have a Medicare Advantage plan that is leaving Medicare or stopping services in your area — or you move out of your plan’s service area — and you want to switch to original Medicare. | A Medigap Plan A, B, C*, D*, F*, G*, K, or L that is sold in your state | You must apply for a Medigap policy 60 days before the date your coverage ends and no more than 63 days after your coverage ends. |
You have original Medicare and are losing coverage through your secondary plan — an employer group health plan, retiree or COBRA plan, or union plan. | A Medigap Plan A, B, C*, D*, F*, G*, K, or L that is sold in your state | You must apply for a Medigap policy no more than 63 days after you lose coverage or are notified of losing coverage (whichever is later). If you are losing COBRA coverage, you can buy a Medigap plan right away or wait until your COBRA coverage ends. |
You have original Medicare and a Medicare SELECT plan, and you move out of the Medicare SELECT plan’s service area. | A Medigap Plan A, B, C*, D*, F*, G*, K, or L that is sold in your state or the state where you’re moving | You must apply for a Medigap policy 60 days before your coverage ends and no more than 63 days after your coverage ends. |
You have a Medigap plan and lose coverage because your company goes bankrupt or for some other reason that’s not your fault. | A Medigap Plan A, B, C*, D*, F*, G*, K, or L that is sold in your state | You must apply for a Medigap policy no more than 63 days after your coverage ends. |
You need to drop your current Medicare Advantage plan (and switch to original Medicare). | A Medigap Plan A, B, C*, D*, F*, G*, K, or L that is sold in your state | You must apply for a Medigap policy no more than 63 days after your coverage ends. |
*Note: Plan C and Plan F are no longer available to people new to Medicare on or after January 1, 2020. But, if you were eligible for Medicare before January 1, 2020 and haven’t enrolled, you may be able to buy Plan C or Plan F. People new to Medicare on or after January 1, 2020 have the right to buy Plan D and Plan G instead.
The bottom line
Original Medicare covers most medically necessary healthcare services and supplies offered by healthcare professionals and hospitals. Medicare Advantage private plans, which are alternatives to original Medicare, match or exceed those baseline benefits. You may be able to buy Medicare supplement insurance (Medigap) to cover some or all of your original Medicare out-of-pocket costs, but Medigap plans do not work with Medicare Advantage.
Thinking about the long haul is a vital consideration from people choosing between Medicare Advantage and Medigap with original Medicare. To help you decide which of these options is right for you, review the upfront costs, your prescription medication coverage options, any additional benefits, and information about what it may take to switch in the future.
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