Medicare Advantage, Medigap and Part D … oh my

Original Medicare coverage doesn't cut it? Here are ten factors to help you decide which private insurance options you might need.

Once you’ve decided that you want more coverage than Original Medicare alone, the next step is figuring out which of the many private insurance options will best fit your needs and budget.

Your options …

You can either opt for Original Medicare and supplement it with a Medigap plan and/or a Part D prescription plan, or you can choose a Medicare Advantage plan.

A Medigap plan will pick up the tab for all or part of your deductibles and coinsurance under Original Medicare, and a Part D plan will provide prescription coverage. A Medicare Advantage plan wraps everything all in one policy: It includes all of the benefits of Original Medicare, has a cap on out-of-pocket costs, and most Medicare Advantage plans also include prescription coverage.

… and ten ways to decide

There’s no right or wrong choice – Medicare Advantage and Original Medicare plus supplemental coverage both work well. But there are numerous factors to keep in mind when you’re making the decision:

1. Medical conditions

Would you qualify for a Medicare Advantage Special Needs Plan (SNP)? SNPs are geared to the needs of very specific populations, and can be a good choice for people with certain medical conditions, as well as those who are institutionalized or who are Medicare-Medicaid dual eligible.

2. Disability

Are you under 65 and on Medicare because of a disability? If so, you may not have access to a Medigap plan. Federal law doesn’t require Medigap coverage to be guaranteed issue for under-65 enrollees; 31 states have some sort of guaranteed-issue provisions for disabled Medigap enrollees, but many of those states still allow carriers to charge higher premiums for younger enrollees.

Although Medigap can be difficult to obtain if you’re under 65, as long as you don’t have end-stage renal disease, you can get a Medicare Advantage plan if you’re Medicare-eligible, even if you’re under 65.

3. Missed enrollment

Are you enrolled in only Original Medicare and your Medigap open enrollment window has already passed? If so, a Medicare Advantage plan might make more sense, since there’s an annual open enrollment period for Medicare Advantage.

With Medigap, if you apply after your original open enrollment period has ended, the carrier can use medical underwriting to determine your premium and eligibility for coverage. Depending on your health, that could make a Medigap plan expensive or impossible to get.

4. Extra benefits

Do you care about extra benefits like dental, vision, hearing aids, and gym memberships? These are often covered on Medicare Advantage plans, but not Medigap.

Do you want included prescription coverage? Most Medicare Advantage plans (83 percent in 2014) offer prescription coverage, whereas if you opt for Original Medicare and a Medigap plan, you’ll need to also purchase a Part D plan in order to have prescription coverage – Medigap plans sold since 2006 do not include prescription coverage.

5. Premiums

Here’s a big one: premium cost. In most areas, there are “zero-premium” Medicare Advantage plans available (although you still have to pay for Medicare B, currently $104.90/month for most enrollees). According to the Kaiser Family Foundation, 78 percent of Medicare beneficiaries have access to at least one zero-premium Medicare Advantage plan in 2015.

The average premium for Medicare Advantage plans that include prescription drug coverage is $53 per month (but only about $34 a month if you include all Medicare Advantage plans) plus the Part B premium. The average Part D premium is about $32 per month, and the Average Medigap premium is $183 per month.

Based on that data, a Medicare Advantage enrollee would pay an average of about $158 per month, including the Part B premium. And an Original Medicare enrollee with Medigap and Part D coverage would pay an average of about $320 per month, including the Part B premium.

But it’s important to remember that these are just averages, and there’s wide variation in premiums from one plan to another.

6. Out-of-pocket exposure

On the other hand, how important is out-of-pocket exposure? With most Medicare Advantage plans, you’ll pay coinsurance and copays, and the out-of-pocket maximum can be as high as $6,700 in 2015. But with Medigap, there are plans available that pay first-dollar coverage for all Medicare-covered services, leaving you with little to no out-of-pocket exposure.

(This will change slightly starting in 2020, but only for new enrollees.) Note that there’s a separate out-of-pocket for prescription coverage, regardless of whether you’ve got a Medicare Advantage plan with prescription coverage, or a stand-alone Part D plan.

7. Plans to travel

Do you plan to travel outside the United States during retirement? Original Medicare doesn’t cover foreign travel except for a few rare circumstances, but six of the ten currently available Medigap plans provide some coverage for foreign travel (80 percent of the cost of emergency care received in the first two months of a trip, limited to a $50,000 lifetime cap, and with a $250 annual deductible).

Medicare Advantage plans can cover foreign travel beyond Original Medicare’s limited situations, but unlike standardized Medigap policies, each Medicare Advantage plan is different, and it’s imperative that you check the plan details regarding foreign travel before enrolling.

8. Network size

Do you care how big your network is?

Ninety-six percent of doctors who provide Medicare-covered services are participating providers with Original Medicare, and the coverage is nationwide. With Medicare Advantage, each plan has its own network, and you may be limited to a much more local or regional area.

Original Medicare paired with a Medigap plan and Part D coverage might be the better choice if network size is a concern.

9. Plan availability

Before you decide on the best solution for your health insurance needs, you’ll want to see what’s available in your area. Although most Medicare beneficiaries have access to a wide range of Medicare Advantage, Medigap, and Part D plans, the options vary considerably from one one area to another.

10. Plan change flexibility

Although Medigap, Part D, and Medicare Advantage are all guaranteed issue for all enrollees during their initial enrollment period, Medigap plans aren’t guaranteed issue after that in most states.  So while Medicare Advantage and Part D have an annual open enrollment period that lets enrollees switch plans, Medigap issuers can use your medical history to determine eligibility and premiums if you’re enrolling after your initial enrollment period. 

If the ability to easily switch back and forth among plans is important to you, a Medicare Advantage plan will give you that flexibility.