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 …
A Medigap plan will pick up the tab for all or part of your deductibles and coinsurance under Original Medicare (the level of coverage you get depends on the Medigap plan you choose), 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.
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; about two-thirds of the states have some sort of guaranteed-issue provisions for disabled Medigap enrollees, but many of those states still allow carriers to charge higher premiums and/or only offer one plan when enrollees are under the age of 65 (you can click on your state on this map to see how Medigap plans are regulated).
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 (as of 2021, even enrollees with ESRD will be able to sign up for Medicare Advantage).
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.
[The limited window of opportunity for a guaranteed-issue Medigap plan is also an important consideration if you’re planning to enroll in a Medicare Advantage plan. Be aware that after your trial right period ends, and assuming you don’t qualify for one of the other limited guaranteed-issue circumstances, you will probably not have an opportunity to enroll in a Medigap plan without medical underwriting in the future (it depends on where you live, and most states do not have ongoing guaranteed-issue rights for Medigap plans). Switching back to Original Medicare is easy during open enrollment or the Medicare Advantage open enrollment window. But if your health is poor, adding a Medigap plan may be expensive or impossible.]
4. Extra benefits
Do you want included prescription coverage? Most Medicare Advantage plans (90 percent in 2020) offer prescription coverage, whereas if you opt for Original Medicare and a Medigap plan, you’ll need to also purchase a Medicare Part D plan in order to have prescription coverage – Medigap plans sold since 2006 do not include prescription coverage.
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 Part B; in 2020, the premium for Part B is $144.60/month for most enrollees). According to the Kaiser Family Foundation, 93 percent of Medicare beneficiaries have access to at least one zero-premium Medicare Advantage plan for 2020.
But while there are zero-premium Medicare Advantage plans available, the average premium for Medicare Advantage plans that include prescription drug coverage in 2020 is about $36 a month. That’s in addition to the Part B premium.
For people who opt for Original Medicare with supplemental coverage, the average premium for a stand-alone Part D plan in 2020 is about $42 per month. And the Average Medigap Plan F (the most popular plan) premium was $143 per month as of 2018, and these premiums are also in addition to Part B premiums (note that Medigap premiums vary significantly from one state to another, and premiums are generally higher for older enrollees and for those who don’t sign up when they’re first eligible).
Clearly, the average total premium for Medicare Advantage (including prescription coverage and Part B) is less than the average total premium for Original Medicare plus Medigap plus Part D, although this has to be considered in conjunction with the fact that an enrollee with Original Medicare + Medigap will generally have significantly lower out-of-pocket costs, if and when they need medical care, than an enrollee with Medicare Advantage (see the next section about out-of-pocket costs).
But it’s important to remember that these are just averages, and there’s wide variation in premiums from one plan to another and from one state to another. Not surprisingly, in states where Medigap plans tend to be more expensive than the average, Medicare Advantage tends to be more popular.
Looking for 2021 Medicare coverage with lower premiums? Talk with a licensed advisor now. Call 1-844-309-3504.
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 2020 (for services that would be covered under Medicare Part A and B; Medicare Advantage enrollees can have additional out-of-pocket costs for the prescription drug component of their coverage, since that’s not a benefit that would be covered by Medicare Parts A and B).
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, for newly-eligible enrollees). These tend to be the most expensive Medigap plans; less expensive options do not cover all of Original Medicare’s out-of-pocket costs.
Note that there’s a separate out-of-pocket for prescription coverage (and it’s not capped), 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-three percent of non-pediatric primary care physicians are participating providers with Original Medicare, and the coverage is nationwide (note that not all of those doctors are accepting new Medicare patients). 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. But if you have a specific provider in mind, do your homework before you pick a coverage option. In some cases, physicians are contracted with certain Medicare Advantage plans, but are not participating providers with Original Medicare.
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 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. But on the other hand, your ability to switch away from Medicare Advantage altogether (and enroll in Original Medicare) at some point in the future could be hindered by the fact that you may find that you can’t enroll in a Medigap plan at that point due to your medical history.
11. Having Medicaid or a Medicare Savings Program
Medicare covers many services, but it doesn’t cover long-term care benefits and can leave its enrollees with large cost sharing expenses. Medicaid pays for some services that Medicare doesn’t cover for enrollees whose incomes and assets make them eligible. If you have Medicaid or a Medicare Savings Program (MSP) – a program where Medicaid pays for Medicare premiums and cost sharing – then your enrollment options are different than if you only had Medicare.
Some Medicare Advantage plans specialize in covering low-income Medicare beneficiaries. These are known as Dual Eligible Special Needs Plans (D-SNPs), and are available in every state. If you have Medicare and Medicaid, you should have few out-of-pocket expenses if you see providers enrolled in both programs – regardless of whether you enroll in a D-SNP. Receiving coverage through a D-SNP requires you to see only providers who participate with the D-SNP insurer.
Some D-SNPs offer additional services, such as home care, dental or vision benefits. D-SNPs can also help coordinate all of the health services you receive. But low-income Medicare beneficiaries are better off with Original Medicare paired with regular (i.e., fee-for-service) Medicaid as secondary coverage if their providers accept those programs, but not D-SNP plans. In many states, the fee-for-service Medicaid benefit also covers dental or vision care.
Here is more information about programs available to Medicare beneficiaries with limited incomes and assets.
There’s no “right” answer
We work with a broker in Colorado who explains that there’s no one-size-fits-all when it comes to Medicare plan options. Two of her clients are siblings who live in the same town; one has a zero-premium Medicare Advantage plan, while the other has Original Medicare plus a comprehensive Medigap plan and a Part D prescription plan.
The one with the Medicare Advantage plan would rather save money on premiums, and doesn’t mind the higher out-of-pocket exposure and limited provider network. The other sibling, on the other hand, is willing to pay higher premiums in trade for the lower out-of-pocket costs and nationwide provider choice that comes with Original Medicare (note that while Original Medicare does allow access to a wider array of physicians overall, it’s not always the best way to ensure access to a specific physician. For example, some physician groups do not take Original Medicare, but do work with certain Medicare Advantage plans).
Ultimately, the choice between Medicare Advantage and Original Medicare with supplements is a personal one that reflects each applicant’s health, risk tolerance, and approach to personal finances.
And there are varying degrees of coverage within each type of plan. Medicare Advantage plans include extra benefits that aren’t available with Original Medicare + supplemental coverage, and some Medicare Advantage plans have out-of-pocket maximums well below the federally-allowed limit. And while some Medigap plans, like Plans F, C, and G, cover all or most of an enrollee’s out-of-pocket costs under Original Medicare, other Medigap plans, like Plan N, for example, are less robust.
Neither option is universally better or worse than the other, and a good broker will help you determine which option is best for you. Here are a few points to keep in mind when you’re working with a broker:
- Depending on the state in which you live, and the carriers that offer plans in your area, total broker commissions could vary considerably between Medicare Advantage and Medigap + Part D coverage. Keep that in mind If your broker seems unwilling to discuss a range of plan options with you.
- Broker commission amounts are capped for Medicare Advantage and Part D plans, but not to Medigap plans, which means there can be more variability in commissions from one Medigap plan to another. [Data on the commission amounts that insurers pay brokers for Medicare Advantage and Part D plans are available here.]
- There are fairly strict Medicare regulations that pertain to marketing tactics that can be used for Medicare Advantage plans, but those rules don’t apply to marketing for Medigap plans. Some brokers will cold call prospects to discuss Medigap coverage, then use bait and switch tactics to push the person towards Medicare Advantage instead, once they’ve made the initial contact.
- A good broker will work to understand your specific needs and goals, show you multiple plan options, and will devote sufficient time to answering your questions. The process shouldn’t make you feel pressured.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.