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Medigap vs. Medicare Advantage
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Important Points
Medicare Advantage plans have network restrictions, have a maximum out-of-pocket limit, and include drug coverage and added benefits.
Medigap plans require separate Part D plans, allow you to see any provider that accepts Medicare, and only has a one-time Medigap Open Enrollment window.
You may change between the two types of plans, although, you may need to answer health questions on the Medigap application, depending on the situation.
What is the difference between a Medigap plan and Medicare Advantage? Can you have a Medicare Advantage plan and a Medigap plan at the same time? These are questions we hear all the time. This article should guide you to the answers.
As you may already know, Original Medicare is a federal government health insurance program that doesn't cover everything. Most beneficiaries will buy additional insurance to bridge the gaps. When you are considering Medigap or Medicare Advantage, it's important to know that both types of plans will help to reduce your out-of-pocket spending.
The two main types of coverage you can buy to help with the gaps in Medicare are Medicare Advantage plans or Medigap (Medicare Supplement) plans. It's important to know how each type of coverage works so you can select the right plan for you.
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Medigap vs. Medicare Advantage
Although both policies help you to cover gaps in your Medicare, they are designed very differently.
Medigap vs. Medicare Advantage
Medigap (Medicare Supplements) pay as a secondary insurance to your Medicare Part A & Part B. This means that your Medicare Part A & B pays its portion of the bill, and then your Medigap plan pays its portion of what is left. You must stay enrolled in Original Medicare, and Medicare sends the remainder of your bills to your Medigap company. The Medigap company pays its share according to which plan you are enrolled in. Each Medigap plan offers different benefits. The two most popular plans are Plan G & Plan N.
Medicare Advantage plans are completely separate from Medicare. When you enroll in a Medicare Advantage plan, you get all of your benefits from the plan, not Medicare. You must agree to use the plan's network of doctors and hospitals except when you are in need of emergency care. You must agree to pay copayments for your health care treatment as you go along. These plans are an alternative to Original Medicare.
The right plan for an individual depends on different factors such as someone's budget, health status, lifestyle, personal preferences, and more.
About Medigap Plans
Medigap plans are also called Medicare Supplement plans. They are the same thing and you will hear those two terms used interchangeably. Having a Medigap plan means you are still enrolling in Original Medicare as your primary health coverage.
You are allowed to see any doctor or hospital that participates in Medicare throughout the U.S., regardless of which Medigap company you choose. You do not have to chose a primary care physician. You will have access to all the Medicare providers nationwide with no referrals necessary. If you enroll in a comprehensive plan like Plan G, you will have very little out of pocket costs. You won't even have copays or coinsurance. Additionally, Medigap plans cover everything that your Original Medicare covers. For instance, since Medicare covers doctor visits, specialist care, surgery, procedures, and exams, your Medigap plan will as well.
Once you enroll, your Medigap insurance company notifies Medicare that you have purchased a policy. Thereafter, when Medicare pays its portion of your bills, it will automatically send the remainder of your bill to your Medigap plan. It happens automatically. There are no claim forms for you to file.
Freedom of Access
Medigap plans offer you the most freedom of access to providers. You have the option to choose your own doctors and hospitals from among the 900,000+ Medicare providers in the country. You do not need referrals to see specialists with a Medigap plan.
Since these plans offer you the most freedom and flexibility, they have higher premiums than a Medicare Advantage plan. For instance, a female, non-tobacco user turning 65 might pay around $150/month for Plan G in 2025.
The cost depends on which Medigap plan is chosen and whether the beneficiary uses tobacco. Plans and rates also vary by age, region, and sometimes gender. Our agency has experience with many insurance carriers. We can also check to see which carriers offer household discounts that may give you the opportunity to reduce your monthly premiums.
Additionally, some Medigap plans offer foreign travel emergency coverage when you are outside the U.S. Insurers will cover 80% of the cost for emergency services once you pay the deductible.
Your Prescription Drug Coverage is Separate
Medigap plans do cover medications administered to you in a hospital setting, such as injectables or chemotherapy, but they do not cover retail medications. For this reason, most beneficiaries will enroll in a separate Medicare Part D plan for their prescription drug coverage. Part D plans are available in every state, starting around $15 per month. If you do not enroll in a Part D prescription drug plan or do not have other creditable coverage, you will receive a late enrollment penalty when you apply in the future.
Medigap Enrollment
If you enroll in a Medigap plan during your one-time open enrollment window (within 6 months of your Medicare Part B effective date), there will be no health questions asked of you. The insurance carrier will approve your application. Most Medigap enrollees will enroll in a Medigap plan during this window.
When you enroll during this window, there are no waiting periods or pre-existing condition exclusions when you apply. If you miss this window and apply later, then you will usually be required to answer a number of medical questions and the policy will be underwritten. Underwriting rules vary with each carrier and state. The underwriter at the insurance company may accept or decline coverage to you based on your medical history.
About Medicare Advantage
More than half of all beneficiaries choose to enroll in a Medicare Advantage plan, which is a private insurance plan. They typically have lower premiums than Medigap plans and many plans even have a $0 premium. There are several types of Medicare Advantage programs such as HMOs, PPOs, PFFS (private-fee-for-service), and SNPs (Special Needs Plans).
When a plan has a $0 premium, it means that you will pay no additional premiums for the plan itself. However, you must still pay for your Medicare Part B premiums monthly. You must be enrolled in both Medicare Part A and Medicare Part B in order to be eligible for a Medicare Advantage plan. Additionally, you don't need to enroll in a Part D plan since most Advantage plans include prescription drug benefits built in.
So why would any carrier offer a $0 premium plan? It is due to the fact that you agree to use the plan's network providers to receive your care. This means that the insurance company has more control over your choice of providers and facilities with whom they negotiate contracted rates.
Check Your Doctors
It is very important to check with your doctors to see if they are in the plan's network as well as your go-to hospital facility. This can be especially important if the Advantage plan you are considering is an HMO plan, which only covers in-network doctors aside from emergencies. You will need to do your homework and search physicians around your location to make sure they accept your plan. It is also important to know that PPOs can offer a broader range of providers. Look for one with a network that has plenty of providers in your service area.
Your Medicare Advantage plan will pay your healthcare bills instead of Medicare paying them. You will have copays for the services you obtain from providers as you go along. Typically, the copays are reasonable, but you will want to review them before you enroll to make sure. The plan has the ability to decide which services will have restrictions, like prior authorization, so make sure you understand your benefits fully.
These copays can vary from plan to plan. For instance, one plan might charge $30 for a specialist visit while another charges $50. Your copays add up to meet your plan's maximum out-of-pocket limit.
Also, Advantage plans may cover benefits that Original Medicare does not cover. These benefits can sometimes include things like dental, vision, hearing, gym memberships, transportation to and from appointments, over the counter items, and telehealth services.
There are no health questions when you apply for a Medicare Advantage plan, but there are certain times of year that are designated for enroll in, dis-enrolling from, or changing your Advantage plan.
Check the Drug Formulary
One of the benefits of a Medicare Advantage plan is that it may also include built-in Part D drug coverage, so there is no need to buy a separate drug plan. This allows you to enjoy the convenience of not paying another premium for a drug plan.
But, just like you would verify that your doctors are in the plan's network, you will also want to verify that your medications are covered under the plan's formulary.
Medicare Advantage plans have specific enrollment periods, such as the Annual Enrollment Period. When you enroll in a plan, Medicare locks you into that plan through December 31st. You can make a mid-year change only if a specific situation grants you a special election period, such as moving out of state. For this reason it is very important that you choose your plan wisely.
Definitely do your homework! (or call us, and we'll do it for you)
Please keep in mind that you must be enroll in both Medicare Part A and Part B in order to be eligible for a Medicare Advantage plan. Enrolling in Medicare Advantage does NOT mean you get to skip the premiums that you are already paying for Part B. You must continue to make your Medicare Part B payment.
Know Your Out-of-Pocket Maximum
All Medicare Advantage plans have an Out-of-Pocket Maximum which limits your costs during the year. In 2025, Medicare has declared that this maximum limit cannot be any higher than $8,850. There will be many years where you won't even come near this, but if you develop a serious illness, like cancer, you can reach it very easily. Many Medicare Advantage plans have out-of-pocket maximums that are lower than the $8,850 limit.
Check the plan's Summary of Benefits to find out what the Out-of-Pocket Maximum is on the plan that you are considering as well as other information on your potential costs. Then ask yourself - "Do I have enough savings for a serious illness? Am I able to meet this Out-of-Pocket Maximum if I had to in a year of bad health?"
If your answer is yes, then a Medicare Advantage plan may work just fine for you. If your answer is no, then you may want to look into Medigap options to find the most cost-effective plan for your needs.
Changing Between Medicare Advantage and Medigap Plans
Many people ask whether they can start with Medicare Advantage and switch to Medigap coverage later if they get sick or need more coverage. It would be great to just buy the cheapest coverage now and then switch to more comprehensive coverage if you get sick. But does this work?
It doesn't work this way! If you leave a Medigap plan to go on Medicare Advantage coverage instead, you may not be able to get back into a Medigap plan later.
By then, you might be outside of your one-time open enrollment window, and that means that Medigap insurance carriers can ask health questions on your application. The insurance company can decline you for certain health conditions or even medications that you take, so please be aware of this before making any changes. However, there are certain circumstances you should be aware of before you are eligible for Medicare.
Trial Right Exception
Here is the exception - There is a trial period for people who try Medicare Advantage for the first time at 65. If you decide to dis-enroll from the plan and go back to Original Medicare within the first 12 months of Medicare Advantage coverage, then you can return to your Medigap plan with no underwriting. After the 12 months is up, you will be subject to underwriting again.
Under 65 Exception
Another exception to the rule is for people under age 65 who got Medicare early due to a disability. Anyone who is eligible for Medicare can enroll in an Advantage plan, but most states do not offer all Medigap plans to those who are under 65 because Federal law does not require Medigap coverage for that population. However, some states, including California, Colorado, Maine, , Missouri, Minnesota, Wisconsin, and Oregon, offer all Medigap plans to those who qualify for Medicare due to a disability.
When the beneficiary turns 65 and becomes eligible for Medicare based on age instead of disability, they will have a second open enrollment window. Here they may change from Medicare Advantage to a Medigap plan without underwriting.
Our Best Advice
We've worked with many people over the years, and here is our best tip. Plan for a rainy day. Medicare Advantage plans can be expensive if you treat for something serious. For instance, if you have cancer you could pay 20% of chemotherapy or radiation costs up to the plan's annual out-of-pocket maximum.
This maximum can be as high as $8,850 out of your own pocket - PER YEAR! A good idea may be to take the money you would have spent on a higher Medigap plan premium and store it in a high yield savings account each month. This savings fund would be a safety net in case you were diagnosed with an expensive health condition.
Medigap plans can have more predictable back-end spending. For instance, with a Medigap Plan G, you know for a fact that you will never pay more than the Part B deductible each year for Medicare-approved services. However, they do have higher premiums which increase each year.
Adults who qualify for Medicaid due to low income may consider enrolling in a Medigap or Medicare Advantage plan unless they are a Qualifying Medicare Beneficiary (QMB). In some cases, Medicaid will only help cover the Part B premium, which leaves you responsible for the cost-sharing expenses.
Each situation is different. Contact a Mohring Insurance Services LLC agent to help you decide. Our service is free.
Get Help Choosing Between Medigap vs. Medicare Advantage
It is critical to compare the costs and benefits of each type of plan in relation to your personal healthcare needs and budget as you approach your Medicare eligibility. A broker who specializes in both kinds of choices can help to evaluate your options. Some of the key factors for comparison are:
Areas where you will need access to care
Expected copays for your medications
Expected costs of healthcare services on each plan
How often you use healthcare services
Monthly premiums
Plan deductibles, if any
Potential out-of-pocket spending for you on Medigap vs. Medicare Advantage
Remember - You get what you pay for
And finally, we understand that check the provider networks and drug formularies for each and every plan can take many hours of work. You can simplify your search by having a Mohring Insurance Services LLC licensed insurance agent do this for you. We have helped many people like you with their plan options. We can search Medigap vs. Medicare Advantage plans in your area so you can be confident that you are choosing the right plan for your needs.
We'll be able to quickly tell you which plans your doctors take and whether or not your medications are covered. Working with one of our agents also gives you back-end policy support because we offer a Client Service Team for our clients. We can direct you in resolving things like billing issues, and that's why we have many five-star reviews online.
Key Points
Medigap plans are secondary plans, and Medicare Advantage plans replace your Original Medicare.
Both types of plans are offered by insurance companies rather than the federal government, so there are many options.
If you want to change between the two, you must do so at specific times of the year or in specific situations.
At Mohring Insurance Services LLC, we are happy to offer assistance with Medicare when you choose to enroll. Give us a call at (866) 440-1885, or to schedule a free consultation, click the link below:
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