Medicare & Medicaid
Medicare Advantage vs. Medigap: which is better?
Deciding between Medicare Advantage vs. Medigap is one of the most important decisions you will make when setting up your healthcare coverage. The option you select determines how much you pay each month, which doctors and hospitals you can visit, and how much you will owe out of pocket when you receive medical care. Understanding the structural trade-offs between these two paths ensures you choose the policy that best matches your budget and health needs.
What is the difference between Medicare Advantage and Medigap?
The core difference is that Medicare Advantage provides your Medicare benefits through a private plan, while Medigap only supplements your Original Medicare coverage. Original Medicare is traditional coverage managed by the federal government, consisting of Part A for hospital insurance and Part B for medical insurance.
A Medigap plan, also called Medicare Supplement insurance, is sold by private insurance companies to fill cost gaps in Original Medicare. It helps pay for expenses that Medicare Parts A and B do not cover, including deductibles, coinsurance, and copayments. A deductible is the amount you pay out of pocket before your insurance starts paying, a copayment is a flat fee per service, and coinsurance is your percentage share of the medical bill. Medigap only covers one individual person, meaning spouses must purchase separate policies.
Medicare Advantage, also known as Medicare Part C, is an alternative way to receive your primary Medicare benefits. Instead of Original Medicare paying your claims, a private Medicare Advantage plan administers your Part A and Part B coverage. These plans typically operate within defined service areas and usually bundle prescription drug coverage into the same policy.
Related reading: Medicare Part A, B, C and D explained · When do I sign up for Medicare, and what happens if I am late?
Medicare Advantage vs. Medigap: which is better for plan costs and out-of-pocket expenses?
Medigap is generally better if you prefer predictable expenses with fewer surprise bills, whereas Medicare Advantage is better if you want lower monthly premiums and are comfortable paying copayments as you receive medical care. Your total healthcare spending depends on the balance between upfront premiums and out-of-pocket costs.
A premium is the fixed monthly fee you pay to keep an insurance policy active. For Medigap plans, estimated monthly premiums range from $44 to $392 per month depending on the specific standardized plan you choose and the private insurer selling it. You must pay this monthly Medigap premium in addition to your standard monthly Part B premium paid to Medicare. In exchange for this higher monthly cost, you face fewer out-of-pocket expenses for covered hospital and medical care.
Medicare Advantage plans feature lower estimated monthly premiums, ranging from $0 to $295 per month. While paying a low or zero-dollar plan premium reduces your fixed monthly overhead, you will encounter more out-of-pocket costs when you actually use healthcare services. These expenses include plan-specific copayments, deductibles, and coinsurance for various medical procedures until you reach the plan’s annual out-of-pocket limit.
| Feature | Medigap Plans (plus Original Medicare) | Medicare Advantage Plans |
|---|---|---|
| Estimated monthly premium | Higher premiums: $44 to $392 per month | Lower premiums: $0 to $295 per month |
| Out-of-pocket costs | Fewer out-of-pocket costs for covered care | More out-of-pocket costs (copays, deductibles) |
| Geographic care area | Works in any state across the country | Works only in your state, by region |
| Provider networks | No provider network required (unless Medigap Select) | Must use a contracted provider network |
| Prior authorization rules | Original Medicare rarely requires prior authorization | May require prior authorization for services and supplies |
| Prescription drug coverage | Part D is not included; must buy separately | Medicare Part D is usually included in the plan |
How do doctor choice and travel rules compare between plans?
Medigap gives you complete freedom to visit any healthcare provider that accepts Medicare across the entire country, whereas Medicare Advantage requires you to receive care within a regional network. This distinction makes Medigap far more convenient for individuals who travel frequently or reside in multiple states.
A provider network is a group of physicians, specialists, and facilities contracted by an insurance company to provide medical services to plan members. With Medigap and Original Medicare, you do not need to use a provider network unless you purchase a specific policy called a Medigap Select plan. You can see any provider in any state who accepts Medicare, and you do not need referrals to schedule appointments with specialists.
Medicare Advantage plans require you to use their contracted provider network to receive covered routine care. Some medical providers may not accept all Medicare Advantage plans available in your county, and certain plans require you to obtain a referral before seeing a specialist. Furthermore, your regular care is restricted to your local service area, which is usually the county you reside in. If you live in another state for part of the year, a Medicare Advantage plan generally will not cover routine services there, though emergency care is covered and some plans offer travel coverage options if you ask.
How do prescription drug coverage and prior authorizations work?
Medicare Advantage plans usually bundle your prescription drug coverage and frequently use prior authorizations, whereas Medigap excludes drug benefits and rarely requires advance treatment approvals. These administrative differences impact both your pharmacy access and how quickly you can receive specialized care.
Medigap policies do not include Medicare Part D prescription drug coverage. If you choose Original Medicare and Medigap, you must purchase a standalone Part D plan from an approved private insurer if you want coverage to lower your prescription medication expenses. In contrast, Medicare Advantage plans usually bundle Part D prescription drug benefits directly into the policy, allowing you to manage your medical and prescription benefits under one plan.
Prior authorization is a requirement where your health insurer must review and approve a medical service or supply before covering it. Under Original Medicare and Medigap, prior authorization is not required in most cases, leaving treatment decisions between you and your healthcare provider. Medicare Advantage plans, however, may require prior authorization from the plan before covering certain supplies or medical procedures, which can add administrative steps to your care.
When can you sign up for or switch your coverage?
You can sign up for or alter your Medicare coverage during specific enrollment windows, and missing these windows can limit your plan choices or trigger health screenings. Understanding the calendar helps you make changes without facing coverage denials.
The best time to enroll in a Medigap plan is during your initial six-month Medigap Open Enrollment Period. This window starts the first day of the month you are age 65 or older and enrolled in both Medicare Part A and Part B. During this six-month period, standardized Medigap plans are guaranteed renewable, meaning insurers cannot cancel your plan or reject your application due to health problems as long as you pay the premium. If you are under age 65, you might not be able to buy the Medigap plan you want, or any Medigap plan, until you turn 65.
If you apply for Medigap outside this initial window, insurers may require you to pass a written health screen. However, you can switch between Medigap policies at any time without a health screen under specific rules: enrollees in Medigap plans B through N can switch at any time to another plan B through N, and enrollees in Medigap plan A can switch to any other plan A. If you switch from another type of health insurance to Medigap, rules vary and an insurer may require a written health screening questionnaire.
For Medicare Advantage and Part D plans, changes occur during the annual Medicare Open Enrollment Period, which runs from October 15 through December 7, with changes taking effect on January 1. During this window, you can make several adjustments:
- Switch between Original Medicare and a Medicare Advantage plan available in your county.
- Change from your current Medicare Advantage plan to a different Medicare Advantage plan.
- Join, drop, or switch an approved Medicare Part D prescription drug plan.
- Keep your existing coverage by choosing to do nothing.
What should you check before buying either plan?
Before you finalize your enrollment in either coverage type, you should verify local rules, provider networks, and extra costs to avoid unexpected financial surprises. Checking plan details in advance ensures your coverage functions smoothly throughout the year.
If you decide to buy a Medigap policy, verify these essential requirements:
- Confirm you are enrolled in both Medicare Part A and Part B, as both are required to qualify.
- Verify that the private insurance company selling the Medigap policy is licensed in your state.
- Plan for separate coverage for your spouse, because Medigap plans never cover more than one individual.
- Remember that you must pay your private Medigap monthly premium in addition to your monthly Part B premium paid to Medicare.
If you decide to choose a Medicare Advantage plan, investigate these factors:
- Check directly with your doctors and specialists to confirm they accept the specific plan in your county, and ask if referrals are required.
- If you have Medicaid (known as Apple Health in Washington), check if your providers accept both Medicaid and the Medicare Advantage plan, or look into dual-eligible Special Needs Plans (SNPs).
- Review plan copayments, deductibles, annual out-of-pocket limits, and the expenses associated with using non-network providers.
- If the plan advertises extra benefits such as dental or eye exams, verify whether they require additional premiums, have provider limits, or demand specific health criteria.
- If you have coverage through an employer or retiree group plan, consult your benefits administrator before leaving, because dropping retiree group coverage usually means you cannot get it back.
Key takeaways
- Medicare Advantage features lower estimated premiums ($0 to $295 per month) and usually includes Part D, but limits care to regional provider networks and may require prior authorizations.
- Medigap policies have higher estimated premiums ($44 to $392 per month) and require a separate Part D plan, but they work nationwide without provider networks and leave you with fewer out-of-pocket costs.
- The best time to buy Medigap without a written health screening is during your first six months being age 65 or older and enrolled in both Medicare Parts A and B.
- Medicare Open Enrollment runs annually from October 15 to December 7, allowing you to join, switch, or drop Medicare Advantage and Part D plans for coverage starting January 1.
Common mistakes to avoid
- Missing your initial six-month Medigap enrollment window: Applying after your first six months of having Part B at age 65 or older means insurers may require you to pass a written health screen before selling you a policy.
- Assuming Medicare Advantage covers regular care nationwide: Failing to check geographic service areas can leave you without coverage for non-emergency medical visits if you travel or live in another state part of the year.
- Forgetting to enroll in Medicare Part D alongside Medigap: Because Medigap plans do not include prescription drug coverage, you must purchase a separate Part D policy to avoid paying full price for medications.
- Dropping a retiree group health plan without consulting your benefits manager: Leaving an employer or union retiree health plan during Open Enrollment is usually irreversible, preventing you from re-enrolling later.
- Ignoring your plan’s Annual Notice of Change: Medicare Advantage plans send this notice each September detailing upcoming changes to copays, deductibles, premiums, drug formularies, and provider networks.
Frequently asked questions
Can you have both a Medicare Advantage plan and a Medigap policy at the same time?
No, you cannot use both plans together. Medigap is designed specifically to supplement Original Medicare, meaning it cannot pay for copayments, deductibles, or coinsurance from a Medicare Advantage plan.
When is Medicare Open Enrollment, and what changes can you make?
Medicare Open Enrollment runs each year from October 15 through December 7, with coverage taking effect on January 1. During this window, you can switch between Original Medicare and Medicare Advantage, change Medicare Advantage plans, or join and switch Part D drug plans.
Can you switch between Medigap plans without answering health questions?
Yes, if you already have a Medigap plan B through N, you can switch at any time to another plan B through N without taking a written health screening questionnaire. If you are enrolled in Medigap plan A, you can switch to any other plan A at any time without a health screen.
Where can you find free, unbiased assistance with your Medicare options?
You can call Medicare directly at 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048) or contact trained, volunteer Statewide Health Insurance Benefits Advisors (SHIBA) in your local community for free, confidential guidance.
