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Original Medicare + Medigap vs. Medicare Advantage – Which is Right for You?

Category: Health and Wellness Issues

September 8, 2019 — As promised, our series on Medicare continues with an analysis of the competing forms of Medicare: Original Medicare + Medigap insurance vs. Medicare Advantage (Part C). This seems like a particularly good time for it, since the Medicare Open Enrollment Period begins on Oct. 15. We are grateful to Tom Cretella, CLU, an insurance broker with almost 50 years of experience and know-how in this field, for answering these frequently-asked questions. You can find the other articles in this series listed at the end. As always, we welcome your comments and questions on this complex and important topic.

Q. What is the significance of the Open Enrollment Period (AEP) which begins Oct. 15 and runs through Dec. 7?

A. The Annual Open Enrollment Period happens each year from Oct 15- Dec 7. During this time people can change coverages without fear of pre-existing conditions not being covered. If they have a Medigap plan and original Medicare they can change plans or elect a Medicare Advantage plan. This enables a Medicare beneficiary to buy a plan that suits their utilization habits and pocketbook. All changes become effective on January 1. On Sept 30 each plan is required to send a Notice of Change to Medicare Beneficiaries outlining any changes for the following year. More Blog articles like this…

Q. What is an SEP?

A: A Special Enrollment Period occurs when a qualifying event occurs. This period also allows a change in plans without fear of pre-existing condition problems. SEP qualifying events include leaving one’s employer plan, moving out of area, aging in to Medicare, becoming eligible for Medicaid. These time periods also apply to Part D prescription plans.

 Q. Medicare seems so confusing. Medicare Part A (hospitals), B (doctors) and D (drugs) are all pretty straightforward. But original Medicare + Medigap  (with parts F N) vs. Medicare Advantage (C) gets very confusing – which is better for me? Could you give us a brief rundown on the overall differences between Medigap and Medicare Advantage (MA)?

A: Original Medicare vs Medicare Advantage plans.

Original Medicare allows a person to go to any provider who accepts Medicare nationwide. There is no network. Original Medicare covers about 80% of Hospital and medical services, so a supplement is needed to complete coverage. Supplements are called Medigap plans and the most common is plan F, which covers 100% of what Medicare doesn’t cover. Plan F will no longer be available soon, but people who have it will be grandfathered, although plan F plan premiums are expected to increase.

Plan G covers 100% except for a $183 part B deductible and Plan N covers 100% except for the $183 deductible and $20 office visit co-pay. Medigap plans require a premium to be paid. As an example, plan F premium is $241 per month, G $209, and N $157. These are CT rates and will vary somewhat from state to state and carrier to carrier. A Prescription Drug plan must also be purchased also with original Medicare: premiums range from $17 to $77 per month for a reasonable plan.

Medical Advantage (MA) plans must cover what Original Medicare covers without exception. The same limitations and exclusions apply to each. Most MA plans include prescription drug coverage (MAPD). A MAPD plan covers the same things as Original Medicare but usually have some added coverages such as dental, vision, or hearing. MAPD plans are written by private insurance companies.

There are several types of MA plans.:

The most popular type of MA plan is a PPO (Preferred Provider Organization). These plans are offered by a few large insurance companies from a national network.

HMO (Health Maintenance Organization) plans are the most restrictive, offering only in-network coverage in a specific geographic area. There are very few national HMOs.

A POS (Point of Service) plan is an HMO hybrid that extends coverage to out of network providers, so it is the most flexible type of plan. If you go out of network you might pay more for service, but you are covered. The type of plan dictates which providers are are in-network or out of network.

All MA plans treat emergencies anywhere as in-network and fully covered. So when traveling your plan continues to protect. MA plans are also characterized to include co-pays, co-insurance, or deductibles for most services except preventative care. There is an annual cap on out of pocket expenses at $6700.

Q: How do the costs compare between Medicare + Medigap and Medicare Advantage Plans?

A. Actuarially speaking, the plans are about the same cost-wise when considering the population at large. The tradeoff for people choosing a plan is how much health care you think you will utilize. If you are a heavy user you might be better off with original Medicare. But if you typically only have 4-5 office visits a year and a few tests you might see savings, because your out of pocket for co-pays and deductibles might only be $600 per year, much less than the $240/month of a typical Plan F premium). In some states the gap is more narrow. Many Medical Advantage plans also offer the added value of vision, dental, and hearing benefits.

Q: What kind of people are best suited for Original Medicare + Medigap policies, and which ones for Medicare Advantage?

A: In some very rural states the networks are not so clearly defined, and so Original Medicare + Medigap becomes the better solution. If you have a variety of chronic illness which require lots of office visits, tests, or possible in-patient hospitalizations, Original Medicare is probably for you. If you need a nursing home with Medicare Advantage you might find one in the network, but then discover it is full, so you might have to go out of network. So in that case Medigap is better.

Snowbirds who go back and forth to areas where they would have to go out of network should probably stick to Medigap. But, you should check your normal providers to make sure they would not be covered by a PPO or POS plan before you decide that.

As we mentioned earlier, people who are lighter users of health care might be better off with a Medicare Advantage plan, since their annual savings on premiums will offset their co-pays and deductibles.

Also on the plus side for Medicare Advantage, insurance companies are busy developing plans to attract new users because these type of plans are getting better results. The insurers have a vested interest in developing programs to try to help keep people healthy. Pro-active programs like telemedicine and follow-up calls from health professionals help bridge the gap in rural areas and keep people healthier. The CMS has a star rating system plan for quality and results: 5 stars (best) or 3. The CMS wants plans that are consumer friendly, and the companies are working hard to to get and keep a good rating.

Q: Where do you think the market is headed – is it true that Medicare Advantage plans are capturing more of the market? If so, why is that? We even heard that some MA plans have a zero premium, how is that possible?

A: MA plans are becoming more and more popular. One reason is the low premiums for MA plans, in fact many have a zero premium ($0). How is that possible you may ask. Medicare pays the plan each month, in CT about $785, and this is why many carriers offer coverage for a $0 premium. The Medicare payment varies from state to state. When you compare the cost of each alternative you can see a significant premium difference which frees up dollars to be used to offset any co-pays, co-insurance or deductibles. If you are relatively healthy and are a low utilizer of medical services a MA plan will save significantly over Original Medicare. Important to remember is that you can switch plans each year without regard to preexisting conditions to reflect your needs for the coming year.

Q: We have seen warnings that you could be charged the full bill if you go out of network with Medicare Advantage. True?

A: All MA plans treat emergencies anywhere as in-network and fully covered. So when traveling your plan continues to protect. Depending on your type of plan, if you go out of network in an HMO plan for routine care you are not covered. One problem that comes up, particularly for an HMO plan, is that you might go in for an in-network facility but end up having a provider like an anaesthesiologist who is out of network, and you aren’t covered for those fees.

Q: Is there an advantage for insurance brokers to sell one type of plan over another?

A; Brokers who sell Medicare plans are strictly regulated by CMS. The commissions paid are the same for Medigap or Ma plans, there is no incentive to sell one or another. 

Q: I saw something on the site about a PACE Plan and a SHIP plan. What are those, or who are they for?

A: PACE is a program for needy who are facing nursing home and SHIP (State Health Insurance Assistance Plan) offers free assistance to helping find a plan offered through state social service programs.

Q: What else do you think Members should know about Medicare and these competing plans?

There are a lot of other concerns that Topretirements readers should be aware of. Those include the penalties for non-creditable RX coverage or late Part B enrollments. Or is it better to elect employer coverage versus individual coverage? Moving from state to state and enrollment guidelines are other issues that come up. These are tricky and are something you should discuss with a professional.

Q: Finally, take my situation as an example. My wife are I Florida residents but spend the summer in CT. Fortunately, we are in good health and neither of us have any current medical conditions.  We take very few prescription drugs. Do you have a recommendation on what kind of plan might be best for us? (we currently each have a Medigap plan – mine is bare-bones and hers is higher end.)

A: As far as your situation, a Aetna PPO with its national network and out of network coverage would save substantial money over a 5 year period. Adding $1000 for dental and other benefits sweeten the pie. Checking the providers you use in Florida and here in CT for network consensus is important. Buying a plan that reflects your utililization habits is of primary driver.

Bottom line

Thanks so much Tom for your helpful answers and insights. We have covered a lot of ground here, and probably raised a few more questions in the process. Any errors that might have crept in here would be the result of our transcription of your notes.

Questions or Comments? You can list your Comments or questions below, or Ask Tom at Cretella and Belowsky.

For further reading:

Part 1: So You’re Turning 65: Here Is Your Medicare 101 Course
Part 2: “Topretirements Members to Washington: We Like Medicare, Please Keep It That Way
Part 3: What to Do about Medical Insurance When You Retire Early
Part 4: Medicare Advantage vs. Original Medicare
Part 5: What Is Medigap Insurance and How Can I Find the Right Policy for Me

Coming Soon –’s New Medicare Comparison Plan Tool

If a future article we will review Medicare’s new Plan Comparison Tool and discuss how to buy the right Medicare supplemental coverage plan.

Posted by Admin on September 7th, 2019


  1. You mentioned the ability during open enrollment to switch between traditional Medicare + supplement and Medicare Advantage without regard to any pre-existing conditions. What about rating the policy for higher cost if you are switching and have some health issues? Can insurance companies do this to switchers between supplement plans and Advantage Plans?
    As an example, what if one selects a low-cost Advantage plan for the first few years of Medicare when presumably more healthy, and then later switch to a combination traditional with Supplement Plan? Would the future cost of the traditional + supplement combo at say age 70, be more than if selected at age 65, due to the insurers ability to experience rate the change for any new health conditions?

    by Bill S. — September 8, 2019

  2. Last year when I went to an insurance broker, I switched from Medigap plan N to MA PPO plan. She said if I wanted to switch back to a Medigap plan I only had one year to do it, otherwise I would have to stay with an MA plan. I could then switch between MA plans, but not switch back to Medigap. Does anyone have any thoughts or info on this?

    by Bill Y. — September 9, 2019

  3. Bill Y., What you have stated is exactly what I have been told. You can switch back, but 1st year only without medical underwriting. You can apply to switch back during any open enrollment, but might not be accepted due to your health. Also, a handful of states override that and do not allow underwriting so best to know what your state rules are.

    by ljtucson — September 9, 2019

  4. When Tom said, “Important to remember is that you can switch plans each year without regard to preexisting conditions to reflect your needs for the coming year,” I read this as you can switch MA plans from year to year, not that you can switch from MA to Medigap from year to year without regard to preexisting conditions. He may want to clarify that.

    by Clyde — September 9, 2019

  5. Does anyone know what states do not allow the underwriting ? Also what kind of questions are asked if you do have to go through that ?

    by Sandy g — September 9, 2019

  6. We checked with Tom and when it comes to the tricky questions that come up going back and forth to original Medicare most of the answers will revolve around state in which they reside. So you really need to ask questions from your broker or insurer to make sure you make the right decision. With the complexity of regulations in different states, it is hard to generalize.

    Here is what says you CAN DO during the Oct 15- Dec Open Enrollment period (It doesnt address underwriting issues):
    Change from Original Medicare to a Medicare Advantage Plan.
    Change from a Medicare Advantage Plan back to Original Medicare.
    Switch from one Medicare Advantage Plan to another Medicare Advantage Plan.
    Switch from a Medicare Advantage Plan that doesn’t offer drug coverage to a Medicare Advantage Plan that offers drug coverage.
    Switch from a Medicare Advantage Plan that offers drug coverage to a Medicare Advantage Plan that doesn’t offer drug coverage.
    Join a Medicare Prescription Drug Plan.
    Switch from one Medicare drug plan to another Medicare drug plan.
    Drop your Medicare prescription drug coverage completely.

    Also, during the Medicare Advantage open enrollment period Jan 1- March 31 you can change your Medicare Advantage plan or go back to original Medicare.


    by Admin — September 9, 2019

  7. Hello All:

    The underwriting needs to be clarified for everyone. I just read Plan N, from my AARP United Healthcare, just purchased from my broker. I am not yet 65–two weeks to go, but clearly for those who switch after the first six months of coverage, the application has questions that have to be answered.. They will underwrite you if you switch after the Open Enrollment period.

    You can feel free to switch but the premiums may go up and more than once a year possibly, once you are enrolled. Check the history of rate increases with your broker how often and by what percentage. Of course your condition and as stated before, the state you live in may play a part in the premiums.

    I did not see any states that prohibit underwriting by the insurance companies, but I did see states that prohibit doctors from charging Medicare Part B Excess charges (15% above what Medicare allows). These states are Pennsylvania, Ohio, Vermont, Connecticut, Massachusetts, New York, Rhode Island, and Minnesota.

    Massachusetts, Wisconsin and Minnesota have their own versions of Medicare Supplemental insurance.

    by Jennifer — September 9, 2019

  8. Perhaps of interest, here’s an article regarding underwriting and the types of conditions checked.

    Editor Comment: Thanks Peder, this is very helpful!

    by Peder — September 10, 2019

  9. In another thread, I recently posted about the issues we encountered (these were resolved in our favor) being initially refused by our Medicare Advantage program for triple-bypass surgery after my heart attack because I was out-of-state the the rep deemed it “not an emergency”. After that experience, we chose to move back to standard Medigap and will stay there until we decide that traveling will no longer be part of our activity.

    Also note that even some Medigap policies may not provide coverage out-of-country. That includes cruises. Pay careful attention to what travel coverage is provided for Medigap.

    by RichPB — September 10, 2019

  10. Boomer Benefits is great. When something goes wrong, they are there for you, even with coding issues in your doctor’s office. They get so many awards for their customer service.

    by Jennifer — September 10, 2019

  11. More good information here including some state specific exceptions:

    by James & Loretta Jankowski — September 10, 2019

  12. Buyer Beware….

    Medicare Advantage Plans are 100% private insurance unlike traditional Medicare. The number one goal is not your healthcare….it is to make as much profit as they can. MA is great for people that are healthy. If and when you get really sick, watch out. You are much better off with traditional Medicare + a Medigap policy to cover the remaining 20% Medicare does not cover. Do your research. They are pushing MA Plans because of profit.

    by Bpent — September 11, 2019

  13. Mayo clinic does not accept and Advantage plan the last time I checked

    by Steve — September 11, 2019

  14. Brent, I don’t agree with your comment. I belonged to Kaiser Permanente, an HMO, for over 30 years when I lived on the east coast. There was never a situation when I didn’t get care I needed because Kaiser wanted to make more money. I gave it up only when I moved to the Midwest where Kaiser isn’t available. An MA may be the best choice for many people. MA plans can cover things such as dental, vision, and hearing benefits that are not available under original Medicare Parts A and B with a Medigap plan. Congress is allowing MAs to provide other additional things such as house ramps. For people with lower retirement incomes who don’t travel much, an MA plan may make much needed benefits available and save money. There are many reasons why an MA plan may be the best option for some people. I worked for SSA for 39 years & now volunteer to help people learn about their Medicare options.

    by Jean — September 11, 2019

  15. Jean:

    The world of insurance was very different 30 years ago. Each year restrictions are placed on patient care. The sicker a person may be, the less the options for the patient, and the ones available may be expensive. I, too, volunteer to help people know their Medicare options and I suspect that where one lives plays a big part. In fact, I just went through this myself as I turn 65 in less than two weeks. I chose a Medi-gap supplement to Medicare Parts A & B.

    The options that an MA will allow for care in the dental arena is something I am very familiar with as I work three days a week for an oral surgeon and just yesterday I had a patient whose maximum yearly benefit for dental was $1200.00, no crowns, root canals, fillings or anything other than strictly preventative care was covered. Each year the insurance companies try to save money. MA’s as I have recently stated, require pre-authorization now for any procedures that need to be performed. If they do not think they are necessary, then either you will have to pay for them out of pocket, or just not have the procedure. One does not need to be a world traveler to suddenly not be covered by MA/HMOs. You can merely cross the state line–one must check that every person who provides services is in the HMO /PPO network, from an Emergency Room doctor to a surgeon to an anesthesiologist and even the lab and x-ray facility. I live near a Johns Hopkins major hospital and I can tell you not all the doctors participate with certain plans so check, check, check. Even a prescription within an HMO can require a pre-authorization. By the way, all insurance companies say that pre-authorization does not guarantee payment of benefits. So even then, be cautious.

    Steve: As for the Mayo Clinic, the one in Rochester Minnesota does accept Medicare assignment. The ones in Jacksonville, Florida and Scottsville/Phoenix do not accept Medicare FOR OUT OF STATE RESIDENTS, if you are a resident of those states you may be covered. Mayo is experimenting to see how this policy will affect their bottom line. Medicare Advantage HMOs require pre-authorization (Good Luck) to be covered at MAYO, so you may or may not be covered. You cannot be seen even if you want to pay out of pocket which was a surprise upon investigation of the MAYO website.

    by Jennifer — September 12, 2019

  16. Mayo Clinic does accept Medicare Advantage (MA) plans under some circumstances. See the information from Mayo’s current website below. Connecticut and New York never allow medical underwriting in order to switch from MA plans to Medigap plans at any time, regardless of how long you’ve been in MA plans. This can be done during any annual open enrollment period and at certain other prescribed times. I guess that’s one of the benefits of the higher taxes often paid in those states.

    by Clyde — September 12, 2019

  17. I have Medicare and Medigap AARP Plan F in NC. During the open enrollment period, can I move to Medigap Plan G without medical underwriting? I am afraid that since Plan F will soon no longer be eligible as an option, that as the years pass that those in the plan will age into more need for medical care and cause a larger increase in premiums than it would have if younger, healthier participants were also being added to the group.

    by Sheila Beaudry — September 12, 2019

  18. Sheila,

    You can contact Danielle at Boomer Benefits and she can answer this for you definitively. The concerns you have for Plan F are well founded. Once they no longer accept new members as of January 1, 2020, they will most likely have sicker people in the plan. The rates already have increased and will again. Plan G is just like plan F EXCEPT you would be responsible for the calendar year deductible ($185.00) for Medicare Part B. Once that is met then Plan G is just like Plan F. Part G will be the new guaranteed issue for those newly signing up for Medicare.

    As a new Medicare recipient, I originally signed up for Part G-Mutual of Omaha, but then within two weeks I decided for Part N (AARP United Healthcare),and changed. Why? Because Plan G (which will be guaranteed issue, meaning they will have to accept everyone regardless of health history during certain open periods) will be flooded with those who would have gone to Plan F and Plan G rates are already beginning to rise. For those who are was fairly healthy this would be a good choice. Plan N is 30% less than Plan G and has nearly the same coverage with a few caveats.

    With Plan N, I must pay the Part B deductible ($185.00), and also up to a $20.00 copay per doctors office visit as well as a $50.00 copay if I go to the emergency room. If I were to be admitted to the hospital, then the $50.00 copay is waived. I also must make sure that all parties involved in my care accept Medicare assignment as payment in full or I will have to pay any excess charges-which is 15% more than Medicare allows. Plan N does not cover those. All else is covered just like plan G. Medicare premiums will likely raise to $144.00 in 2020. The history of rate increases is much more reasonable with Plan N since it is not guaranteed issue. I asked for a history of rate increases on both Plan G and Plan N. Be sure to check what other options you might have in your state. Some states have a high deductible Plan F. I live in the District of Columbia and that is not offered here.

    Congress wants Seniors to be conscious of costs as they found that those who had Plan F went to see the doctor more(because everything was covered), than those on plans who paid more out of pocket. In years to come Medi-gap plans that pay for most everything will no longer be offered.

    by Jennifer — September 13, 2019

  19. One most interesting comment endorsing Original Medicare and a Medigap plan as the best coverage because the MAPD plans were Insurance company plans and profit driven and thus a lower or inferior plan.
    True insurance companies are in business to make a profit and they do so under the watchful eye of CMS. All MAPD PLANS must cover what Original Medicare covers, no exceptions. MAPD plans have there roots in the idea that they can get better results and keep costs under control with a little management of fraud , Waste and Abuse.
    In my opinion the cost must be considered. 12 x 134+241+77 x20 years plus interest =$141,024 as opposed to
    $32,160… the difference , $108,864, is what can be used to offset any deductibles, copays or Co insurance. Or increase ones disposable income over 20 years. My comparison is based on Current Connecticut plans and prices and a 1% interest rate. It might vary from state to state but you get my point.
    Certainly Original Medicare and a Medigap plan have distinct advantages but not so enough to draw a line in the sand.

    by Tom Cretella — September 14, 2019

  20. Tom Cretella, thanks so much for your further analysis from a professional agent’s standpoint. When it comes right down to it, Medicare and its rules can primarily be examined only on an objective basis. It’s not like whether someone does or doesn’t like certain aspects of a retirement state, or a particular retirement community. Those are subjective analyses, while all forms of Medicare are controlled by law and the explicit terms of the policy (albeit variable from state-to-state and county-to-county) and should be judged almost exclusively by objective criteria, usually best provided by an industry professional like yourself. I feel we see too many personal opinions on this blog about Medicare and Medicare Advantage (MA), without backup citation or web links. That is why it is so important for all of us to EVERY YEAR seek professional advice during any open enrollment period for Medicare. Medicare sales agents do not charge for this advice, and are paid the same amount for each policy sold, so have no financial incentive to steer a customer towards on policy or another. The agent’s duty is to help the customer select the best policy (whether Medigap or Medicare Advantage) for the particular needs and situation of each individual customer.

    Tom, I have one question for clarification about your post. Is the $141,024 figure for Medigap over time, and the $32,160 for Medicare Advantage over the same period of time, using the assumptions in Connecticut you mentioned? Or is it the other way around? I couldn’t quite tell. Thanks again for your assistance and professional knowledge.

    by Clyde — September 14, 2019

  21. For me, the big takeaway from this article is that the Open Enrollment Period is a time to stop and re-evaluate our Medicare coverages. Make sure we have the right plan and change it if our needs have changed or something better has come along. Not unlike the Zero Based Budgeting idea – nothing is sacred and everything should be re-evaluated.
    Thanks Tom for this article, it really helped clarify a lot of things.

    by Admin — September 15, 2019

  22. The best thing everyone should do, whether new to Medicare or during open enrollment, is to locate your local SHIP or SHINE organization to sit with a volunteer counselor to get unbiased information. These counselors are all certified and receive continuing education:
    They are very familiar with all the guaranteed issue rights for their state. They are also familiar with all the assistance programs for low to moderate income clients. They are not paid and are not tied to any insurance company. They can give you print outs to review in case you want to think about your choices.

    Drug plans and drug formularies change every year. Even if you are on a Medicare Advantage plan, you should always check your drug coverage for the new year.

    Remember not all insurance agents sell all insurance products and they do get paid to sell. If you join a Medicare Advantage program, the agent gets an initial payment and then gets a residual payment every month you stay on that plan.

    Once you know what you want to enroll in, then you can enroll on-line or you can work with an insurance agent.

    by Roberta — September 16, 2019

  23. There have have been several recommendations for contacting SHIP volunteers for advice regarding Medicare advice. My experience was that they were not familiar with how TriCare operates as the secondary for Medicare for military retirees who turn 65. I contact two different SHIP counselors, and both admitted they didn’t know what the details were in this regard, or if another medigap or Medicare advantage policy was better or worse than TriCare. I realize this information only applies to a relatively small portion of the TR community, but for those it applies to, you are likely better off contacting the local TriCare office.

    by Partagas — September 16, 2019

  24. This has been a useful discussion as it forced me to go back and look at all of the information that I received when I turned 65. With regard to Tricare-for-Life (TFL), which is what military retirees get when they hit 65: TFL works as a Medigap policy for military retirees and includes coverage for medications. It covers many of the copayments and the like. It does require that people use providers that accept medicare who have not opted out of Medicare. Some, but not all, military bases will take care of TFL participants.

    by Lynn — September 16, 2019

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