The Complete Guide to Medicare, Medicare Advantage, and Medigap

05 September 2023
Tillman Hartley

As you approach your golden years, healthcare planning becomes increasingly important—and often more financially challenging. While traditional Medicare offers a basic level of coverage starting at age 65, it doesn't cover everything. This leads many people to consider options such as Medicare Advantage or supplemental health insurance (known as Medigap) to reduce their out-of-pocket expenses.

But if you're new to Medicare, how do you determine which option is best for you?

In most cases, your choice between Medicare Advantage and Medigap will largely depend on your lifestyle, budget, and healthcare needs. In this blog article, we’ll explore the key information you need to know to help you make an informed decision about your healthcare coverage in retirement.

Understanding What Original Medicare (Parts A & B) Covers

Medicare is a federal health insurance program primarily aimed at individuals 65 and older. Though it serves as the cornerstone of healthcare for many retirees, navigating its various components can be complex.

Here's a simplified overview of traditional Medicare's components:

Part A (Hospital Insurance): Covers inpatient hospital stays, skilled nursing facility care, hospice care, and limited home healthcare services.
Part B (Medical Insurance): Manages outpatient care, doctor's visits, preventive services, and some home healthcare services. As of 2023, the standard monthly premium for Medicare Part B is $164.90; however, individuals with higher incomes may pay more.
Part D (Prescription Drug Coverage): Aims to reduce prescription drug costs for beneficiaries. The cost varies depending on the plan you choose and your income level.

While Medicare offers a broad range of services, it's not all-encompassing. For example, Original Medicare (Parts A and B) doesn’t cover routine vision and dental care, hearing aids, or long-term care.

Moreover, beneficiaries are typically responsible for additional out-of-pocket expenses like deductibles, copayments, and coinsurance. These costs can be both unpredictable and substantial, potentially increasing your overall cost of living in retirement.

To fill these coverage gaps and mitigate unexpected healthcare expenses, many Medicare beneficiaries look for additional options—specifically, Medicare Advantage or Medigap.

Both aim to provide more comprehensive coverage than Original Medicare, and they can ease the financial burden of unplanned out-of-pocket expenses. However, since each option achieves this in a distinct way, careful consideration and planning are essential.

Medicare Advantage (Part C): An Alternative to Original Medicare

Medicare Advantage, also known as Part C, serves as an alternative to Original Medicare, offering beneficiaries a more comprehensive healthcare package. While these plans come in various forms—such as Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs)—most combine the benefits of Medicare Parts A and B. Many Medicare Advantage plans even include prescription drug coverage (Part D).

One important aspect to note about Medicare Advantage is that it's administered by private insurance companies. Yet, these companies operate under stringent regulations.

Every Medicare Advantage plan must be approved and regulated by Medicare, ensuring that beneficiaries receive a standard of care that aligns with the program's objectives. This blend of private-sector efficiency and public-sector oversight often results in a diverse array of plans that meet Medicare's quality standards.

Additionally, Medicare Advantage plans frequently offer benefits that Original Medicare doesn’t cover. These may include:

Routine Vision Care: From eye exams to discounts on eyewear, these benefits are essential for maintaining good eye health.
Dental Services: Coverage may extend to regular dental check-ups, cleanings, and occasionally, more complex procedures.
Hearing Aids and Exams: As hearing often diminishes with age, the inclusion of hearing services provides a significant advantage.
Wellness Programs: Some plans include gym memberships, fitness programs, or even nutrition counseling, emphasizing preventive health and overall well-being.

In summary, Medicare Advantage aims to provide beneficiaries with a more streamlined, holistic approach to healthcare. By consolidating various services into one plan and offering additional benefits not found in Original Medicare, it presents a compelling option for those seeking comprehensive coverage without the complexity of managing multiple plans.

Benefits of Medicare Advantage

Recently, Medicare Advantage has grown in popularity due to its enhanced coverage, extra benefits, and cost structure. In fact, the share of Medicare beneficiaries enrolled in Medicare Advantage increased from 19% in 2007 to 50% in 2023, according to data from CMS.

Comprehensive Coverage. A defining characteristic of Medicare Advantage is its holistic coverage. Rather than juggling separate plans for hospital care (Part A), medical services (Part B), and prescription drugs (Part D), enrollees of Medicare Advantage can amalgamate these benefits into one cohesive plan, streamlining their healthcare management.
Extra Benefits. In addition to providing the core coverage comparable to Original Medicare, many Medicare Advantage plans go above and beyond by offering benefits not typically included in Original Medicare. These may encompass routine vision and dental care, hearing aids, and wellness programs. Recently, some plans have even integrated non-medical perks such as meal provisions, non-medical transportation, social support resources, and pest control.
Cost Structure. Often, Medicare Advantage plans boast lower monthly premiums compared to the collective costs of Original Medicare combined with supplemental plans. In some cases, plans may even have $0 monthly premiums. It's important to note, however, that this doesn’t eliminate other types of out-of-pocket expenses.

Medicare Advantage Drawbacks

Despite its benefits, Medicare Advantage has its own set of potential drawbacks, which include network limitations, referral requirements, and travel restrictions.

Network Limitations. Depending on your chosen plan, Medicare Advantage may restrict you to a specific list of doctors or hospitals. This can be a limitation, particularly if you have established relationships with healthcare providers who are not in your plan's network, or if you prefer having a wider range of choices for your healthcare needs.
Referral Requirements. Certain Medicare Advantage plans, particularly HMOs, necessitate a referral from your primary care doctor to consult a specialist. This adds an extra administrative step to your healthcare journey and could result in delays in receiving the specialized care you need.
Travel Restrictions. For those who travel frequently or live in multiple locations, Medicare Advantage may not be the most flexible option. Many plans operate within defined service areas, creating potential gaps in your coverage if you seek medical care outside of these regions.

Medigap: Medicare Supplement Insurance

Unlike Medicare Advantage, which replaces Original Medicare, Medicare Supplement Insurance (Medigap) is designed to complement Original Medicare. These policies aren't provided by the federal government; rather, they are offered by private insurance companies. This allows for a variety of plan options and pricing structures.

Here’s a more detailed look at what Medigap policies usually cover:

Copayments: When you visit a doctor or specialist under Original Medicare, you're typically responsible for a copayment. These fees can accumulate, particularly if you require frequent medical care. Medigap can alleviate this burden by covering these copayments, making routine doctor visits more financially manageable.
Coinsurance: Unlike a copayment, which is a fixed amount, coinsurance is a percentage of the cost of a particular service. For example, after you've met your deductible, Original Medicare might cover 80% of a service, leaving you responsible for the remaining 20%. Medigap policies can help by covering this percentage, or a portion of it, thus reducing your out-of-pocket expenses.
Deductibles: Like most insurance policies, Original Medicare requires you to pay an out-of-pocket deductible before your coverage takes effect. Medigap policies can cover these deductibles, easing the initial financial impact of medical expenses within a given period.
Medical Care Outside the U.S.: Original Medicare typically doesn't provide coverage for healthcare services obtained outside the U.S. However, some Medigap policies offer coverage for emergency medical care when you're traveling abroad, adding an extra layer of security for retirees who love to travel.

For many retirees, Medigap serves as a financial safety net by enhancing Original Medicare and covering many costs that would otherwise come out-of-pocket. This can bring greater predictability and peace of mind to healthcare expenses in retirement.

Benefits of Medigap

Medigap offers Medicare beneficiaries several potential advantages, including flexibility, predictability, and enhanced coverage while traveling.

Flexibility. Unlike some insurance options that limit you to a specific network of healthcare providers, Medigap offers the flexibility to visit any doctor or specialist who accepts Medicare. This freedom can be particularly advantageous if you have long-standing relationships with certain physicians, or if you require specialized care and want the liberty to choose the best providers without network restrictions.
Predictability. Medigap policies usually come with fixed monthly premiums, making it easier to budget your healthcare expenses. The well-defined scope of Medigap coverage often translates into fewer unexpected out-of-pocket costs, bringing greater predictability to your financial planning.
Travel Coverage. While Original Medicare generally doesn't provide coverage for healthcare services outside the U.S., some Medigap policies extend emergency medical coverage to international travel. This feature can be valuable if you intend to travel frequently during retirement.

Medigap Drawbacks

While Medigap has several potential benefits, it may not be suitable for everyone. Before purchasing a policy, you may want to consider the following drawbacks.

Cost. While Medigap can offer more predictability in healthcare expenses, it often comes with a higher price tag. In contrast to Medicare Advantage plans, which typically range from $0 to $100 per month, Medigap premiums can vary between $50 and $1,000 monthly.
Drug Coverage. Unlike Medicare Advantage plans, which often include prescription drug coverage, Medigap policies typically don't cover prescription medications. This means you'll need to purchase a separate Part D plan to manage your medication expenses.
Limited Extras. Although services like dental check-ups, vision tests, and hearing aids are important for comprehensive healthcare, Medigap policies generally don't offer coverage for these additional services.

Choosing Between Medicare Advantage and Medigap

Choosing between Medicare Advantage and Medigap is a pivotal decision that can shape your healthcare experience and financial plan during your golden years. Your choice will depend on several factors, including your financial situation, healthcare needs and lifestyle.

Financial Considerations. While Medigap may have higher upfront costs, it provides a financial safety net against unexpected medical expenses, particularly if you anticipate needing extensive medical care. On the other hand, Medicare Advantage may have lower premiums, but the out-of-pocket costs can accumulate, especially if unexpected medical issues arise.
Healthcare Considerations. Reflect on your past healthcare usage as well. Have you frequently required specialized care or undergone surgeries? If you have a history of needing specialized medical services, Medigap may offer the flexibility to choose any healthcare provider that accepts Medicare. In contrast, Medicare Advantage may restrict you to a specific network of doctors and hospitals.
Lifestyle Considerations. If you're a frequent traveler, particularly abroad, the comprehensive coverage offered by some Medigap plans may be invaluable. On the other hand, if you generally stay closer to home and have access to a strong local healthcare network, Medicare Advantage could be the more appropriate option for you.

Navigating the Complexities of Medicare

Navigating the complexities of Medicare, along with Medicare Advantage and Medigap, can be overwhelming. However, when armed with the right information and a clear understanding of your healthcare needs, you can make an informed choice that supports your lifestyle and financial goals in retirement.

An experienced financial advisor can help you understand the complexities of Medicare, Medicare Advantage, and supplemental insurance while helping you prepare financially for the rising cost of healthcare in retirement. If you need additional help registering for Medicare or deciding between these options, there are specialized insurance brokers who can assist. To begin your retirement planning journey, please contact us. We’d love to hear from you.