Medigap vs Medicare Advantage
Which plan type is right for me?
The Medigap Positives
I want predictable monthly costs for my health care
“Budgeting a set amount of money each month to pay all or most all of my Medicare-covered health services is my goal.” I don’t want surprises in my monthly bills for health care. Medigap Plan G, Plan N, and Plan F can do this for me.”
I want access to the top hospitals and physicians in the US (that accept Medicare insurance)
“Having access to all doctors/hospitals locally and the rest of the United States that accept Medicare insurance just makes sense to me. Why should I be limited on where I can get my health care?”
If you choose a Medigap plan, you can have access to all hospitals in the US (which accept Medicare insurance). These are listed here.
The top hospitals by type of surgery for 2025 are found here.
What if I join a Medicare Advantage plan?
If you join a Medicare Advantage plan, you need to be aware of which hospitals/physicians/other providers are in each plan’s network you are considering. These are documented in the plan’s ‘Provider directory’ and may be a subset of the doctors/hospitals/etc. available in your area.
The plan member should also be familiar with the plan’s ‘Evidence of Coverage’ (EOC). This document contains rules the plan member should be aware of.
For example, if you joined an HMO and the plan you will see language like “You must receive your care from a network provider (for more information about this, see Section x in this chapter). In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan’s network) will not be covered. This means that you will have to pay the provider in full for the services furnished.”
If the member joined a PPO plan, they would see language like “As a member of our plan, you can choose to receive care from out-of-network providers. However, please note providers that do not contract with us are under no obligation to treat you, except in emergency situations.
Our plan will cover services from either network or out-of-network providers, if the services are covered benefits and are medically necessary. However, if you use an out-of-network provider, your share of the costs for your covered services may be higher.”
People that stay with Original Medicare (just enroll in Medicare Part A and B) can use these same resources and avoid this issue as well as most prior authorizations for health care services. If you get the right Medigap plan, much of or all of the left-over costs are paid by the plan.
Be aware one of the top 50 hospitals in the US no longer accepts Idaho Medicare Advantage PPO plans. Read their announcement here.
My goal with my health insurance is transparency and simplicity
“Any health insurance plan I get today should pay for most or all my doctor visits and other health costs now and later in life. I know my use of health care services should go up as I get older. The Medigap policies that pay for most all my health care costs catch my attention.”
I want a health plan that continues to provide the same coverage when I move.
Idaho Medigap plans offer this basic feature. You can move anywhere in the US and your same Medigap plan will continue operate as it did when you were still in Idaho.
Idaho Medicare Advantage plans are based on the County where a resident resides.
If a resident moves to another Idaho County or another State and their existing plan is not available at that location, they will have to get a plan that is available in their new County of residence. This sounds like another burden has just been added to the decision to relocate.
“I understand if I stay with Original Medicare (Part A and B) and have a Medigap plan, my health coverage stays with me. I do not need to change my health insurance…just my prescription drug plan. This sounds much simpler.”
I do not want delays getting the health care my doctor prescribes
“My friends with a Medicare Advantage plan often complain about needing ‘prior authorization‘ from their insurance carrier to use plan covered medical services.
This just delays me getting the services I need and the doctor prescribed.
This feels like my insurance company is looking at me as a “cost center that needs to be managed.” Learn more about this here and here.
“I know this is not an issue when you stay with Original Medicare with or without a Medigap plan.”
Medigap plans only have one open enrollment period. Medicare Advantage plans have an annual open enrollment period. Removing the confusion of comparing plans each year makes the choice of a Medigap plan easier.
“I understand there is a single, one-time open enrollment period to apply for a Medigap plan. I am familiar with ‘guaranteed issue’ periods. If I miss these two opportunities to join a Medigap plan, my application could be denied based on my health history. I want simplicity, great coverage, and freedom to choose my providers. I better pay attention to Medigap enrollment rules.”
Two of the 12 Medigap plans are an attractive alternative to Medicare Advantage plans.
They have an ‘out of pocket limit’ (Medicare refers this to a ‘deductible’) less than $2,900 for 2025. This ‘deductible’ is less than 1/2 of the ‘Maximum out of pocket limit found in many Idaho Medicare Advantage plans. This may mean more money kept in my pocket.
They put a maximum limit on my share of my annual Part A and Part B medical expenses. When I hit that number, the plan pays 100% of all other Part A and B health care covered services for the year.
There are 2 Medigap plans that offer a similar feature.
These Medigap plans are a ‘hi-deductible’ versions of both Medigap Plan F and Plan G. This ‘deductible’ (like a MOOP) is $2,870 (2025 limit).
When the plan members share of the left-over Part A and B costs hits this figure, the plan pays the left-over costs that Part A and B do not cover. This is done for the rest of the calendar year.
Medicare sets the maximum MOOP a Medicare Advantage plan can have; the insurance company offering a specific plan sets the MOOP for that specific Medicare Advantage plan.
I like the clarity of the ‘Medicare and You’ book.
“The rules for Medicare Advantage plans are in a 200 – 300-page long document. This is called the ‘Evidence of Coverage’ or the EOC.
I understand this document can change annually and each plan can have its own rules. This sounds like a lot to keep up with and it is hard to compare one plan from the others.
The CMS publication ‘Medicare and You’ documents one set of rules that apply to everyone that stays with Original Medicare. The concept of Medigap plans is straight forward and the table on page 11 of the ‘Choosing a Medigap policy‘ is clear. This seems so much easier to follow. “
My older friends have a Medigap Plan F and their monthly premiums are over $300. Plan F is a good concept, but not at that price point.
Medigap Plan G and Medigap Plan N are good choices for you to consider.
We suggest you let your older friends know with a Plan F there is a very good possibility they can lower their monthly premiums. Why? Because of the 3/1/2022 Idaho law change. Now your friend(s) can get a Plan F from a creditable company for less than $250/month. People enrolled in Plan C or Plan J may also see similar savings. Ask them to call us. They will thank you when they understand their savings are real and how easy it is to get them.
I like having choices for my prescription drug plan. My Medicare Advantage plan doesn’t give me this.
”I understand there are over 10 Idaho Medicare prescription drug plans that I can choose from”. These plans are only available to people that stay with Original Medicare. I recognize my prescription drug needs may change over time. Having a choice between prescription drug plans and the ability to change plans when my needs change makes sense. Keeping the health insurance decision separate from the prescription drug plan decision feels right to me. I recognize most Medicare Advantage plans have only one prepackaged drug plan and you must use that drug plan.”
How can I learn more about Medigap plans?
If Medigap plans sound interesting to you, learn more about your Idaho choices of Medigap policies and carrier differences.
Ready to select Medigap as your choice? Contact us if you are a resident of Idaho; we can help you get the Medigap policy that matches up with your needs and meets your goals.
The Medicare Advantage Positives
Below are several reasons people choose a Medicare Advantage plan. These include:
Monthly premiums for plans range from $0 to over $100
Their zero or low-cost monthly premium fits their budget.
Pay as you use health care services feels right
They like the concept of pay as you use health care services. This means people must have either monthly cash flow or a savings account to pay for higher cost services are needed. This concept can also become a financial burden because as we age out, it is a documented fact we start using more medical services. That often means more of the retirement budget is used to pay for health care costs.
There is a limit on my annual out of pocket cost for health care services
Having a limit on a Medicare Advantage plan members share of health care costs is appealing. Plans refer to this limit as the Maximum Out Of Pocket Limit (MOOP). For 2025, the maximum an HMO plan can have is $9,350. If the plan lets members use out-of-network providers (like PPO plans), this limit can be as high as $14,000.
Can the Federal Government change the funding arrangements to support insurance companies offering Medicare Advantage Plans?
Yes. Recall the 2010 Affordable Care Act. The Obama administration noted it cost the Government about 14% more to support Medicare Advantage plans than Original Medicare (Part A and B). The ACA contained a schedule to cut back on this funding starting in 2014 and ending in 2020. At the end of 2020, the cost to the Government to support both programs were planned to be equal. With the change in administrations in 2016, this changed and support for Medicare Advantage plans continued to expand.
I can change plans annually without going through underwriting
Having the flexibility to change plans annually without any concern about going through underwriting is nice.
Effective 3/1/2022, people enrolled in a Medigap plan have the same opportunity. With this law change, Idaho residents can switch insurance companies and get the same (or less comprehensive) plan without going through underwriting. This can be done on the policy’s ‘birthday window’. This starts on their birthday window and lasts for 63 more days.
If the policy holder chooses to change insurance companies (or switch to a more comprehensive plan) they will have to pass underwriting.
Many Medicare Advantage plans include prescription drug coverage
With prescription drug plans bundled into the health care plan makes the Medicare process easier to navigate. It is easy to use the prescription drug plan included with my health plan. I recognize the annual out of pocket costs (monthly premium allocated to the drug side of the plan + the prescription refill costs) between the prescription drug side of these plans can vary by 300% or more for the same set of medications. This means I must pay attention to this annually and change Medicare Advantage plans when I can save money.
Having a defined network of doctors and hospitals is ok with me
Having a network of doctors, hospitals and other providers is ok. I recognize I must pay more or all of their medical expenses if I receive medical care from an out of network provider (medical emergencies excluded).
Extra non-Medicare services are included in many plans
I like the idea that my plan can include extra services not covered by Medicare. Features like help pay for some of my needed dental, eye care, hearing, trips to the pharmacy/doctor offices/hospital, meals delivered when I return home from the hospital, etc.
The Idaho Medicare Advantage market
We suggest you read further information about Idaho Medicare Advantage plans. The article gives you a head start on plans available in Idaho Counties. It also identifies which Counties which do not have any Medicare Advantage plans available.
The prescription drug side of Medicare Advantage plans
Some Medicare Advantage plans include prescription drug coverage. The drug plan, like the health care side of the plan, have their own monthly premiums and when added together it is the plan’s premium.
Each insurance company decides which medications to include in their plan’s formulary.
The number of medications covered by these plans can vary widely. The difference between plans with the fewest to the highest medications in their plan’s formulary can be over 1000. We use the resource found here to keep track of this information.
It is not unusual for us to see the same medications (and same dosage) to be classified in different drug tiers between Medicare Advantage plans AND the cost for fills/refills by drug tier to be different between plans.
The cost variance for the same set of medications can be 300%+/- between plans.
By the way, we recommend Idaho residents always check with resources like GoodRx or Blinkhealth to compare fill/refill costs. If you can save money, consider doing so. Be aware when you buy medications outside of your drug plan, the figures do not count towards your plan’s deductible and ability to move to either the coverage gap or the catastrophic stages.
Medigap vs Medicare Advantage: Resources to learn more
You can learn more about Idaho Medicare Prescription Drug plans here.
You can learn more about the state of the Medicare Advantage marketplace available here.
If you are an Idaho resident and undecided about this decision, call us.
Closing thoughts
When you are ready to get your Medicare insurance, let us help you select and enroll in the plan that fits your needs and budget. We will review the available plans that fit you, bring at least two plans when we get together, explain the differences, answer your questions and help you enroll in the plan you choose.
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