But often, the low initial premiums that Medicare Advantage plans can be deceiving. A zero premium Medicare Advantage plan is fine, as long as you don’t need healthcare.
But if you do need care, you may find that Medicare Advantage plans can be more restrictive and expensive than you expect.
If you are one of those people who thought original Medicare (ref: Medicare.gov) would be enough, or if you’re unhappy with your Medicare Advantage plan, you might be wondering: can I switch to Medigap?
The short answer is yes –– provided you’re still within your initial enrollment eligibility period, or you can pass medical underwriting.
What’s more, you can apply for a Medigap plan at any time. You don’t have to wait for any particular enrollment period.
If you’re no longer in your initial Medigap enrollment eligibility period, and you’ve had some health problems, however, you could be required to pay a higher premium. Or you could be turned down altogether.
For these reasons, if you’re thinking about switching back to Original Medicare and joining a Medigap plan, you should apply now, before you have an unexpected medical setback that could affect your eligibility.
But if you’re in reasonably good health, and your Medicare Advantage plan isn’t working for you, you can, and should switch out of it as soon as you’re able to.
In this article, we’ll take a closer look at some of the pros and cons to help you make the right choice. A Personal Benefits Manager can help guide you through the process at any time.
Learn More: Medicare Supplement Vs. Medicare Advantage: Which is Better?
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Original Medicare Isn’t Enough
Enrolling in Original Medicare is a great place to start.
For many people, the process is automatic once you turn 65. So you may not have thought much about adding any other coverage, or choosing an alternate plan.
But there are many reasons why people feel Original Medicare alone is no longer working for them:
- Deductibles and Coinsurance Expenses. As of 2024, the annual Part A deductible is $1,632 for hospital stays, per benefit period (not per year. You could face multiple benefit periods, and pay multiple deductibles, within the same year.) For Part B (physician’s insurance), the deductible is $240 for doctor visits, physician services, lab and imagery costs, and outpatient services. After deductibles, Medicare Part B only covers 80%, leaving you responsible for the remaining 20%.
- Excess Charges. In certain cases, doctors who do not accept Medicare assignment can charge up to 15% over Medicare’s approved amount for services. Under Original Medicare alone, excess charges are not covered. You’ll have to pay them.
- No Out-of-pocket Cap. There is no out-of-pocket maximum. This means there’s no limit on what you could owe for deductibles, coinsurance, and other charges throughout the year. This creates a vulnerability that could leave you liable for hundreds of thousands of dollars in physicians’ charges and durable medical equipment.
- No prescription drug coverage. Original Medicare by itself doesn’t include prescription drug coverage.
- Limited coverage. Original Medicare only allows for a certain amount of time at a skilled nursing facility, and then only for recovery periods immediately following for hospitalization. It severely limits coverage when traveling internationally.
- No Routine Vision and Dental Care. Original Medicare does not cover routine vision or dental care, eyeglasses (with certain exceptions), or dentures.
- No Long-term Care Coverage – Does not cover custodial care, which includes assistance with activities of daily living like bathing, dressing, and using the bathroom.
Some people may be able to manage with just Original Medicare if they are in good health and have enough savings to cover unexpected medical bills. But as the years go on, this coverage alone may not be enough.
Why Do People Leave Medicare Advantage?
Medicare Advantage plans are often presented as a great alternative to Original Medicare.
They can look like a better choice because they are privately managed, and the up-front costs appear to be lower.
People are drawn in by the promise of great benefits:
- Predictable Costs – Many plans have built-in caps on out-of-pocket expenses. This can provide peace of mind knowing there’s a limit on what you’ll owe in a given year.
- Bundled Coverage – Instead of having multiple insurance plans to deal with, Medicare Advantage Plans bundle your Part A benefits (hospital), Part Benefits (doctor) and Part D (prescription drug insurance) into a single plan. This simplifies things by having one plan to manage and one premium to pay. And in many cases, Medicare Advantage plans are free.
- Extra Benefits – Medicare Advantage plans often offer additional benefits that Original Medicare doesn’t cover, like dental, vision, hearing services, and even fitness memberships.
- Potential Savings – The lower costs upfront compared to Medigap plans seem like a better option for some.
But as many soon discover, Medicare Advantage plans also have significant drawbacks.
Their networks often have limitations on which doctors you can see and may require referrals for specialists.
The HMO or PPO networks they use make deals with certain doctors and hospitals to treat you for less money. Because of this, you can’t always choose your own doctor.
If you need care that’s not an emergency, you have to see the doctors and go to the hospitals that are in the plan’s network, or you’ll have to pay a lot more!
Medicare Advantage plans also tend to have much higher out-of-pocket costs than people expect.
They are lured in by the low monthly premiums (sometimes as low as $0) just to discover the out-of-pocket limits can be as high as $8,850!
It doesn’t take long to realize that Medicare Advantage plans work best for people in excellent health who don’t expect to need much medical care each year.
Nearly everyone else is better off in a Medigap Part G or N plan, together with a standalone Part D plan. Together, these plans along with Original Medicare provide comprehensive coverage, along with prescription drug insurance.
Learn More: How to Get Out of Medicare Advantage Nightmares
Switching to Medigap
Medicare Supplement Insurance, more commonly known as Medigap, can help cover some of the costs Original Medicare doesn’t.
To join Medigap, you must be enrolled in Original Medicare Part A and Part B.
Your Medigap plan is layered on top of your Original Medicare and helps pay deductibles, coinsurance, and excess charges.
See Any Doctor
One of Medigap’s most valuable benefits is that you are free to see any doctor or provider that accepts Medicare assignment, anywhere in the U.S. There are no narrow networks of contracted physicians and healthcare providers with Medigap.
Some plans even provide benefits out of the country – 80% of costs, up to $50,000.
So Medigap is an excellent choice if you plan on traveling outside the United States.
The catch: you must pay a monthly premium for this additional insurance, and the costs and coverage vary between plans. You will also need to be aware that your Medigap premiums aren’t fixed, and could creep up over time.
Medigap does not cover prescription drugs. So you may need to consider adding Medicare Part D as well.
More comprehensive plans like Plan F and Plan G typically have higher premiums but better benefits. After you pay your $240 Part B deductible, Medigap Plan G will cover all your other out-of-pocket expenses!
How to Enroll
Technically, you can switch to a Medigap plan at any time.
However, there are some factors to consider if you missed doing so during your initial enrollment.
During your Initial Enrollment Period, insurance companies can’t deny you a Medigap policy based on your health status, and they must offer you the standard plans at their lowest rates.
You can still enroll in a Medigap plan anytime after your open enrollment period ends. But as we mentioned, after your enrollment period ends, your guaranteed acceptance privileges go away. You’ll have to pass medical underwriting.
Different carriers have different underwriting criteria, however.
For example, some carriers are more forgiving of smokers than others. Others are more accepting of diabetics, prior heart conditions, or other specific health concerns than others.
It’s always a good idea to get connected with a Medigap expert to help you find the best plan for your situation, and assist you with enrollment.
Consider Medi-Share 65+
When you are looking for more help with high out-of-pocket costs, Medigap plans aren’t the only option.
Another excellent alternative is Medi-Share 65+.
This is a great program to switch over to if you are looking to take more control of your own healthcare needs, and keep your costs more reasonable. And most brokers out there won’t even mention it!
Medi-iShare 65+ is not an insurance plan. Instead, it’s a community-based health sharing program designed exclusively for people enrolled in Medicare Part A and Part B.
Members pay a monthly contribution, similar to a premium. They are then eligible to have their medical costs shared by the other members of the group.
Get a Free Medicare Advantage Quote
Medi-Share 65+ Advantages
One of the best perks of this program is that you are free to choose any doctor or provider you want to see at any time. The benefits are very similar to Medigap Plan G, but Medi-Share 65+ offers even more flexibility and affordability.
The costs for Medigap plans vary depending on your age, sex, and location, and depending on which type of plan you select. Average monthly premiums for a Medigap Plan G can range from about $160 to over $360, depending on your location, age, and sex.
But the Medi-Share 65+ contributions are only $99 for ages 65-74, and $150 for anyone over 75. The price is the same for men and women in every state.
Medi-Share 65+ isn’t the best match right for everyone. There are a few restrictions and exclusions to be aware of.
For example, Medi-Share 65+ has a 6-month waiting period before they will share costs for treating pre-existing conditions, and there are some lifestyle agreements all members must adhere to. So make sure to read all the fine print before enrolling.
A Personal Benefits Manager can help you compare the details, and answer any questions you may have. Switch to a great plan that will grow with you as you age!
For Further Reading: 10 Medicare Mistakes to Avoid When Choosing a Plan | What is the “Maximum Out-of-Pocket” in Medicare Plans? | Medicare Penalties and How to Avoid Them | Medicare Advantage Plans in 2024
Lou Spatafore works for MediGap Advisors. As a PBM, his focus is to help people find the best Medicare plan for his clients. Read my full Bio.