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Medigap vs. Medicare Advantage: What’s the Difference?

July 13, 2020

Any senior that is nearing 65 has likely been contacted with choices about their Medicare options. This season is an important time to look at all the data and come to a decision about what to do next. Whether you are coming off a group plan or an ACA plan, now that you are eligible for Medicare you have some choices.

As an agent, it’s your privilege to educate and guide them on their option. Original Medicare consists of Part A (inpatient hospital coverage) and Part B (outpatient hospital coverage). Original Medicare is a benefit that has been earned by seniors by paying into the program through their taxes for 40 quarters or approximately 10 years. Now that they have gained Original Medicare, many don’t realize that this only covers about 80% of medical costs. Now they need something to complete the coverage and you are here to help.

Medicare Supplements (medigap)

A Medigap plan also referred to as a Medicare Supplement, is designed to “gap” or “supplement” Original Medicare. A Medigap plan covers the other 20% ensuring the senior is completely covered. This plan gives the client freedom of choice allowing them to go to any doctor or hospital that accepts Original Medicare.

There is a premium with a Medigap, and seniors can fondly think of this plan as a “pay upfront” plan. If you make your monthly premium, you will have this plan for the rest of your life and not be terminated. The premium associated with a Medigap varies by age, gender, carrier, and area so being educated on a simple quote to know your area is important. These quotes can be run with very minimal information and give an idea of what the best fit would be. In addition to a Medicare Supplement, the senior will need a drug plan. These are inexpensive plans that can be tailored to the senior’s individual drug needs.

Medicare Advantage

A Medicare Advantage plan, in contrast, is a “pay as you go” plan. This plan generally has a low or no premium associated with it. The benefits of a Medicare Advantage will vary by each carrier, each market, and each plan. These plans have networks with doctors and hospitals assigned to them. The carriers work closely to build relationships making the network as competitive as possible. It’s important to make sure your client’s doctor accepts the plan you are offering so a quick lookup can verify this.

There are fees that go along with each appointment and many require referrals for specialist services, but if you don’t need that service, there is no fee. There is max-out-of-pocket (MOOP) associated with each plan and the senior will not have to pay more than that amount each year; many seniors don’t reach the MOOP. Medicare Advantage usually includes extra ancillary benefits like dental, vision, and hearing.

What you Should be Asking

It’s important to never assume someone’s resources or wants.  Asking questions can help you decide which is the right plan for your client.

For example:

  • Do you currently have a primary care doctor?
  • Do you like him/her?
  • When was the last time you saw him?

Be sure to pay attention to the timing of when the senior is coming to you for help. If they are turning 65 and/or just getting their part B, they have extensive options that can be overwhelming.   Are they happy with making a monthly premium with the flexibility to travel outside of the area or live in a rural or remote area? A Medicare Supplement would be a great choice. However, if they are comfortable with a low or no premium plan that includes a managed care plan of doctors and networks, a Medicare Advantage plan is perfect for them.

Bigger metropolitan areas have larger networks and more doctors to choose from so this could save the client money, however, if the client develops cancer and needs expensive treatments or surgeries the Medicare Supplement would be more economical. Both options are great so if you are representing both, you are sure to help your client make the best choice for their healthcare needs.

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Leigha Hayes | Medigap Sales Director


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