Can You Have Medigap with Medicare Advantage

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Like many people with health insurance, Medicare enrollees can have concerns about out-of-pocket costs. On the Medicare journey, you have to pick one of two options for your healthcare coverage: original Medicare, which is federal government-managed insurance that offers the broadest network of healthcare professionals and hospitals, and Medicare Advantage (MA) - a private plan that replaces original Medicare and often offers additional benefits.

While Medicare Advantage plans have an annual out-of-pocket limit, people with original Medicare have no cap on their portion of cost-sharing during a year.

People with original Medicare can cover all or part of their out-of-pocket costs with a Medicare supplement plan known as Medigap. If you have Medicare Advantage, you cannot buy a Medigap plan.

What is Medigap?

Medigap is an insurance supplement plan for people enrolled in original Medicare (Part A and Part B). There are 10 types of Medigap plans, and they are organized by letter names: A, B, C, D, F, G, K, L, M, and N. All plans with the same letter name have the same benefits; premiums will be the only difference.

It's important to note that Medigap plans in Massachusetts, Minnesota, and Wisconsin are organized in a different way than the letter-name concept.

Your Medigap plan can help you pay for deductibles, coinsurances, and copayments.

Can you buy Medigap if you have Medicare Advantage?

No, you can't. Medigap and Medicare Advantage cannot be combined. Medigap only supplements original Medicare.

If having access to an insurance supplement for your Medicare out-of-pocket costs is important, you may want to choose original Medicare instead of Medicare Advantage. This is especially important if you are enrolling in Medicare for the first time.

Who is eligible to buy Medigap?

Here are the general requirements for Medigap eligibility:

• Age: You must be at least 65 years old.

• Original Medicare enrollment: You must have Medicare Part A and Part B.

• Residence: You must reside in the U.S.

It's important to note that if you are a Medicare enrollee younger than 65 with end-stage renal disease (kidney failure) or certain disabilities, you may or may not be able to buy a Medigap plan in your state.

When can I buy a Medigap plan?

Typically, your window to purchase a Medicare supplement plan is the 6-month Medigap open enrollment period when you are both age 65 or older and have Medicare Part B. During this time, you can't be denied coverage for pre-existing conditions - no matter your health status. You also generally have access to more plans and better prices during your Medigap open enrollment period.

If you are past your Medigap open enrollment period, you may still be able to buy a Medigap plan, but you are likely to face medical underwriting, or a review of your health status.

You may be able to avoid medical underwriting under special circumstances. For instance, if you joined a Medicare Advantage plan when you were first eligible for Medicare and don't like your coverage within the first 12 months, you have a "trial right" to buy any Medigap plan sold in your state after you switch to original Medicare. You also have a trial right if you left original Medicare and Medigap for Medicare Advantage less than a year ago but want to return to original Medicare and resume Medigap coverage.

What is medical underwriting?

Medical underwriting is a risk assessment that can include health questions, documentation, and a health exam to determine if an insurance company will sell you a policy. At the end of the medical underwriting process, a Medigap plan can accept you, accept you and charge more, or deny you coverage.

Disqualifying conditions

Though not a complete list, here are some of the conditions or circumstances that can make you ineligible for Medigap coverage:

• AIDS

• Alzheimer's disease or dementia

• Amyotrophic lateral sclerosis (ALS) and other neurodegenerative disorders, such as Parkinson's disease, or multiple sclerosis (MS)

• Bipolar disorder or schizophrenia

• Cancer, including melanoma, leukemia, Hodgkin lymphoma, or lymphoma

• Chronic obstructive pulmonary disease (COPD) or emphysema

• Cirrhosis of the liver

• Congestive heart failure

• Diabetes in an advanced stage

• Hepatitis C

• Inflammatory bowel diseases, such as Crohn's disease and ulcerative colitis

• Kidney failure

• Lower-extremity conditions, such as diabetic neuropathy and peripheral vascular disease

• Lupus

• Myasthenia gravis

• Osteoporosis with fracture

• Oxygen use

• Psoriatic arthritis

• Recent or frequent hospitalizations

• Residency in a nursing home

• Transplant, including bone marrow or organ

Choosing between Medigap and Medicare Advantage

There are many factors when considering Medicare Advantage versus Medigap.

Original Medicare and Medigap

Pros

• Original Medicare covers care at the widest network of healthcare professionals and hospitals.

• Depending on the plan you choose, Medigap covers all or some of your out-of-pocket costs, including deductibles, coinsurances, and copayments.

• Some Medigap plans offer coverage for foreign travel.

• Coverage and benefits for original Medicare and Medigap are typically the same year to year.

Cons

• Original Medicare requires you to buy a separate Part D plan for prescription coverage.

• Original Medicare does not offer extra benefits for vision, dental, or hearing care.

• Medigap premiums within the same letter name can vary widely and are generally higher than any additional premium you pay for a Medicare Advantage plan.

Medicare Advantage

Pros

• Bundles Parts A, B, and often Part D for prescriptions into one plan.

• Many plans offer extra benefits, such as vision, dental, and hearing care.

• You have no out-of-pocket costs once you reach the annual maximum (though most people with Medicare Advantage don't reach that limit).

• You still pay your Part B premium with Medicare Advantage, but any additional premium is typically lower than what you pay for a Medigap premium.

Cons

• Medicare Advantage plans have a limited network of healthcare professionals and hospitals in a particular service area.

• Referrals are often required for specialists.

• Premiums and benefits can change annually.

Can I switch from Medicare Advantage to Medigap?

Yes. There are ways to switch from Medicare Advantage to original Medicare with Medigap without being denied for pre-existing conditions or paying higher premiums. These happen during times when you have a "trial right" or "guaranteed issue" rights. Here is more information about situations when you would have those rights:

Trial right situations

Common guaranteed issue rights circumstances

*Note: Plan C and Plan F are no longer available to people new to Medicare on or after January 1, 2020. But, if you were eligible for Medicare before January 1, 2020 and haven't enrolled, you may be able to buy Plan C or Plan F. People new to Medicare on or after January 1, 2020 have the right to buy Plan D and Plan G instead.

Where can I get help with Medicare or Medigap?

• Call 1-800-MEDICARE (800-633-4227).

• The State Health Insurance Assistance Program (SHIP) offers free access to trained, unbiased benefits counselors who can help you navigate Medicare and Medigap issues.

• Talk to a knowledgeable Medigap salesperson where you live.

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