What is the difference between Medi-Gap and Medicare advantage insurance?

The best way to understand this is as follows:

Medicare beneficiaries have two options to obtain Medicare benefits
1. "Original Medicare" (which is how it is officially termed), or
2. Medicare Advantage aka "Part C" plans.

(There are four "Parts" to Medicare. Part A covers hospitalization and hospital services under Original Medicare, Part B covers physician services under Original Medicare, Medicare Advantage plans are designated as Part C, and stand-alone Medicare Prescription Drug plans are designated as Part D.)

The two choices explained:

Original Medicare –
1. Beneficiary pays Part B and in some cases Part A premium to the US Treasury.
2. Beneficiary claims are paid to the provider by the US Treasury.
3. Beneficiary may see any provider that accepts Medicare (freedom of choice)
4. Beneficiary must pay deductibles and co-insurances.
5. Deductibles and co-insurances may be insured against by purchasing Medicare supplement insurance (also known as “Medi-gap insurance) from an insurance company.
6. Because the Medi-gap premium is fixed for the year, and in most cases all deductibles and co-insurances will be covered, the beneficiary knows in advance what the maximum out of pocket medical expenses may be for the year.
7. Beneficiaries must purchase a stand-alone Part D prescription drug plan.

Medicare Advantage –
1. Beneficiary pays Part B and in some cases Part A premium to the US Treasury.
2. Beneficiary contracts with a profit or not-for-profit corporation to provide medical benefits to the beneficiary.
3. Corporation or “managed care company” (many times an “HMO” – Health Maintenance Organization) receives a monthly stipend from the Federal government for each beneficiary enrolled in its program.
4. Corporation is responsible for all expenses incurred by the beneficiary and providers are paid by the corporation, not the US Treasury.
5. There are usually no deductibles but there are copayments required at the time of service.
6. Many plans do not have an out of pocket annual maximum limit on copayments.
7. Many plans do not require a premium to be paid (Part B/A premiums must continue to be paid).
8. Most plans require that beneficiaries use only providers that are contracted with the corporation. Some plans allow for non-contracted providers at a higher co-payment rate or other reimbursement schedule (lack of freedom of choice).
9. Many plans include Part D prescription drug cover at no extra charge.

Which plan is best for you or your loved one? As always, it depends. In larger service areas where there are many choices of contracted providers Medicare Advantage plans work well and are generally less expensive to use than Original Medicare with or without a Medi-gap insurance supplement.
In general, it has been my experience that those beneficiaries who are younger and/or healthier are more satisfied with Medicare Advantage plans than those who are older and not as healthy.
But if freedom of choice is your primary concern then the best option is Original Medicare.

There are many Medigap insurances available.
A Medicare Advantage is an HMO/PPO that replaces traditional Medicare and a Medigap insurance. So instead of having the two(Medicare/Medigap) you will have only one insurance that will cover everything - including Rx. Highmark, Humana, Aetna have a good plans. It is important to make sure your physician is participating in the plan that you choose - whether a Medigap or Medicare Advantage.

Medigap (aka Medicare Supplement Plan) has better coverage, you have your choice of providers, but is more expensive and you need to also enroll in a separate Part D drug plan. Medicare Advantage (HMO) is less expensive, has drug coverage included, but there are copays to pay everytime you go to the doctor, hospital, SNF, etc. and your choice of doctors and hospitals is dependent upon the network. There are pros and cons to each. We just changed my mother over from the HMO plan to a medi-gap plan this year, as her out of pocket costs were sky-high on the HMO plan.

Whatever medicare will not cover can either be paid out of pocket or by a privately purchased insurance policy usually thru AARP. That is called medigap.

If you had insurance coverage when retired before the age you got medicare coverage, check to make sure that your employer does not have an obligation to cover costs not covered by medicare. If you secured health insurance in retirement privately it often becomes your medigap coverage in essence once medicare becomes your 'primary' health care coverage.

I would ask medicare to get you information on the medigap plans and the Medicare Advantage programs. Some people have liked the Medicare Advantage programs but they are in essence privatized Medicare benefits. The companies need to make a profit off the plans. I suspect if you're in failing health needing lots of services, you might be a person the private plans aren't
looking for.

Elizabeth

Everyone is correct. Even if you have Medicare insurance, there's always a part (unless you have Medicaid and Medicare) that will come out of your pocket. If you don't qualify for Medicaid, you may want to look into Medigap insurance as they would cover whatever your primary medicare insurance you have. Normally Medicare pays up to 80%, Medigap will cover the remaining 20%. Check with your medicare plan first but do not just get theirs, be smart about it and check with others as well. Nowadays, they are very competitive prices out there due to the Obamacare reform. Good luck. By they way, if you or whoever you are looking for this Medigap insurance for.... remember first check with your primary doctor to see if you might qualify for Medicaid first.