What Happens If You Change from Medigap to Medicare Advantage?

Medigap to Medicare Advantage

With Medicare’s Annual Enrollment Period just around the corner, you may be considering switching from a Medigap to a Medicare Advantage plan. If so, you need to know what to expect. How will your coverage change? What about your costs – will they be higher or lower overall? Can you change your mind and switch back later?

In this post, we walk you through what you can expect when you switch to a Medicare Advantage (MA) plan. Even though all MA plans must offer the same benefits as Medicare Part B, how that coverage works is quite different.

Learn to Stay Within Your Network

One of the reasons Original Medicare has such high approval ratings among enrollees is the enormous network of providers that accept Medicare. If you have Original Medicare, you can see any doctor that accepts assignment, even when traveling in another state.

It works a little differently when you have a Medicare Advantage plan. These more closely resemble traditional health plans, such as those provided by an employer or union, in that you have a network of approved providers. This includes physicians, hospitals, labs, and any other professionals who provide your healthcare.

Network sizes vary according to the insurer and your particular area. Before changing to any MA plan, make a list of all of your providers and compare it to the plan’s network. Or, just give us a toll-free call at 855-350-8101 and one of our licensed agents can assist you.

Choosing a Primary Care Physician

Most Medicare Advantage plans require you to choose a primary care physician, particularly HMOs. Of course, you likely have a primary provider now. The difference with an HMO – and some PPOs – is that your primary care physician must provide referrals to a specialist.

Seeing a doctor that is not part of your network, or a specialist without a referral, usually leaves you footing the bill if you have an HMO. If you have a PPO, you can typically see a doctor outside the network if you’re willing to pay a higher co-pay. It’s important to remember, though, that just because you can see a doctor outside your network does not mean that doctor will see you. Even if that doctor accepts Medicare, he or she may not accept your MA plan.

Cost Differences with Medicare Advantage

Depending on your Medigap plan, you have few out-of-pocket costs. For example, Medigap Plans F and G pay co-pays and co-insurance for all covered services under both Parts A and B.

If you have a Medicare Advantage plan, you cannot also have a Medigap plan. That means you are responsible for your co-pays. Of course, that also means you do not have a Medigap premium every month. Which option works better for your bottom line depends on your unique circumstances.

Medigap to Medicare Advantage

Each MA plan details all of your costs in its summary of benefits. Review it carefully. In addition, coverage changes yearly. If you make the switch to a Medicare Advantage plan, review your Annual Notice of Change every year. Common changes include:

  • Monthly premiums
  • Co-pays
  • Provider network
  • Drug formulary (if the MA plan includes prescription drug coverage)

Your plan may even go away next year, or stop covering services not included in Medicare Part B.

Medicare Advantage and Out-of-Pocket Maximums

One advantage (no pun intended) to MA plans is that they have annual out-of-pocket maximums, while Original Medicare does not. These vary by plan, but Medicare sets the yearly maximum at $6,700. However, it’s important to note that those out-of-pocket maximums are per calendar year. That means that you could max out your spending in December and, in January, your out-of-pocket clock resets.

Possible Extra Services Under Medicare Advantage

Many MA plans include extra coverage beyond that offered by Original Medicare. The most common is prescription drug coverage, but some MA plans offer vision, dental, hearing, or other services.

Can You Switch Back to Medigap?

The only time switching back to your Medigap plan is guaranteed is if you qualify for guaranteed issue rights. That’s because, outside of your Initial Enrollment Period, you have to apply for Medigap coverage. Part of that application process is medical underwriting.

In medical underwriting, the insurer may decide that selling you a Medigap policy is too risky. Or, they may sell you the policy but charge a higher rate.

However, if this is the first time you’ve changed to a Medicare Advantage plan, you qualify for guaranteed issue rights IF you change back to Original Medicare within 12 months. That’s because the Medicare program allows beneficiaries trial rights. This lets you test out your various plan options to determine what works best for you.

Is a Medicare Advantage Plan Right for You?

To help answer this question, consider the following:

  • Are you okay with getting referrals to specialists? Would a PPO plan work better?
  • Are your providers included in the plan’s network?
  • Does the plan include drug coverage? If so, what are the out-of-pocket costs for medications?
  • What is the out-of-pocket maximum?

Sometimes, though, the answer comes down to one simple question: Do you travel a lot? If you split your year between two states – or plan to after you retire – then a Medicare Advantage plan probably won’t work well for you due to its network requirements.

If you need help juggling your options, the agents at Medicare Solutions are happy to answer your questions. We’ll look at the options in your area and help you determine whether Medigap or a Medicare Advantage plan is best for you.

Chris Gasparini

Chris Gasparini

Licensed Insurance Agent at Medicare Solutions
Chris Gasparini has been a licensed insurance agent since 2005. He enjoys helping Medicare beneficiaries navigate their options to find the best solution for their unique needs. Chris feels as though his work truly helps people. Because he represents multiple insurance companies and plan types, Chris is able to help Medicare beneficiaries find the best, most cost-effective plan. Every day, he leaves work knowing he did what was right for each and every client he serves.
Chris Gasparini

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Chris Gasparini

Author: Chris Gasparini

Chris Gasparini has been a licensed insurance agent since 2005. He enjoys helping Medicare beneficiaries navigate their options to find the best solution for their unique needs. Chris feels as though his work truly helps people. Because he represents multiple insurance companies and plan types, Chris is able to help Medicare beneficiaries find the best, most cost-effective plan. Every day, he leaves work knowing he did what was right for each and every client he serves.

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