Medicare Advantage vs. Medigap — Which One Is Actually Right for You

YOUR MONEY — Issue No. 5

Medicare Advantage vs. Medigap — Which One Is Actually Right for You

The decision most people get wrong — and what a Family Practice PA actually sees in the exam room.

Most people approaching Medicare make this decision the wrong way.

They call an 800 number from a television commercial. They talk to an agent who gets paid a commission based on what they sell. They pick a plan based on a $0 premium and a free gym membership.

Then they get sick. And they find out what they actually bought.

This issue is about making that decision correctly — before you need it.

What is Medicare Advantage — and what's the actual advantage?

Medicare Advantage — Part C — is an alternative to Original Medicare. Instead of the government paying your claims directly, a private insurance company takes over your Medicare benefits and manages your care.

The "advantage" that gets advertised most is the $0 premium. Many Medicare Advantage plans charge no monthly premium beyond what you already pay for Part B. The average Medicare Advantage premium in 2026 is $14-17/month — and the majority of plans available are $0 premium. They also frequently bundle in benefits that Original Medicare doesn't cover — routine vision, dental, and hearing care.

Those benefits are real. For a healthy person who rarely uses the healthcare system they can be genuinely valuable.

But there are things the commercials don't tell you.

The $0 premium — what it actually means

A $0 premium does not mean free healthcare. It means the insurance company is being paid by Medicare to manage your benefits — and they make money by managing what care you receive.

What you pay instead of a premium:

Copays every time you see a doctor. Coinsurance for procedures and hospital stays. Out of pocket maximums that can reach up to $9,250 annually in 2026 depending on the plan. Prior authorization requirements — meaning the insurance company must approve certain tests, procedures, and specialist visits before you receive them.

A $0 premium plan with a $9,250 out of pocket maximum is not a free plan. It is a plan where you pay nothing until you get sick — and then you may pay a great deal.

Will my provider accept my plan?

This is one of the most important questions to ask — and one of the most commonly overlooked.

Medicare Advantage plans have networks. Your current doctor, your specialist, your hospital — they may or may not be in your plan's network. Out of network care is either not covered or covered at significantly higher cost depending on the plan type.

Before enrolling in any Medicare Advantage plan — call your providers directly and ask: "Do you accept [plan name]?" Do not assume. Networks change annually. A provider who accepted your plan last year may not accept it this year.

Vision, dental, and hearing — what's actually included

Medicare Advantage plans frequently advertise vision, dental, and hearing coverage. These benefits are real but often limited.

Vision coverage typically includes one routine eye exam per year and an allowance toward eyeglasses or contacts — often $100-200. Dental coverage varies widely — basic cleanings and x-rays are commonly covered but major dental work may have significant limitations. Hearing benefits typically include an exam and an allowance toward hearing aids — often $500-1,500 — helpful but rarely covering the full cost of aids that can run $2,000-6,000 per pair.

Beyond vision, dental, and hearing — many Medicare Advantage plans include additional benefits that Original Medicare and Medigap do not offer at all. Transportation to medical appointments, over the counter health product allowances, in-home aide services, and meal delivery after hospitalization are increasingly common. For patients living alone — the transportation benefit and in-home aide services can be genuinely life-changing. Getting to a medical appointment without depending on family or paying out of pocket for a ride, or having help with daily tasks during recovery, are real quality of life benefits that no premium savings calculation fully captures.

Read the plan's Evidence of Coverage document before enrolling — not the marketing brochure.

What is Medigap — and how does it work?

Medigap — also called Medicare Supplement — works alongside Original Medicare to cover the costs that Medicare leaves behind.

Original Medicare covers 80% of approved costs after your deductible. That remaining 20% has no cap — meaning a serious illness or hospitalization could leave you with tens of thousands of dollars in out of pocket costs.

Medigap covers that gap. Depending on the plan you choose it may cover your Part A deductible, your Part B coinsurance, excess charges, and in some cases foreign travel emergencies.

With Medigap you keep Original Medicare — which means any provider who accepts Medicare accepts your coverage. No networks. No referrals. No prior authorization for most services. You see who you want, when you want.

Are Medigap plans the same from one company to the next?

Yes — and this surprises most people.

Medigap plans are standardized by the federal government. A Plan G from Blue Cross Blue Shield covers exactly the same benefits as a Plan G from Aetna or United or any other carrier. The letter determines the benefits — not the company.

What differs between companies is the premium, the customer service, and in some cases additional perks. Shop Medigap plans on price and reputation — not on benefits, because the benefits are identical.

One gap Medigap does not fill:

Just like Original Medicare, Medigap plans do not cover routine vision, dental, or hearing. Medigap patients who want this coverage need to purchase a separate dental, vision, and hearing plan — commonly called a DVH plan. Bundled DVH plans are widely available for $32-50/month depending on coverage level. When comparing total costs between Medicare Advantage and Medigap, factor in this additional premium.

I want to be clear about something. I work in a rural Family Practice setting where many of my patients choose Medicare Advantage because it is what they can afford. I understand that completely. Both options require the $202.90/month Part B premium. But beyond that, Medicare Advantage adds $0-17/month while Medigap Plan G with Part D and a dental, vision, and hearing plan adds approximately $166-284/month. That is not a small difference on a fixed income.

Medicare Advantage is not a bad product. For the right patient — healthy, budget conscious, with local providers who accept the plan — it can work very well.

What I want you to have is a clear picture of what each option offers and what each one asks in return. Go in with your eyes open — whichever direction you choose.

And honestly — watching my patients navigate these decisions makes me work harder every day. If I can help keep blood pressure controlled, diabetes managed, and chronic disease stable — my patients need the healthcare system less. That's fewer prior authorization battles, fewer surprise bills, and less financial stress. Better health is the best insurance plan there is. Plain Medicine exists because I believe that.

The Member deep-dive this week covers how to choose between specific Medicare Advantage plans, prescription drug tiers and what they cost, what affects your Medigap premium and whether discounts exist, why Plan G is the most popular Medigap plan, home health and physical therapy coverage explained, and five real patient scenarios with direct recommendations on which coverage fits each situation.

Next week: Social Security — when to claim, how your benefit is calculated, and why the timing of this one decision matters more than most people realize.

Plain Medicine is published for educational purposes only and does not constitute medical advice or establish a patient-provider relationship. Always consult your healthcare provider before making medical decisions.

— Kyle