Medigap or Medicare Advantage in California?

Path 1: Original Medicare, Medigap, and Part D

Original Medicare is Part A and Part B from the federal program. You can add a Medigap policy to help pay some Part A and Part B cost sharing, and you can add a separate Part D drug plan.

Medigap policies are standardized by letter. The benefit rules for the same letter are generally the same, while premiums and company rules can differ. Medigap does not include Part D drug coverage.

Path 2: Medicare Advantage

Medicare Advantage is another way to receive Part A and Part B benefits through a Medicare-approved private plan. Most plans include Part D. The plan sets its network, referral, prior authorization, and cost-sharing rules within Medicare rules.

Ask for the plan's Evidence of Coverage and provider directory. Do not treat a plan advertisement as a complete description of what you will pay or how you get care.

Network and referral differences

With Original Medicare, you can use any doctor or hospital that takes Medicare. With Medicare Advantage, you may need to use the plan network and service area for non-emergency care. An HMO usually requires a primary care doctor and a referral for many specialists.

Before switching, check the exact doctor, hospital, medical group, specialist, and pharmacy. A doctor who accepts Medicare may not accept your Medicare Advantage plan.

Travel and foreign emergencies

Original Medicare generally does not cover medical care outside the United States. Some Medigap policies cover foreign travel emergency care. Medicare Advantage plans generally do not cover foreign care, but some plans may offer emergency or urgent travel coverage. Check your plan before leaving.

Medicare's official foreign coverage fact sheet says Medigap Plans G and N are among the lettered plans that may pay 80% of billed charges for covered foreign travel emergency care after a $250 yearly deductible, when the emergency begins during the first 60 days of a trip, up to a $50,000 lifetime limit. Check the policy because the benefit has limits.

Open enrollment and underwriting

Your six-month federal Medigap Open Enrollment Period starts the first day of the month you are 65 or older and enrolled in Part B. During this window, a company generally cannot use medical underwriting to deny the policy or change the price based on health.

After the window, federal law may not guarantee that a company will sell the policy you want. California has additional rights, including the birthday rule described below. Ask HICAP or the California Department of Insurance before dropping coverage.

California birthday rule

The California Department of Insurance says a person who already has Medigap insurance has a 60-day open enrollment period commencing with the birthday to transfer to an equal or lesser Medicare Supplement plan. Ask the company, CDI, or HICAP which plan and application rules apply before making a change.

Can I have Medigap and Medicare Advantage at the same time?

No. Medigap supplements Original Medicare. You cannot use it to pay Medicare Advantage copayments, deductibles, or premiums.

Which path usually has a network?

Medicare Advantage plans may require a network and service area. Original Medicare lets you use any doctor or hospital that takes Medicare, and Medigap supplements Original Medicare.

Does Medigap cover prescriptions?

No. Medigap policies sold after 2005 do not include prescription drug coverage. You can add a separate Part D plan to Original Medicare.

What is the California birthday rule?

California says an existing Medigap policyholder has a 60-day open enrollment period starting with the birthday to transfer to equal or lesser benefits. Confirm details with CDI, HICAP, or the insurer.

Do Plan G and Plan N cover Vietnam emergencies?

The official Medicare fact sheet says Plans G and N are among the plans that may cover 80% of certain foreign travel emergency charges after a $250 yearly deductible, for the first 60 days of a trip, up to a $50,000 lifetime limit. Check your policy.

Can a plan use medical underwriting?

Outside a protected enrollment or guaranteed issue right, a Medigap company may be able to use health questions or charge more. Check your timing before switching.