The Choice You Can't Take Back

Medicare

Back in the enrollment letter, I promised the Advantage vs Medigap decision its own newsletter because it's bigger than most people realize and nearly irreversible in practice. Here it is.

At 65, after you enroll in Medicare Parts A and B, you face a fork: Original Medicare plus a Medigap supplement, or a Medicare Advantage plan. The mailers make it look like choosing a cell phone carrier. It's closer to choosing a citizenship.

The two roads

Original Medicare + Medigap + Part D. Medicare pays its share, the Medigap policy picks up most of the rest, and a separate Part D plan covers drugs. You see any doctor in America who takes Medicare, no networks, no referrals. The cost: a real monthly premium, often $150 to $300 per person for the Medigap policy on top of the $202.90 Part B premium, plus the drug plan.

Medicare Advantage. A private insurer bundles everything, often with dental, vision, and a gym membership, frequently for a $0 additional premium. The cost shows up differently: networks (your doctors or not), prior authorizations (the insurer approves care before you get it), copays as you go, and an annual out-of-pocket maximum that can run $5,000 to $9,000 in a bad year.

Roughly half of new enrollees now pick Advantage. The $0 premium does a lot of that work.

The part the mailers skip

Here's the asymmetry that makes this a one-way door for many people.

When you first enroll at 65, you have a 6-month Medigap open enrollment window during which insurers MUST sell you a policy at standard rates, no health questions asked. Diabetes, heart history, cancer five years ago: doesn't matter. They have to take you.

That guarantee expires. In most states, including Texas, if you pick Advantage at 65 and want to switch to Medigap at 72 after a diagnosis, the Medigap insurer can underwrite you: ask about your health, charge you more, or simply decline. The people most likely to WANT out of an Advantage network (the newly sick) are exactly the people Medigap can refuse.

So the real question at 65 isn't "which plan fits me today?" It's "which plan do I want at 78, and can I still get it then?" Advantage to Medigap: often blocked. Medigap to Advantage: open every year. The doors only swing one way.

Who genuinely fits where

Advantage can be the right call: if your doctors and hospital are in-network and you verify it annually, if cash flow is tight and the $0 premium matters, if you're a healthy traveler within your plan's service area, and if you're comfortable with an insurer between you and your care. Plenty of people ride Advantage happily for decades.

Medigap earns its premium: if you want any-doctor freedom (snowbirds and people near renowned out-of-state hospitals, take note), if family history suggests you'll use serious care someday, if you hate surprise bills (Medigap turns healthcare into a flat monthly cost), and above all if you value the option to never be underwritten again.

A useful frame: Advantage is cheaper while you're healthy. Medigap is cheaper while you're sick. You're buying at 65 for the version of you that exists at 80.

If you're approaching the fork

List your doctors and your preferred hospital, and check them against any Advantage plan's CURRENT directory, not last year's. Networks change annually; your plan can drop your oncologist in October.

Price the honest comparison: Advantage's worst-case year (the out-of-pocket max, times two spouses) against Medigap's premiums-every-year. Total cost of ownership, not sticker price.

If you choose Medigap, do it inside the 6-month window. Plan G is the workhorse for new enrollees; in Texas you'll find it from roughly $130 to $250/month depending on age, zip, and insurer, for functionally identical coverage. Shop the price, not the brand.

If you choose Advantage, re-shop it EVERY fall during open enrollment. The plan that was great this year can quietly gut its network or raise its out-of-pocket max for next year.

And whichever road you take, decide it on paper before the mailers and the TV ads decide it for you. This is a 25-year contract disguised as a coupon.