Medicare Advantage or Medigap? Questions to Ask Before Open Enrollment Ends

Eli Howard, CEO, E. H. Howard Wealth Management

Every fall the mailbox fills up. Glossy postcards, plan brochures, a commercial during the evening news promising extra benefits at no extra cost. By the time open enrollment wraps up on December 7, plenty of people have picked a plan mostly because they got tired of thinking about it.

The choice between Medicare Advantage and Original Medicare with a Medigap policy deserves more care than that, because for many people it's harder to reverse than it looks. Here's how the two paths differ and the questions worth asking before the deadline.

The two paths, in plain terms

Original Medicare is the federal program itself: Part A for hospital care and Part B for doctors and outpatient care. It leaves gaps such as deductibles and coinsurance, and on its own it has no annual limit on what you pay. Many people fill those gaps with a Medigap policy, also called a Medicare Supplement, and add a separate Part D plan for prescriptions.

Medicare Advantage, sometimes called Part C, is a private plan that takes the place of Original Medicare as the way you receive your benefits. Most include drug coverage, many add extras like dental or vision, and every plan has a yearly out-of-pocket limit. For 2027, the federal ceiling on that limit for in-network care is $9,850 (BenefitsUSA). The tradeoff is usually a network of doctors and hospitals, and in many plans, approval before certain care.

What open enrollment lets you do

From October 15 through December 7, anyone with Medicare can change their health plan and prescription drug coverage for the following year (CMS). That includes moving between Original Medicare and Medicare Advantage, with changes starting January 1. If you're already in a Medicare Advantage plan, there's a second window from January 1 through March 31 to switch plans or return to Original Medicare (WLFI).

Here's the part most mailers leave out. Open enrollment lets you change your Medicare coverage. It does not require a Medigap insurer to sell you a policy.

Why the Medigap question matters more than the brochure

Federal law gives you a one-time, six-month Medigap open enrollment period when you're 65 or older and first enroll in Part B. During that window, insurers can't turn you down or charge more because of your health. Outside of it and a handful of specific situations, federal law lets Medigap insurers use medical underwriting, which means they can deny a policy or charge higher premiums based on your health history (KFF).

One of those situations is a trial right. If you try Medicare Advantage and decide within a year of first signing up that you want to go back, you generally have a guaranteed right to buy a Medigap policy (KFF). After that, the door may still be open, but you may have to pass a health review to walk back through it.

That window closes for most people. KFF found that 90 percent of Medicare Advantage enrollees 65 and older did not have guaranteed issue protections to buy Medigap beyond the initial trial period, as of 2022 (KFF). In practical terms, someone who chooses Medicare Advantage at 66 and develops a serious condition at 74 may struggle to get a Medigap policy at a reasonable price, or at all. Some states add protections beyond federal law, so ask Texas HICAP (more on them below) which rules apply to you.

Questions to ask before December 7

1. Are my doctors, hospitals, and pharmacy in the plan's network for next year? Networks can change every year. In West Texas, check the specialists you see in Lubbock, Dallas, or Houston too, not just the clinic down the street.
2. How much time do I spend away from home? Medicare Advantage networks are usually local. If you winter somewhere else or spend weeks visiting the grandkids, ask how the plan handles care outside its service area.
3. What would a bad year cost me? Look past the premium to the out-of-pocket maximum, hospital copays, and what a few nights in the hospital plus follow-up care would run.
4. Are my prescriptions covered, and at what tier? For 2027, the standard Part D deductible rises to $700 and the yearly out-of-pocket cap on covered drugs rises to $2,400 (Kiplinger). Run your actual drug list through the Medicare.gov plan finder rather than trusting a brochure.
5. Does the plan require prior authorization for care I'm likely to need? Ask specifically about imaging, rehab, skilled nursing, and specialist referrals.
6. If I choose Medicare Advantage now, could I get a Medigap policy later? Know whether you're inside a trial right or guaranteed issue window, and what happens if you're not.
7. Is the "$0 premium" really zero? Most Medicare Advantage members still pay the Part B premium on top of any plan premium.
8. How does my income affect my premiums? Higher-income retirees pay a surcharge, called IRMAA, on Part B and Part D premiums, based on the tax return from two years earlier. A large IRA withdrawal, Roth conversion, or land sale can push you over a threshold, which is one reason Medicare belongs in your tax planning.

Who tends to lean which way

There's no right answer for everyone, but a few patterns come up often. Medicare Advantage tends to appeal to people who are in good health, are comfortable with a network, want a lower premium, and like having extras bundled into one card. Original Medicare with Medigap tends to appeal to people who want to see any doctor nationwide who accepts Medicare, travel often, manage ongoing health conditions, or would rather pay a higher premium for more predictable costs.

Your health, your budget, how much you travel, and where your doctors practice matter more than any commercial. So does the fact that the Medigap decision can be hard to undo later.

Where to get unbiased help

Texas HICAP, the state's free Medicare counseling program, can be reached at 1-800-252-9240 (SHIP National Technical Assistance Center). Medicare.gov has a plan finder that compares plans using your own prescriptions and pharmacies. If you're working with an agent, it's fair to ask which companies they represent and how they're paid.

As an independent fiduciary, we look at Medicare as one piece of your retirement plan, alongside Social Security timing, taxes, insurance, and how much cushion you keep for health costs.

Frequently asked questions

Talk it through

If you or a parent are weighing this before December 7, we're glad to look at how the choice fits into the bigger retirement picture. Book a call with our team.

E. H. Howard Wealth Management, LLC is an independent fiduciary firm and is not affiliated with or endorsed by Medicare, the Centers for Medicare & Medicaid Services, or any government agency. The information shared is for educational purposes only and does not constitute personalized financial, tax, legal, insurance, or investment advice. Consult your own qualified professional regarding your specific circumstances.

Sources

• CMS: Medicare Open Enrollment
• WLFI: Medicare Open Enrollment starts October 15th
• KFF: Medigap guaranteed issue requirements, federal and state rules
• BenefitsUSA: Medicare Advantage out-of-pocket maximum 2027
• Kiplinger: Medicare 2027 projections
• SHIP National Technical Assistance Center: Texas HICAP

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