Medicare Advantage vs. Original Medicare + Medigap?

I'm trying to help my mom figure out a few things (so there will likely
be more posts in this thread as time progresses :).
One bit of simplificiation to get out of the way up front -- neither
the "when you first sign up for Medicare B" Medigap guaranteed issue
condition nor the "tried Medicare Advantage for the first time and
have been in it less than a year" guaranteed issue condition (or any
of the other guaranteed issue conditions) apply.
So, some questions:
1) You can always (during the annual open enrollment) switch from
Medicare Advantage to Original Medicare regardless of age, health,
etc., correct?
2) If you do so, you have the guaranteed right to also join Medicare D
prescription coverage?
3) However, you have no right to be issued a Medigap policy? (I
imagine that's true, unless state law provides to the contrary).
4) Is there any guaranteed right to be able to join a Medicare
Advantage plan?
5) If you switch from Medicare Advantage to Original Medicare (with or
without an associated Medigap policy), do you have a guaranteed
right to go back to a Medicare Advantage plan in the future
(including the same plan you were previously in if it is still
being offered)?
6) You often hear about doctors refusing to take Medicare patients.
Is that in the context of Original Medicare, Original Medicare +
Medigap, or Medicare Advantage? Or with all of them?
7) How do pre-existing exclusions work when switching between Medicare
Advantage and Original Medicare (in either direction) or between
Medicare Advantage plans, or between Medigap plans, assuming you
have been in the plan you're switching from at least 6 months and
have no gaps in coverage?
I'm sure I'll think of more questions :)
Rich Carreiro
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Rich Carreiro
Do you have your mother's copy of "Medicare & You 2010"? This should have arrived in October by snail mail. You may also try the site's downloadable, quasi-generic edition at
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Be aware themanual your mother received is state specific and may be preferablefor answers to some questions.
Short answer: In general, yes. See page 58 at the link above.
With original Medicare and to get Medicare Part D, you must have Medicare Part A and/or Medicare Part B. See page 63.
Page 43 says those with Original Medicare can choose to buy a Medigap policy to get coverage that fills the gaps in Original Medicare.
See page 52. To be guaranteed the right to join a Medicare Advantage plan, your mother has to have Part A and Part B; live in the service area of the plan; not have end stage renal disease (ESRD) with some exceptions for ESRD as explained on page 53.
See 4) above.
I do not have experience with this.
See page 58.
1. A social worker friend of mine who works with the elderly explained to me that there is a huge shakeup nationwide with Medicare, due to the recession. I know this sounds vague, but after working with the Medicare system for about a year now on behalf of a relative, I am astonished at how chaotic the system seems, in particular with Medicare Part D. My friend assured me that the system is far more out- of-whack now than it was a few years ago.
2. Medicare Part D went into effect just four years ago. I am sure you have read of people's annoyance with it. It is difficult to understand, due to for example, the same plan taking different names; the vocabulary being inconsistent among representatives; the same plan switching subcontractors (the subcontractors being the actual drug insurer, if this somehow makes sense). My personal contact with Medicare Part D providers (on behalf of a relative, as POA) has been nightmarish. One gets different information on the same subject from different reps. Some Part D repts will try to sell you something; remember they are not the government but for profit companies. They tend to be slippery, in the used car salesmen sense of the word. Document every call you have with Medicare Part D. Keep phone records. Speak with the pharmacy who supplies your mother's drugs and make sure they know exactly which Medicare drug insurance coverage she has, so they bill the Medicare plan and not your mother.
3. 1-800-Medicare is in fact a very good resource. The catch for you may be that you may lack POA and/or being the Social Security Representative Payee (an SS term) and so they are not authorized to tell you anything specific to your mother. She however may call and you can listen on an extension.
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also has an online calculator site to help people pick between Part D plans. There are dozens, typically, from which to choose for any given part of the country. Many recommend this online site. I thought it good or at least better than nothing.
5. I try to find logic in this system. It is very hard to do. At this point it is no wonder to me that there is so much Medicare fraud.
Good luck.
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My personal experience (and understanding) is that providers can pick and choose which, if any, plans they accept. Having just turned 65 last August, I was surprised to learn that my regular doc only accepts 2 specific Advantage plans No Traditional, No Medigap ! (I had planned on the Medigap route). A friend had the opposite situation. His doc accepted Medigap but no Advantage plans.
In addition to the sources Elle mentioned, each state also has a program called SHIP "Senior Health Insurance Assistance Program," that you can call and get answers specific to your state. Find yours here
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Having spent the previous year studying up on Medicare, I found it to be exceedingly complicated to understand the choices, only to find out my doc had made my "choice" for me. I've only been on for 5 months with no needs as yet. What worries me some is I may be moving out of state soon, and am not looking forward to finding a provider who is accepting new Medicare patients. (BTW, my current doc does not)
Good luck
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Right now the HMO's love the Advantage program. They get the whole premium upfront and dont have to bill the government per service. Plus they are getting a 14% sweetener to take patients. But most of the health reform bills phase out the sweetener.
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