Navigating the world of Medicare can feel like exploring a financial maze—particularly when you’re trying to decide between Medicare Advantage (Part C) and Medicare Supplement (Medigap) plans. With significant updates rolling out in 2025, it’s more crucial than ever to understand the nuances of each option. In this in-depth guide, we’ll break down everything you need to know: What do these plans cover? How do costs compare? What new changes should you be aware of for 2025? By the end of this post, you’ll have a clear, side-by-side comparison of Medicare Advantage versus Medigap, complete with real-world examples, a detailed comparison table, and actionable advice to help you choose the best fit for your healthcare and budgetary needs.
Throughout this article, we’ll cite authoritative sources—like Centers for Medicare & Medicaid Services (CMS) fact sheets, reputable financial publications, and official Medicare resources—to ensure you have the most up-to-date, accurate information. If you want to dive deeper or verify any specifics, simply click the hyperlinks embedded within the text to access the source directly.
What Is Medicare Advantage?
Medicare Advantage plans, often referred to as “Part C,” are offered by private insurance companies approved by Medicare. These plans bundle Original Medicare (Part A for hospital coverage and Part B for medical services) and often include Part D (prescription drug) coverage, as well as additional benefits like dental, vision, hearing, and wellness programs. Instead of going to any provider that accepts Medicare, you typically use a network of doctors and hospitals—or pay more if you go out of network.
Key Features of Medicare Advantage Plans
Bundled Coverage
Hospital (Part A) & Medical (Part B): Always included.
Prescription Drug (Part D): Usually included, though you should verify each plan’s formulary.
Supplemental Benefits: Many plans offer extras such as dental, vision, hearing, fitness memberships, and transportation to doctor visits. According to CMS, over 99% of Medicare Advantage plans offered at least one supplemental benefit in 2024, with a median of 23 supplemental benefits per plan (CMS, CMS).
Networks
Health Maintenance Organization (HMO): Requires you to use in-network providers, except in emergencies.
Preferred Provider Organization (PPO): Offers more flexibility to see out-of-network providers; however, you’ll typically pay higher cost-sharing.
Private Fee-for-Service (PFFS) & Special Needs Plans (SNPs): Cater to specific populations, such as those with chronic conditions or dual eligibles (Medicare and Medicaid).
Costs
Premiums: In 2025, the average Medicare Advantage premium is projected to be $17.00 per month, compared to $170 for Medigap Plan G (on average).
Out-of-Pocket Maximum: Every MA plan sets its own annual out-of-pocket limit for Part A and Part B services—$9,350 in-network and $14,000 combined (in-network + out-of-network) for 2025 . Once you hit that limit, Medicare pays 100% of covered services for the rest of the year.
Deductibles & Copays: Vary widely by plan. Some have a $0 deductible for Part A and Part B services, while others have separate deductibles or cost-sharing requirements.
Enrollment Periods
Initial Enrollment Period (IEP): Same as Original Medicare (three months before you turn 65, the month you turn 65, and three months after).
Annual Enrollment Period (AEP): October 15–December 7 each year, when you can switch between Original Medicare, Medicare Advantage, and Part D plans. Changes take effect January 1 of the following year.
Special Enrollment Period (SEP): For qualifying life events (e.g., moving, losing employer coverage).
Care Coordination & Management
Many MA plans include case management for those with chronic conditions, wellness programs, telehealth services, and disease-management support—benefits Original Medicare doesn’t provide directly. For example, CMS’s 2025 final rule for MA plans emphasizes improved access to behavioral health providers and expanded network adequacy standards for mental health specialties .
What’s New for Medicare Advantage in 2025?
Star Ratings & Quality Incentives
CMS adjusted the methodology for the 2025 Star Ratings, adding Tukey outlier deletion to improve accuracy and stability of cut points for non-CAHPS measures, and introduced bidirectional guardrails for Part D Plan Finder measures to ensure rating consistency .
Plans with high star ratings (4 or 5 stars) may receive quality bonus payments, which can translate into additional benefits for enrollees.
Behavioral Health Network Adequacy
Plans must ensure that outpatient behavioral health providers meet network adequacy time and distance requirements, including telehealth options, under CMS’s Consolidated Appropriations Act, 2023 guidelines .
Supplemental Benefit Utilization & Outreach
CMS now requires plans to proactively notify enrollees about available supplemental benefits—like vision, hearing, dental, and social determinant services (e.g., meal delivery, transportation)—to increase utilization and ensure program integrity .
Increased RADV Audits & Enforcement
Effective May 21, 2025, CMS expanded Risk Adjustment Data Validation (RADV) audits to include all eligible MA plans annually (instead of a limited sample), aiming to curb improper payments and over-coding of diagnoses. There is a goal to clear the RADV backlog for payment years 2018–2024 by early 2026 (JD Supra, JD Supra).
Broker Compensation Limits
CMS finalized limits on broker and agent compensation, capping volume-based bonuses to prevent misaligned incentives and ensure beneficiary interests are prioritized when marketing MA plans (American Hospital Association).
Premiums & Plan Stability
Average MA premiums are expected to remain stable in 2025, averaging $17.00 per month, with plan choices and benefits staying relatively consistent, influenced by improvements from the Inflation Reduction Act (IRA) and other CMS initiatives (CMS).
Part D Changes within MA
The “donut hole” coverage gap for prescription drugs has closed in 2025, and a $2,000 annual out-of-pocket cap for Part D drugs is introduced, which applies to both standalone Part D and MA-Part D plans. Plans may adjust formularies and cost-sharing accordingly (Kiplinger).
What Is Medicare Supplement (Medigap)?
Medicare Supplement, commonly known as Medigap, consists of standardized policies sold by private insurers to help pay costs that Original Medicare doesn’t cover—such as copayments, coinsurance, deductibles, and excess charges. Unlike Medicare Advantage, Medigap plans do not include Part D drug coverage or extra benefits like dental or vision. Instead, they “fill the gaps” in Original Medicare by covering certain out-of-pocket expenses.
Key Features of Medigap Plans
Standardized Plan Designs
Medigap plans are labeled by letters (Plan A, B, C [no longer available to new enrollees], D, F [phase-out for new enrollees after 2020], G, K, L, M, and N). Each lettered plan must follow federally standardized benefits (e.g., Plan G covers all Part A and Part B coinsurance and hospital costs up to an additional 365 days after Medicare benefits end, except the Part B deductible).
2025 Plan Offerings: Plans A, B, D, G, K, L, M, and N are available in most states. Plan F and Plan C are only available to those who were eligible for Medicare before January 1, 2020 .
Costs & Deductibles
Premiums: Vary by carrier, plan, and region. For instance, the average monthly premium for Medigap Plan G in 2025 is around $170, while Plan D might average slightly less—though rates depend heavily on location, gender, age, and tobacco use.
High-Deductible Plan G (HDG): In 2025, the deductible for HDG is $2,870; beneficiaries pay this amount first before the plan covers cost-sharing for Part A and Part B services.
Out-of-Pocket Limits (Plans K & L):
Plan K: Covers 100% of Part A hospital coinsurance/clay day 61–90 and 365–lifetime days; 50% of Part B coinsurance; 50% of the first three pints of blood; and 100% of Part B excess physician charges after you meet the plan’s $7,220 annual out-of-pocket limit.
Plan L: Similar to Plan K but covers 75% of Part B coinsurance after the plan meets the $3,610 out-of-pocket limit (MediGap Advisors, AMAC Medicare).
Guaranteed Renewable
As long as you pay your premium on time, your policy can’t be canceled—even if you have health issues.
Eligibility & Enrollment
Open Enrollment Period (OEP): A six-month window that begins on the first day of the month you turn 65 and are enrolled in Part B. During this period, insurers cannot use medical underwriting (i.e., they can’t charge you more or deny you coverage based on health conditions).
Guaranteed Issue Rights: You may have a guaranteed issue right to buy a Medigap plan without medical underwriting if you lose certain types of health coverage (e.g., leaving employer-sponsored coverage) or if your MA plan leaves the Medicare program or changes its service area. Outside of these situations, insurers can use medical underwriting to determine eligibility and premiums.
Switching Plans: If you want to switch Medigap plans outside your OEP, insurers can review your health status and potentially charge higher premiums or deny coverage.
Covered Services
Every Medigap plan covers the Medicare-approved amount for covered services (no balance billing).
Plans may cover: Part A coinsurance and hospital costs, Part B coinsurance or copay, blood (first three pints), Part A hospice care coinsurance or copayments, skilled nursing facility coinsurance, Part A deductible, Part B deductible (only Plans C & F if eligible), Part B excess charges (Plan G covers these), and foreign travel emergency care (up to certain limits).
Prescription Drugs (Part D)
Medigap plans do not include drug coverage, so beneficiaries typically enroll in a standalone Part D plan if they need prescriptions. With the new $2,000 Part D annual out-of-pocket cap in 2025, the need for extra prescription coverage alongside Medigap may decrease slightly (The Modern Medicare Agency).
What’s New for Medigap in 2025?
High-Deductible Plan G Deductible Increase
The 2025 deductible for HDG rose to $2,870 (from $2,600 in 2024), making it more costly before the plan begins paying benefits (MediGap Advisors, AMAC Medicare).
Out-of-Pocket Limits for Plans K & L
Plan K: Increased to $7,220 for 2025.
Plan L: Increased to $3,610 for 2025 .
Plan Availability & State-by-State Variations
Some states have been reducing the number of Medigap issuers, leading to fewer plan choices for new enrollees in certain regions. However, existing policyholders can typically renew their plans. For example, as of early 2025, a handful of rural states may only offer Plans A, G, and N, while more populous states still provide a full suite of lettered plans .
Elimination of Plan F for New Enrollees
Plan F is no longer available to new Medicare beneficiaries who became eligible on or after January 1, 2020. That means new enrollees in 2025 cannot purchase Plan F, although those who previously enrolled can keep it. Most new beneficiaries choose Plan G, which provides nearly identical benefits—except the Part B deductible (Plan G pays for this, whereas Plan F did).
Impact of Part D Out-of-Pocket Cap
The $2,000 annual Part D out-of-pocket cap in 2025 may influence how beneficiaries pair Medigap with standalone Part D plans. Since Part D out-of-pocket spending can now be spread throughout the year and capped, some may layer Part D onto Original Medicare + Medigap (especially if they anticipate high drug costs).
Conversely, if a beneficiary chooses an MA plan that includes Part D, they’ll automatically benefit from the $2,000 cap without purchasing a separate Part D policy (The Modern Medicare Agency).
Key Differences Between Medicare Advantage and Medigap Plans
To help you visualize the contrast between Medicare Advantage and Medigap, here’s a comprehensive comparison table:
Feature
Medicare Advantage (Part C)
Medicare Supplement (Medigap)
Coverage Base
Combines Original Medicare (Part A & B) and usually Part D (prescription drugs), plus often extra benefits (dental, vision, hearing, fitness).
Works with Original Medicare (Part A & B); does not include Part D or extra benefits like dental/vision.
Provider Network
Usually network-based (HMO, PPO, PFFS, SNP). Out-of-network services often incur higher costs or may be denied.
No network restrictions. Beneficiary can see any provider that accepts Medicare; no need for referrals.
Premiums
Average $17/month in 2025 (many plans have $0 premium). Premium varies by county and plan; some may charge up to $50–$100.
Varies by plan letter, insurer, and location. Average Plan G premium $170–$250 per month; Plan G deductible ($2,870 for HDG).
Deductibles
Varies—some MA plans have $0 Part A/B deductibles; prescription deductibles vary by plan.
Plan-specific: HDG deductible $2,870 in 2025. Standard plans have no Part B deductible (except Plans C & F, if eligible).
Out-of-Pocket Maximum
Yes: $9,350 in-network; $14,000 combined for 2025 (in-network + out-of-network). Once met, 100% covered.
No annual cap for services; cost-sharing varies by plan: Plans K & L have out-of-pocket limits ($7,220 and $3,610).
Prescription Drug Coverage
Usually included (Part D). Automatic benefit of $2,000 Part D out-of-pocket cap.
Must purchase a separate Part D plan; $2,000 Part D cap in 2025 applies to standalone Part D.
Supplemental Benefits
Often includes dental, vision, hearing, fitness (e.g., SilverSneakers), telehealth, transportation, and other social determinants of health services.
None. Must purchase separate insurance for vision, dental, hearing, and other non-Medicare-covered services.
Prior Authorization
Many MA plans require prior authorization for services, procedures, or specialist visits.
Original Medicare covers services as medically necessary; any prior authorization requirements come from the provider.
Referrals to Specialists
HMOs often require referrals; PPOs do not but may have higher out-of-pocket costs for out-of-network specialists.
No referrals required; patient can self-refer to specialists who accept Medicare.
Enrollment Restrictions
Must live in plan’s service area; can only enroll during designated periods (IEP, AEP, SEP).
Guaranteed issue without underwriting during the six-month Medigap OEP; otherwise, subject to medical underwriting unless guaranteed issuance rules apply.
Plan Changes Mid-Year
Limited—except for specific SEPs.
Can switch Medigap or Part D plans during annual election or guaranteed issue situations; outside OEP, underwriters can apply.
Stability of Benefits
Benefits and provider networks can change annually; plan cancellations possible—must review ANOC every September.
Standardized benefits do not change from year to year (for the same lettered plan); can renew as long as premiums are paid.
Plan Availability
Over 3,000 MA plans nationwide; choice varies by county.
Hundreds of carriers sell Medigap plans; availability depends on state regulations and insurer participation.
Ideal For
Beneficiaries seeking low/no premiums, extra benefits, integrated drug coverage, and are comfortable with network restrictions.
Beneficiaries who prefer unrestricted provider choice, predictable cost-sharing for hospital/doctor visits, and want Original Medicare’s flexibility.
Pros and Cons of Medicare Advantage Plans
Pros
Lower Out-of-Pocket Premiums
Many MA plans have $0 monthly premiums. Even plans with premiums rarely exceed $50–$100 in most counties for 2025, making them attractive to budget-conscious beneficiaries. According to CMS, the average MA premium for 2025 is $17/month (Kiplinger).
Integrated Prescription Drug Coverage
Instead of buying a separate Part D plan, most MA plans include prescription drug coverage. Beneficiaries automatically benefit from the new $2,000 annual out-of-pocket cap on Part D drugs (AMAC Medicare).
Extra Benefits Not in Original Medicare
Dental, vision, hearing, fitness memberships (e.g., SilverSneakers), transportation assistance, meal delivery, and other social determinant-related services. In 2024, over 99% of MA plans offered at least one supplemental benefit, with a median of 23 benefits per plan (CMS, CMS).
Out-of-Pocket Maximum for Part A & B
A federally mandated cap, protecting beneficiaries from catastrophic medical costs. In 2025, the maximum is $9,350 for in-network services and $14,000 combined for in- and out-of-network (Kiplinger).
Care Coordination & Disease Management
Many MA plans include care coordination, telehealth services, case management, and nurse hotlines. Behavioral health network adequacy has improved for 2025, ensuring better access to mental health providers, including telehealth options (CMS, American Hospital Association).
Simplified Claims Process
When you see in-network providers, there’s generally no balance billing or additional paperwork—your plan pays the provider directly.
Cons
Limited Provider Networks
Must use doctors and hospitals in the plan’s network (unless you’re willing to pay more for out-of-network services). If your favorite doctor leaves the network or the plan narrows its network, you may have to switch providers or pay higher costs.
In 2025, nearly 30% of beneficiaries reported receiving a “Notice of Credit Balance” when they attempted to use out-of-network services, reflecting stricter network rules (Barron’s).
Plan Changes & Cancellations
Each year, MA plans can change their provider networks, benefits, and cost-sharing. Some plans get discontinued; in such cases, beneficiaries must choose a new plan during the AEP (Oct 15–Dec 7). Approximately 10% of MA enrollees in 2024 discovered their plan was no longer offered for 2025 (Barron’s).
Prior Authorizations & Utilization Controls
Many MA plans require prior authorization for hospital stays, specialist visits, or certain procedures—whereas Original Medicare does not have prior authorization requirements (though it does have coverage rules).
This can lead to delays or denials if paperwork isn’t submitted correctly.
Potential for Higher Out-of-Pocket Costs
While premiums might be low, some MA plans have significant copays or coinsurance. For example, a plan might pay 100% after you reach the in-network out-of-pocket max, but only after you spend $3,400 in cost-sharing first.
According to CMS, in 2025, the average in-network out-of-pocket max is $9,350—meaning some beneficiaries could face high costs before reaching that threshold (Kiplinger).
Complex Rule Changes & Audits
CMS’s expanded RADV audits for 2025 (auditing all eligible MA plans annually) have created uncertainty around plan stability. Some insurers, like Humana and UnitedHealth Group, saw stock price drops in May 2025 after CMS announced the audit ramp-up, signaling financial strain for insurers heavily reliant on MA revenues (Barron’s, JD Supra).
Pros and Cons of Medigap Plans
Pros
Freedom to Choose Any Medicare-Accepted Provider
No network restrictions. You can see any doctor or hospital in the U.S. that accepts Medicare—even if you travel outside your home state. This flexibility is particularly important for those who travel frequently or split time between residences (e.g., “snowbirds”).
Providers cannot bill you more than Medicare-approved amounts; no surprises.
Predictable Cost-Sharing
Plans cover a significant portion (or all) of the Medicare Part A and Part B cost-sharing requirements. For instance, Plan G covers nearly everything except the Part B deductible ($257 in 2025) (Kiplinger, MediGap Advisors). Knowing exactly what you pay each year (premium + Part B deductible) simplifies budgeting.
Stable Benefits Year-to-Year
Since lettered Medigap plans are standardized, your benefits don’t change unless you switch plans. If you’re enrolled in Plan G, you know exactly what’s covered—and that will remain the same across carriers (though premiums might rise).
No mid-year plan cancellations or network changes.
Guaranteed Renewable
As long as you pay premiums on time, the insurer cannot cancel your policy—even if you develop serious health conditions. This offers peace of mind that coverage won’t vanish.
Original Medicare determines medical necessity; Medigap simply pays cost-sharing. You generally won’t face prior authorization hassles for Medicare-covered services.
Cons
Higher Monthly Premiums
In 2025, Medigap Plan G premiums average $170–$250 per month (depending on location and underwriting). Even Plans K and L, which have lower premiums, require significant out-of-pocket spending before reaching the plan’s out-of-pocket limit ($7,220 for Plan K; $3,610 for Plan L) (MediGap Advisors, AMAC Medicare).
Separate Part D Enrollment Required
Since Medigap plans don’t include prescription drug coverage, you must buy a standalone Part D plan if you need medications. While the $2,000 Part D cap in 2025 reduces risk, it also means paying a separate premium and tracking two policies .
Limited Extra Benefits
No dental, vision, hearing, or fitness benefits. If you want these extras, you must purchase separate coverage—often through a Medicare Advantage plan or individual policies.
Medical Underwriting Outside OEP
If you don’t buy a Medigap plan during your six-month Open Enrollment Period (when you have guaranteed issue rights), insurers can use medical underwriting to determine your eligibility and premium rates. Those with health issues can be denied coverage or charged higher premiums.
Premium Increases Over Time
While benefits remain standardized, premiums can increase annually based on insurer pricing strategies, healthcare inflation, and age. Some insurers use “attained-age” pricing—premiums rise as you age. Other insurers use “community-rated” pricing—everyone pays the same regardless of age (but premiums can rise due to claim costs).
Comparing renewal rates and pricing methods is crucial, since a $200/month premium at age 65 might jump to $400/month by age 75, depending on the carrier’s pricing model.
Cost Considerations for 2025
When choosing between Medicare Advantage and Medigap, costs often play a pivotal role. Below, we break down the main cost components for both options, referencing the latest figures for 2025.
Medicare Advantage Costs
Monthly Premium
Average Premium: $17.00/month in 2025 (many plans have $0 premiums).
Range: Some counties offer $0 premium plans, while others may charge up to $50–$100 for richer supplemental benefits. Always check your local plan options via Medicare’s Plan Finder (Kiplinger).
Part B Premium & Deductible
All MA enrollees still pay the standard Part B premium: $185/month (for 2025).
Part B deductible: $257 per year.
Some MA plans incorporate the Part B deductible as part of their cost-sharing structure, but you remain responsible for paying it before your plan’s benefits kick in (Kiplinger).
Out-of-Pocket Maximum (OOPM)
In-Network: $9,350 for 2025.
Combined (In + Out-of-Network): $14,000.
Once you reach the OOPM, the plan pays 100% of covered Part A and Part B services for the remainder of the year.
Out-of-pocket costs include deductibles, copays, and coinsurance for Part A and Part B services (enrollment fees for Part D not included).
Copays & Coinsurance
Varies widely by plan. For example:
Primary care visits: $0–$20 copay.
Specialist visits: $15–$50 copay.
Inpatient hospitalization: $325–$500 per day (days 1–5), then 20% coinsurance.
Emergency room: $80–$90 copay (waived if admitted).
Drug deductibles typically range from $0 to $515 (Part D deductible limit) depending on the plan (Kiplinger).
Prescription Drug (Part D) Cost-Sharing
Three coverage phases:
Deductible Phase: Up to $515, if the plan includes a deductible.
Initial Coverage Phase: You pay copays/coinsurance until $5,030 total drug spending (plan + you).
Coverage Gap (“Donut Hole”): In 2025, this gap is effectively closed, meaning you pay 25% of brand-name and generic drug costs, but this counts toward your out-of-pocket limit.
Catastrophic Coverage Phase: After you reach $2,000 out-of-pocket in 2025, you pay $0 for covered drugs the rest of the year (Kiplinger).
Additional Premiums
If you have higher income (e.g., $97,000+ single, $194,000+ joint), you pay an Income-Related Monthly Adjustment Amount (IRMAA) on top of your Part B and Part D premiums (Kiplinger).
Medigap Costs
Monthly Premiums
Plan G (Most Popular in 2025): $170–$250/month (varies by carrier, location, age, and rating method).
Plan D: Slightly lower premiums than Plan G but covers the Part B deductible (Plan D covers Part B deductible up to $257 for 2025).
Plan N: Even lower premiums (since you pay copays for office visits and emergency room visits).
Plan K: Low premiums, but 50% coverage for Part B coinsurance and other cost-sharing until you hit a $7,220 out-of-pocket limit.
Plan L: Moderate premiums, covers 75% of Part B coinsurance until a $3,610 out-of-pocket limit.
High-Deductible Plan G (HDG): Low premiums (e.g., $50–$70/month), but you must pay $2,870 out-of-pocket before the plan pays anything (MediGap Advisors, AMAC Medicare).
Part B Premium & Deductible
You still pay the standard Part B premium: $185/month.
For most Medigap plans (G, N, etc.), you also pay the Part B deductible ($257 for 2025) out of pocket; Plan D and Plan F (if previously eligible) cover the Part B deductible.
Other costs depend on plan letter:
Plan G: Pays 100% of Part A coinsurance, Part A deductible ($1,676 in 2025), Part B coinsurance (20%), and Part B excess charges after you meet the Part B deductible.
Plan D: Pays Part B deductible and same benefits as Plan G except for excess charges.
Plan F (only for pre-2020 enrollees): Covers Part B deductible, coinsurance, copayments, skilled nursing facility care coinsurance, home health care coinsurance, etc.
Plan N: Requires $20 copay for office visits and $50 for Urgent Care/ER (waived if admitted), covers Part B excess charges (some amount; see insurer’s policy).
If you enroll in a standalone Part D plan, you pay a separate premium (average $46.50 in 2025).
IRMAA may apply if your income is above certain thresholds, adding $13.70–$85.80 to your Part D premium in 2025 (Kiplinger).
Annual Deductibles
High-Deductible Plan G: $2,870 deductible.
Plan D & Plan C/F (if applicable): $257 Part B deductible (Plan D covers the Part B deductible).
Most other plans (like G & N) have no additional deductible beyond the Part B deductible (MediGap Advisors, AMAC Medicare).
Premium Pricing Methods
Issue-Age Rated: Premium based on age at purchase; does not increase as you age, but may rise due to inflation/claims.
Attained-Age Rated: Premium increases as you get older.
Community-Rated (No-Age Rated): Same premium for everyone, regardless of age (subject to inflation/claims).
When comparing carriers, ask which rating method they use—issue-age premiums typically cost more at purchase but can be cheaper long-term if you live into advanced ages.
Enrollment Periods and Eligibility
Choosing the right enrollment period is crucial to ensure you get the coverage you want—without facing denials or higher premiums.
Medicare Advantage (Part C) Enrollment
Initial Enrollment Period (IEP)
Begins three months before you turn 65, includes the month you turn 65, and extends three months after.
If you enroll in Original Medicare (Parts A & B) during IEP, you can also enroll in an MA plan without penalty.
Annual Enrollment Period (AEP)
Dates: October 15–December 7 each year.
What You Can Do:
Switch from Original Medicare to Medicare Advantage.
Switch from one Medicare Advantage plan to another.
Switch from Medicare Advantage back to Original Medicare.
Change or drop your Part D plan (if your MA plan doesn’t include Part D).
Medicare Advantage Open Enrollment Period (MA-OEP)
Dates: January 1–March 31 each year.
If you’re already in an MA plan, you can switch to a different MA plan or revert to Original Medicare (with or without a standalone Part D plan). You can only make one change during MA-OEP, and the change takes effect the first of the next month.
Special Enrollment Period (SEP)
For life events such as moving out of your plan’s service area, losing employer coverage, qualifying for Medicaid, etc. Each situation has its own timeline and rules; check Medicare.gov SEPs for details.
Medigap Enrollment
Medigap Open Enrollment Period (OEP)
Start: The month you turn 65 and are enrolled in Part B.
Duration: Six months (including that month).
Guarantees: Insurers cannot use medical underwriting. They must sell you any plan they offer in your state, charge the same premium as other applicants of the same age, and cannot impose pre-existing condition waiting periods.
Guaranteed Issue Rights
If you lose certain health coverage (e.g., employer-sponsored or retiree), move out of an MA plan’s service area, or a plan terminates coverage, you may have guaranteed issue rights to buy Medigap without underwriting—often for a limited time (e.g., 63 days after losing coverage).
During these windows, insurers can’t deny you or charge more due to health conditions.
Outside OEP
Insurers can require medical underwriting—meaning they can charge you higher premiums or refuse coverage based on health status, unless you qualify for guaranteed issue.
Premiums can vary significantly based on age, gender, tobacco use, and pre-existing conditions.
Switching Medigap Plans
If you’re still within your OEP or guaranteed issue window, you have broad options and protections.
Outside these windows, you need underwriting to switch carriers, which can result in higher premiums or denial.
Considerations for 2025 Changes
Both Medicare Advantage and Medigap are feeling the impact of key policy changes and broader healthcare trends in 2025. Below are the most significant developments to keep in mind when making your decision:
1. Part D Out-of-Pocket Cap of $2,000
Impact on MA & Medigap:
With a $2,000 annual cap on Part D out-of-pocket spending effective January 1, 2025, beneficiaries who choose MA plans with integrated Part D automatically benefit from this protection—no need to shop for a standalone Part D plan.
For those in Original Medicare + Medigap, you now know your maximum prescription drug out-of-pocket is $2,000, which may make the combination of Original Medicare + Medigap + standalone Part D more predictable than before (Kiplinger).
Why It Matters:
In prior years, the coverage gap (“donut hole”) exposed beneficiaries to high drug costs mid-year. Now, a $2,000 limit significantly reduces financial risk. This change may tilt some beneficiaries toward Original Medicare + Medigap if their primary concern was uncontrolled drug costs.
2. Expanded RADV Audits & Plan Scrutiny
What’s Happening:
CMS announced on May 21, 2025 that it will audit all eligible Medicare Advantage plans annually for coding accuracy and fraud prevention—clearing a backlog of audits for payment years 2018–2024 by early 2026 (JD Supra, JD Supra).
Implications:
Insurers may tighten provider networks, raise premiums, or reduce supplemental benefits to mitigate potential repayment risks.
Some MA plans in 2024 were discontinued rather than face uncertain audit liabilities; more plan cancellations could occur in late 2025 as insurers adjust to audit demands.
For beneficiaries, this means reviewing your plan’s stability each AEP—ensuring your preferred providers remain in-network and your benefits aren’t reduced unexpectedly.
3. Behavioral Health & Telehealth Emphasis
Network Adequacy Standards:
Under CMS’s 2025 rule, MA plans must verify that behavioral health providers treat a minimum number of patients, including telehealth encounters, to count toward network adequacy (CMS).
This change aims to close mental health access gaps, but it could also lead plans to narrow networks to only include high-volume providers.
Why It Matters:
Beneficiaries with mental health needs should confirm that their plan’s network includes psychiatrists, therapists, and telehealth options that meet the new standards—especially in rural areas where provider availability is historically limited.
4. Medigap Plan Availability & Premium Pressure
States Reducing Medigap Options:
Some states have seen insurers exit the Medigap market, leaving only a few carriers. This can lead to higher premiums due to reduced competition.
In certain rural or less-populous states, new enrollees may only find Plans A, G, and N available.
Why It Matters:
If you live in a state with diminishing Medigap choices, premiums can rise sharply. Checking your state’s Medigap market before your Medigap OEP in 2025 is critical—especially if you want Plan G or N.
If your state is consolidating to fewer carriers, shopping for Medigap outside your OEP could require underwriting, increasing your risk of denial or exorbitant premiums if you have health issues.
For 2025, high-income beneficiaries (e.g., individuals earning $97,000+ or couples earning $194,000+) face additional surcharges on Part B ($74–$443.90) and Part D ($13.70–$85.80) premiums (Kiplinger).
Why It Matters:
Even if you choose an MA plan, you still pay Part B IRMAA if your income exceeds thresholds. Those who combine Original Medicare + Medigap + Part D must budget for IRMAA as well.
Evaluate how these surcharges impact your annual healthcare budget, especially if you expect to have moderate to high medical and drug costs.
6. Star Ratings & Quality Bonus Payments
Rating Methodology Changes:
For the 2025 Star Ratings, CMS implemented Tukey outlier deletion for non-CAHPS measures and introduced guardrails for the Part D Plan Finder measure to stabilize ratings year-over-year (CMS).
Plans that achieve 4 or 5 stars can receive quality bonus payments, which can fund extra benefits, reduce cost-sharing, or lower premiums for enrollees.
Why It Matters:
A 4- or 5-star MA plan not only indicates higher performance but may also translate into tangible savings—particularly if you qualify for low-income subsidies or extra help programs that tie into star-rated plan selection.
Always check a plan’s star rating for 2025 when comparing MA options. Plans with higher ratings often maintain robust networks and coordinate care effectively.
How to Decide: Factors to Weigh for 2025
Choosing between Medicare Advantage and Medigap ultimately boils down to your unique healthcare needs, financial situation, provider preferences, and willingness to accept certain trade-offs. Below are questions and considerations to guide your decision:
1. Provider Choice & Flexibility
Do you have a favorite specialist or hospital network?
If yes: Medigap + Original Medicare offers broader freedom—any provider that accepts Medicare can see you. You’ll never worry about in-network vs. out-of-network.
If no: MA might work fine if your primary care physician and key specialists are in-network. Many MA plans have expansive PPO networks that still include major health systems.
Do you travel frequently (e.g., snowbird, seasonal relocator)?
If yes: Medigap is generally preferable, as you’re covered nationwide by any Medicare-accepting provider.
If no: A local MA plan with good network coverage may suffice.
2. Premiums & Out-of-Pocket Cost Tolerance
Do you want predictable, minimal out-of-pocket costs?
If yes: A Medicare Advantage plan with a low or $0 premium and a known out-of-pocket maximum (e.g., $9,350 in-network) might suit you—especially if you rarely visit the hospital.
If no: Perhaps a Medigap Plan G, with stable cost-sharing (you pay Part B deductible $257, then 20% of Part B costs), plus a monthly premium, might feel more predictable—especially if you anticipate multiple doctor visits or hospital stays.
Are you concerned about high prescription drug costs?
If yes: With MA-Part D, you benefit from the new $2,000 cap automatically. If you choose Medigap, you’ll need a Part D plan to gain the same $2,000 protection—though that involves paying a separate Part D premium (average $46.50 for 2025).
If no: If you rarely use medications, the $46.50 Part D premium might feel like wasted money, making an MA plan more appealing.
3. Supplemental Benefits Importance
Do you need dental, vision, hearing, or wellness perks?
If yes: Many MA plans include these extras at little to no additional cost—benefits you won’t get with Medigap. For instance, a common MA plan might offer an annual $1,000 dental allowance, free hearing exams, and a fitness membership.
If no: If you’re comfortable purchasing separate dental and vision insurance or don’t need those services, Medigap’s narrower focus on hospital and medical cost-sharing might suffice.
4. Willingness to Deal with Plan Changes & Network Restrictions
Are you comfortable with possible mid-year plan changes?
If yes: MA plans can adjust provider networks, change formularies, and tweak benefits annually—requiring you to review your Annual Notice of Change (ANOC) each September.
If no: Medigap benefits remain standardized and stable year over year. You’ll never worry about a “Notice of Credit Balance” for using out-of-network providers because there are none.
5. Health Status & Underwriting Concerns
Do you have chronic health conditions requiring frequent specialist visits?
If yes: Medigap might be the safer choice—no referrals, no network disruptions, predictable 20% coinsurance under Plan G for Part B services.
If no: A well-rated MA plan can provide robust care coordination, disease management programs, and case management—especially for chronic conditions—often with lower monthly premiums.
Are you subject to medical underwriting for Medigap?
If you enroll: During your Medigap OEP (six months from Part B start), you have guaranteed issue rights. If you miss that window, insurers can review your health history and potentially charge extra or deny coverage, making MA your only guaranteed-issue option if you’re outside the OEP (Legal Not Legal).
Conclusion
Choosing between Medicare Advantage and Medicare Supplement (Medigap) plans isn’t a one-size-fits-all decision—especially with the new landscape in 2025. Here’s a quick recap to help you decide:
Medicare Advantage (Part C) May Be Best If You Want:
$0–$17 average monthly premiums (plus $185 Part B premium) in 2025.
An all-in-one bundle with Part D drug coverage, dental, vision, hearing, fitness, and other extras.
A defined out-of-pocket maximum (e.g., $9,350 in-network) to limit catastrophic costs.
Care coordination, telehealth services, and disease management programs through plan networks.
Comfort with network-based care and willingness to review yearly plan changes.
Access to Star Ratings to gauge plan quality and benefit from potential quality bonus payments.
Medicare Supplement (Medigap) May Be Best If You Want:
Unrestricted access to any Medicare-accepting provider in the U.S., including specialists and hospitals.
Predictable cost-sharing (especially with Plan G) after the $257 Part B deductible—no copays or unexpected network denials.
Stable, standardized benefits that don’t change year-to-year (though premiums may rise).
Protection against high hospital and medical bills (e.g., Plan G covers 20% coinsurance for Part B services).
Freedom from prior authorizations for Medicare-covered services.
Ultimately, consider your health needs, financial situation, preferred doctors, and tolerance for change. Here are a few next steps you can take right away:
Compare Plans via Medicare’s Plan Finder
Visit Medicare.gov Plan Finder to see available MA plans in your ZIP code (including premiums, star ratings, provider networks, and formularies).
Compare standalone Part D plans if you’re leaning toward Medigap.
Speak with a State Health Insurance Assistance Program (SHIP) Counselor
SHIP offers free, unbiased counseling to all Medicare beneficiaries. To find your state’s SHIP number, check shiphelp.org or call 1-800-MEDICARE. Trained counselors can walk you through plan comparisons, eligibility concerns, and enrollment windows (NerdWallet).
Review Your Annual Notice of Change (ANOC) Each September
If you’re already on an MA plan, make sure nothing critical has changed—especially provider networks, formularies, cost-sharing, or premiums—before October 15.
Similarly, if you have a Medigap plan, compare premium trends of different carriers to ensure you’re not overpaying.
Assess Your Prescription Drug Needs
Check if your medications are on a plan’s formulary (MA or standalone Part D).
Keep the new $2,000 Part D out-of-pocket cap in mind, which applies to both MA Part D and standalone Part D in 2025.
Factor in Health Status & Future Needs
If you expect heavy utilization (hospital stays, frequent specialist visits), Medigap’s predictable coinsurance coverage might prove cost-effective.
If you’re relatively healthy but want flexibility in budgeting (lower premiums, fixed out-of-pocket max), a high-quality MA plan could be ideal.
By weighing the pros, cons, and costs—while staying informed about 2025 changes—you’ll be well-equipped to pick the plan that best aligns with your health and financial goals. Remember, every year between October 15 and December 7, you have the chance to switch plans or change coverage during the Annual Enrollment Period. Mark your calendar, review your options, and stay proactive. Medicare can be complex, but with the right information and resources, you can find coverage that gives you peace of mind and the freedom to focus on what matters most: your health and well-being.
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