When you're new to Medicare, the marketing makes Medicare Advantage look like the clear winner. TV ads tout $0 premiums and all-in-one convenience. It’s tempting — especially when you’re healthy. But what happens when your health changes? That’s when the cracks in Medicare Advantage start to show — and when many people wish they’d chosen Medigap from the start.
In this article, we’ll take you behind the curtain and show you what’s really happening with both options — the fine print most agents gloss over. You'll also see real-life examples and cost comparisons to help you make a confident, informed choice.
The Shiny Appeal of Medicare Advantage
There’s a reason Medicare Advantage plans get so much attention:
$0 or low monthly premiums
Extras like dental, vision, hearing aids, gym memberships
Bundled medical and drug coverage in one plan
Sounds great, right? On paper, it is.
But once you actually need care, the experience can shift dramatically.
What You Don’t See: The Hidden Costs of Medicare Advantage
Medicare Advantage plans are run by private insurance companies. When you join one, you give up Original Medicare and let the plan manage your care.
That means:
1. Utilization Reviews
Before you can get certain services, your provider must get approval from the plan — even for medically necessary care like rehab, imaging, or surgeries. This process can delay care or result in outright denials.
2. Prior Authorizations
Over 35 million prior authorizations were submitted to Medicare Advantage plans in a single year — and thousands were wrongly denied. That’s a lot of time spent waiting or appealing.
3. Copays Add Up
You may owe $35 for a specialist visit, $300–$400 for outpatient surgery, and hundreds more if you're hospitalized. It doesn’t take long to reach your plan’s maximum out-of-pocket, which can be as high as $8,850/year (in-network).
4. Narrow Networks
Your plan may not cover your favorite doctor or nearby hospital. And if you travel or spend time in another state, coverage can become confusing — or unavailable.
Real-Life Member Story: Marie’s Denied Rehab
Marie, age 72, had a knee replacement. Her surgeon ordered inpatient rehab, but her Advantage plan said no. She was discharged home too early, fell twice, and was readmitted to the hospital. “We lost weeks appealing. It set her healing back and caused unnecessary pain,” her daughter said. “With Medigap, she would’ve gone straight to rehab. No questions asked.”
Medigap: Simpler, Smarter, and Far Less Stress
Medigap (Medicare Supplement) plans work with Original Medicare — not instead of it. You keep your red, white, and blue Medicare card. You see any doctor nationwide who accepts Medicare. No networks, no referrals. Then, your Medigap plan steps in to cover the bills that Medicare doesn’t: the 20% coinsurance, hospital deductibles, and more.
Benefits of Medigap:
No prior authorizations
No provider networks
No surprise billing
No max out-of-pocket
No delays in care
Just straightforward coverage and peace of mind.
Real-Life Member Story: Robert’s Cancer Care
Robert, age 68, was diagnosed with prostate cancer. Thanks to Medigap Plan G, his specialist visits, scans, and treatments were fully covered after meeting his Part B deductible. “There was no one second-guessing my doctor,” he said. “I just focused on getting better.”
Cost Comparison: Advantage vs. Medigap (Annual)
Category | Medicare Advantage | Medigap Plan G |
Monthly Premium | $0–$40 | ~$140 |
Part D Drug Plan | Included | ~$20 |
Primary Care Copays (5 visits) | $75 | $0 |
Specialist Copays (6 visits) | $300 | $0 |
Outpatient Surgery | $400–$600 | $0 |
Hospital Stay (5 days) | $1,000–$1,500 | $0 |
Annual Drug Copays | $300 | $300 |
Total Out-of-Pocket Estimate | $2,175–$2,835 | $2,160 |
Result: You may save little or nothing with Advantage in a moderate health year — and you take on more risk and complexity.
When Denial Costs More Than Premiums: Janet’s Story
Let’s go one step further. What happens when your Medicare Advantage plan denies care?
Category | Medicare Advantage (Janet) | Medigap Plan G (Linda) |
Monthly Premium | $0 | $140 |
Part D Drug Plan | Included | $20 |
Outpatient Back Surgery (Approved) | $400 | $0 |
Rehab Therapy (Denied - Out of Pocket) | $4,200 | $0 |
8 Specialist Visits @ $50 | $400 | $0 |
Annual Drug Copays | $300 | $300 |
Annual Out-of-Pocket Total | $5,300 | $2,180 |
Lesson: Janet’s “free” plan ended up costing her more than double what Linda paid — plus the stress of a denial while trying to recover.
What Most Agents Don’t Tell You: You Only Get One Medigap Golden Window
When you first turn 65 or leave employer coverage, you enter a 6-month Medigap Open Enrollment Period. During this time, you can enroll in any Medigap plan — no medical exams, no denials, no rate increases due to health.
After that? If you want to switch from a Medicare Advantage plan to Medigap later — say, when you’re 75 or 80 and develop health conditions — you’ll likely face medical underwriting. Many are denied coverage due to preexisting conditions.
This is one of the most common and costly mistakes people make:
“I’ll just switch later if I need to.”
Unfortunately, later may not be an option.
Why Don’t More Agents Mention This?
To be transparent: many agents earn more selling Medicare Advantage plans than Medigap plans. That’s why some skip over the long-term risks and focus on the low premium today.
At 65Plus Advisory, I do things differently. I don’t push one option over the other — I walk you through both, explain the fine print, and help you make the best decision for your future.
Final Thoughts: Choose Based on Reality, Not Just the Brochure
Medicare Advantage can look attractive when you’re healthy. But when life throws you a curveball — surgery, illness, chronic care — Medigap shines for its simplicity, stability, and protection.
Want help comparing your options? Book a consultation today and I’ll help you find and customize a plan specifically for you. No pressure. Just real talk.