Medicare Advantage vs. Medicare Supplement in Spokane
Medicare Advantage and Medicare Supplement Insurance (Medigap) are not two versions of the same product.
- Medicare Advantage is another way to receive Medicare Part A and Part B benefits through a private plan approved by Medicare.
- Medigap works with Original Medicare and helps pay some of the deductibles, copayments, and coinsurance Original Medicare leaves to the beneficiary.
You generally cannot use Medigap with Medicare Advantage. The decision is therefore about the entire coverage structure, not just a premium.
The two basic structures
Original Medicare + optional Medigap + Part D
In this structure:
- Original Medicare remains the primary medical coverage.
- A Medigap policy may pay some of the beneficiary's share for Medicare-covered services.
- A separate Part D plan usually provides outpatient prescription coverage.
- The beneficiary normally pays the Part B premium, Medigap premium, and Part D premium.
- Providers generally can be used nationwide if they accept Medicare.
Original Medicare by itself has no annual limit on beneficiary out-of-pocket costs for Part A and Part B services. Medigap can make those costs more predictable, depending on the standardized plan selected.
Medicare Advantage
In this structure:
- A private Medicare Advantage plan provides Part A and Part B benefits.
- Most plans include Part D.
- The beneficiary continues to pay the Part B premium and may also pay a plan premium.
- The plan sets copayments, coinsurance, network rules, and a yearly maximum for covered Part A and Part B services.
- Plans may offer benefits Original Medicare does not cover, such as certain dental, vision, hearing, fitness, transportation, or over-the-counter benefits.
Benefits and costs vary by plan and county and can change each year.
Side-by-side decision factors
| Decision factor | Original Medicare + Medigap | Medicare Advantage |
|---|---|---|
| Medical coverage | Original Medicare | Private plan provides Part A and Part B benefits |
| Provider access | Any provider nationwide who accepts Medicare | Usually plan network and service-area rules |
| Referrals | Usually not required | May be required |
| Prior authorization | Original Medicare generally requires less prior authorization | Plans may require prior authorization |
| Prescription coverage | Separate Part D plan | Usually included |
| Medical out-of-pocket limit | Original Medicare has none; Medigap can pay covered gaps | Plan has an annual maximum for covered Part A and Part B services |
| Monthly premiums | Part B + Medigap + Part D | Part B + any plan premium |
| Extra benefits | Generally separate or not included | May include additional benefits |
| Annual review | Part D and premiums still require review | Full plan should be reviewed annually |
| Travel in the U.S. | Broad access when providers accept Medicare | Emergency/urgent care covered; routine care depends on plan |
| Medigap underwriting concern | Timing can affect ability to buy or change policies | Not applicable while enrolled, but future Medigap access may be limited |
This table is a starting point. The exact plan, policy, medications, providers, and costs determine the practical result.
Provider access
Original Medicare with Medigap
Original Medicare allows use of doctors and hospitals throughout the United States that accept Medicare. Medigap policies generally do not use ordinary provider networks because they supplement Medicare-approved services.
Ask:
- Does the provider accept Medicare?
- Does the provider accept assignment?
- Is the service covered by Medicare?
- Does the Medigap plan cover the applicable beneficiary share?
Medicare Advantage
A Medicare Advantage HMO usually requires in-network non-emergency care and may require referrals. A PPO may allow some out-of-network care at higher cost, but this varies.
Verify:
- Primary-care provider
- Specialists
- Preferred hospital
- Urgent care
- Behavioral-health providers
- Therapy
- Imaging and laboratory facilities
- Skilled nursing facilities
- Home health agencies
- Durable medical equipment suppliers
Use the exact plan and network. A provider participating with an insurer does not mean the provider participates in every plan that insurer offers.
Prior authorization
Original Medicare generally does not require prior authorization for most covered services, although coverage rules and limited prior-authorization programs still apply.
Medicare Advantage plans may require plan approval before certain services or supplies are covered. This can affect imaging, surgeries, rehabilitation, skilled nursing, home health, equipment, and other care.
Ask:
- Which services require authorization?
- Who submits the request?
- What happens if authorization is denied?
- Is an expedited review available for an urgent need?
- Does an existing authorization continue after January 1 or after a plan change?
Medical costs
Original Medicare without Medigap
After applicable deductibles, a beneficiary commonly pays 20% of the Medicare-approved amount for Part B services when the provider accepts assignment. There is no annual medical out-of-pocket maximum under Original Medicare alone.
Medigap
Medigap plans are standardized by letter. The same letter provides the same standardized medical benefits regardless of insurer, but premiums, rating methods, household discounts, service, and rate history can differ.
Examples:
- Plan G pays many Original Medicare cost-sharing amounts after the beneficiary pays the annual Part B deductible.
- Plan N pays many similar gaps but can require certain office and emergency-room copayments and does not cover Part B excess charges.
- High-Deductible Plan G requires the beneficiary to pay Medicare-covered cost sharing up to the annual high-deductible amount before the policy begins paying. The 2026 high-deductible amount is $2,950.
For High-Deductible Plan G, the beneficiary first satisfies the 2026 Part B deductible of $283. For Part B services after that deductible, Medicare generally pays 80% of the Medicare-approved amount and the beneficiary pays 20%; eligible beneficiary cost sharing accumulates toward the $2,950 High-Deductible Plan G amount. Medicare-covered Part A cost sharing, including an applicable Part A deductible, can also count under the policy's rules.
High-Deductible Plan G can reduce the monthly premium while increasing the amount the member may pay before the supplement begins paying. It should be evaluated using both a low-use and high-use year.
Medicare Advantage
Medicare Advantage uses plan-specific copayments and coinsurance. Review:
- Hospital admission cost
- Outpatient surgery
- Specialist visits
- Imaging
- Therapy
- Skilled nursing facility care
- Ambulance
- Durable medical equipment
- Part B drugs
- In-network maximum out of pocket
- Any separate out-of-network maximum
A $0 plan premium does not mean $0 medical cost.
Prescription drugs
Medigap policies sold today do not include outpatient prescription coverage. A person using Original Medicare with Medigap generally evaluates a separate Part D plan.
Most Medicare Advantage plans include Part D. In either structure, check:
- Exact drug
- Strength
- Dose
- Quantity
- Formulary tier
- Pharmacy
- Deductible
- Copayment or coinsurance
- Prior authorization
- Step therapy
- Quantity limits
- Specialty-pharmacy requirements
The medical structure and the drug result should be evaluated together.
Premiums and predictability
Medigap structure
Typical recurring costs can include:
- Part B premium
- Medigap premium
- Part D premium
- Any Part D income-related adjustment
- Drug costs
- Services not covered by Medicare or Medigap
Medigap premiums can increase over time. Compare the current price and the insurer's pricing approach, discounts, and rate history when available.
Medicare Advantage structure
Typical recurring or usage costs can include:
- Part B premium
- Any plan premium
- Copayments and coinsurance
- Drug costs
- Out-of-network costs when covered
- Costs for extra benefits beyond plan limits
Medicare Advantage can have a lower monthly premium, but the beneficiary may pay more when using medical services. The annual medical out-of-pocket maximum provides a ceiling for covered Part A and Part B services, but prescription and non-covered costs generally are separate.
Extra benefits
Medicare Advantage plans may advertise dental, vision, hearing, fitness, meals, transportation, or over-the-counter benefits.
Ask:
- What exact service is covered?
- Which providers can be used?
- Is there an allowance or service limit?
- Does unused allowance expire?
- Are prior authorization or network rules involved?
- Is the benefit medically or eligibility restricted?
- Would you use it enough to affect the decision?
Extra benefits can be valuable, but they should not outweigh access to essential doctors, prescriptions, and medical care.
Original Medicare and Medigap generally do not include routine dental, vision, hearing aids, or long-term custodial care. Separate coverage or personal payment may be needed.
Travel and seasonal residence
Original Medicare with Medigap can be useful for people who want routine access to Medicare providers across the country. Some Medigap plans include limited foreign-travel emergency benefits.
Medicare Advantage covers emergency and urgent care while traveling in the United States, but routine care outside the plan's service area depends on the plan. PPO out-of-network benefits may help, but costs and rules vary.
Snowbirds and frequent travelers should verify:
- Routine care away from Spokane
- Dialysis
- Infusions
- Physical therapy
- Durable medical equipment
- Prescription refills
- Network access at the second residence
- Foreign emergency coverage
Enrollment and future flexibility
Medigap Open Enrollment
The one-time federal Medigap Open Enrollment Period lasts six months beginning the first month a person is 65 or older and enrolled in Part B. During this period, an insurer generally cannot deny a Medigap policy it sells because of health history or charge more because of pre-existing conditions.
Outside protected enrollment rights, medical underwriting may apply and a person may be denied or charged differently, depending on federal and Washington rules.
Medicare Advantage enrollment
Medicare Advantage enrollment and disenrollment are allowed only during applicable election periods or Special Enrollment Periods.
Switching later
Do not assume you can always move from Medicare Advantage to Medigap later. Leaving Medicare Advantage may be allowed during an enrollment period, but buying Medigap can be a separate question involving underwriting unless a guaranteed-issue, trial-right, or Washington-specific protection applies.
Likewise, do not cancel a Medigap policy until the replacement coverage is approved, issued, and understood.
Trial rights
Federal rules provide limited trial rights in certain situations, such as trying Medicare Advantage when first eligible at 65 or leaving a Medigap policy to try Medicare Advantage for the first time and returning within the permitted period.
Trial rights are specific. Verify the exact dates and available Medigap options before making a change.
Annual review differences
Medicare Advantage plans should be reviewed every year because premiums, networks, benefits, formularies, copayments, prior authorization, and maximum out-of-pocket amounts can change.
A Medigap policy's standardized benefits generally remain the same as long as the policy remains in force, but premiums can change. The separate Part D plan should still be reviewed annually because drug formularies, pharmacies, premiums, and costs can change.
Who may prefer Original Medicare with Medigap?
This structure may deserve closer review for someone who prioritizes:
- Broad nationwide provider access
- Fewer network restrictions
- More predictable Medicare-covered medical cost sharing
- Less reliance on plan prior authorization
- Frequent domestic travel or seasonal residence
- Ability to choose a separate Part D plan
The higher combined monthly premium may be the principal tradeoff.
Who may prefer Medicare Advantage?
This structure may deserve closer review for someone who prioritizes:
- Lower monthly plan premium
- One plan that usually combines medical and Part D coverage
- An annual maximum on covered medical out-of-pocket costs
- Additional benefits
- Comfort using a local network
- Willingness to review and potentially change coverage annually
The principal tradeoffs can include network, prior-authorization, and service-area rules.
Questions to answer before choosing
- Are all essential providers in-network or accepting Medicare?
- What will each prescription cost at the preferred pharmacy?
- What are the likely annual premiums?
- What could a high-use medical year cost?
- How do hospital, skilled nursing, therapy, imaging, and equipment costs compare?
- Is prior authorization likely for current care?
- Is routine care needed outside Spokane?
- How important are extra benefits?
- Is Medigap guaranteed available now?
- What could happen if coverage is changed later?
- Are retiree, union, VA, TRICARE, Medicaid, or employer benefits affected?
- Which insurers and plans does the adviser represent?
Use official comparison tools
Use Medicare Plan Compare with the person's exact medications and pharmacies. Verify providers directly with the plan and the provider. Review the Evidence of Coverage, Summary of Benefits, formulary, provider directory, and Medigap outline of coverage.
Washington SHIBA offers free, unbiased counseling. A licensed agent can compare the plans and insurers the agent represents.
The best choice is personal
Medicare Advantage is not automatically better because the premium is lower or because it includes extra benefits. Medigap is not automatically better because it offers broader provider access or more predictable medical costs.
The stronger choice is the structure that fits the person's providers, prescriptions, budget, risk tolerance, travel, expected care, and ability to change coverage later.
Health Insurance Options LLC is a licensed independent insurance agency. We may be compensated by insurers and do not represent every Medicare plan. Currently, we represent 8 organizations offering 75 products in the area. Contact Medicare.gov, 1-800-MEDICARE, or Washington SHIBA for information about all options. We are not affiliated with or endorsed by the U.S. government or Medicare.
Official sources
- Your Medicare coverage options — Medicare.gov; checked Jul 30, 2026
- Compare Original Medicare and Medicare Advantage — Medicare.gov; checked Jul 30, 2026
- Compare Medigap and Medicare Advantage plans — Washington Office of the Insurance Commissioner; checked Aug 10, 2026
- How Medigap works — Medicare.gov; checked Aug 10, 2026
- Compare Medigap plan benefits — Medicare.gov; checked Aug 10, 2026