Medicare Products: Advantage, Part D, and Medigap
Domain 2 asks you to match a beneficiary's health needs, budget, and travel patterns to the right product - and to know what each product legally can and cannot do.
Medicare Advantage (Part C)
Plans must cover everything Original Medicare covers, and may add dental, vision, hearing, and fitness benefits. Structures include HMOs (network-only, referrals often required), PPOs (out-of-network care at higher cost), PFFS, and Special Needs Plans: C-SNP for chronic conditions, D-SNP for dual-eligibles, and I-SNP for institutional residents. Key features to compare: the annual out-of-pocket maximum, prior authorization, provider networks, and the formulary. Benefits reset each January 1.
Standalone Part D
Prescription drug plans vary by formulary, tier placement, pharmacy network, deductible, and utilization management. A beneficiary enrolled in an MA-PD cannot also hold a standalone PDP, and someone in an MA-only plan generally cannot add one; they must move to an MA-PD or return to Original Medicare first.
Medigap
Medigap supplements Original Medicare only - never an MA plan. Benefits are standardized by letter in every state except Massachusetts, Minnesota, and Wisconsin; premiums are not. Plans C and F are closed to anyone newly eligible for Medicare after January 1, 2020. Plan G covers the Part A deductible and all of the Part B coinsurance except the Part B deductible itself; Plan N leaves modest copays and does not cover Part B excess charges. The federal guaranteed-issue window is the six-month Medigap Open Enrollment beginning when the person is 65 and enrolled in Part B; afterward, most states allow medical underwriting.
Worked example
A 67-year-old with diabetes travels out of state frequently and wants predictable costs. A Medigap Plan G plus a standalone PDP gives nationwide provider access and no network restrictions, at a higher premium. An MA-PD in her county may cost less monthly but restricts her network and requires prior authorization. Either can be defensible - the exam wants the tradeoff stated, not a slogan.
Traps
Assuming Medigap benefits differ by insurer; assuming Plan G covers the Part B deductible; quoting Plan F to a newly eligible beneficiary; and presenting Medigap and an MA or PDP plan in the same appointment.