The Centers for Medicare and Medicaid Services (CMS) announced it is pursuing further limits on Medicare Advantage plans’ use of prior authorization and artificial intelligence — the latest move in an ongoing effort to address Medicare Advantage guardrails that protect seniors from coverage denials. Here’s what the proposed rules would do and what they mean for Arizona Medicare enrollees.
Why CMS Is Proposing Medicare Advantage Guardrails
Prior authorization — requiring insurer approval before medical care can be delivered — has become one of the most significant complaints from Medicare Advantage enrollees. A Senate Finance Committee investigation found that major Medicare Advantage insurers denied prior authorization requests at rates far higher than originally reported, and that many denials were for care that Original Medicare would have covered without question.
Adding to the concern, many insurers began using artificial intelligence algorithms to make or assist with prior authorization decisions. In some cases, these AI systems were denying care without adequate review by a physician.
What the Proposed Medicare Advantage Guardrails Would Do
CMS’s proposed Medicare Advantage guardrails target several specific practices:
- AI-based denials — Plans would be required to have physician oversight of any AI-assisted prior authorization decision. An algorithm alone could not deny a claim.
- Criteria alignment — Plans would need to use coverage criteria that align with Original Medicare, reducing the ability to deny care that Medicare would otherwise cover.
- Faster decisions — Stricter timelines for prior authorization decisions, particularly for urgent care situations.
- Continuity of care — Protections for patients who are mid-treatment when a plan changes its network or coverage.
What This Means — and What It Doesn’t Fix
The proposed rules are a step in the right direction. However, they don’t eliminate the fundamental structure of Medicare Advantage guardrails — they only constrain how plans can implement them.
According to CMS, even with these new rules in place, Medicare Advantage plans will still require prior authorization for many services. Original Medicare does not require prior authorization for most care. That fundamental difference remains.
The Alternative: Original Medicare With Plan G
If you’re concerned about prior authorization, AI-based denials, or narrow networks, the most reliable solution is returning to Original Medicare with a Medicare Supplement Plan G.
With Plan G, you pay the Part B deductible once per year — $257 in 2026 — and after that, Medicare and Plan G cover your costs for the year. No prior authorization. No AI deciding your care. No networks.
Questions About Your Medicare Coverage Options?
I’m Andy Orlikoff, an independent Medicare broker in Surprise, AZ. I help Arizona seniors understand what the latest Medicare Advantage guardrails and policy changes mean for their coverage — and whether Original Medicare with Plan G is a better fit.
Call or text: (623) 742-3878
Email: andy@azhealth.us
Fill out the contact form →
Serving Surprise, Phoenix, Peoria, Glendale, Goodyear, Buckeye, Scottsdale, Mesa, Chandler, Gilbert, and all of Arizona.
American Insurance Benefits | 14955 W Bell Rd #8031, Surprise, AZ 85374 | Licensed Arizona Insurance Broker since 2004
When it comes to Medicare vs Medigap, the question isn’t really whether you need Medicare — you do. The real question is whether to stick with Original Medicare alone, add a Medicare Supplement (Medigap) plan, or opt for Medicare Advantage instead. Here’s how to think through that decision clearly.
Medicare vs Medigap: What’s the Difference?
Medicare is the federal health insurance program for people 65 and older. It has two core parts:
- Part A — Hospital insurance. Free for most people (if you or a spouse paid Medicare taxes for 10+ years).
- Part B — Medical insurance covering doctor visits, outpatient care, and lab tests. The standard premium in 2026 is $185/month.
Original Medicare covers about 80% of most approved medical costs. The other 20% — plus deductibles, coinsurance, and hospital stays — comes out of your pocket. There’s no out-of-pocket maximum with Original Medicare alone, which means a serious illness can cost you tens of thousands of dollars.
A Medicare Supplement (Medigap) plan is private insurance you buy to cover most of what Original Medicare leaves behind. Plan G is the most comprehensive option available to new enrollees — after the Part B deductible ($257 in 2026), it covers 100% of Medicare-approved costs for the rest of the year.
Are Consumers Better Off With Medicare Plus a Medigap Plan?
For most people who can qualify medically and afford the premium, yes. Here’s why the Medicare vs Medigap math usually favors adding a supplement:
- Predictable costs — You know your maximum out-of-pocket before January 1. Plan G + Part B deductible = your total annual exposure.
- No networks — You can see any doctor in the U.S. who accepts Medicare. No referrals, no prior authorization, no in-network restrictions.
- Stability — Medigap benefits are standardized by federal law and don’t change annually. Your Plan G in 2026 covers the same things in 2027.
- Mayo Clinic access — Most Medicare Advantage plans are not accepted at Mayo Clinic. Plan G is.
When Medicare Advantage Might Make Sense
Medicare Advantage — also called Medicare Part C — bundles Medicare with private insurance. It often has lower or zero premiums but comes with networks, prior authorization requirements, and annual benefit changes.
According to Medicare.gov, Medicare Advantage may make sense if:
- You can’t afford a Medigap premium
- You qualify for low-income assistance programs that make Advantage more affordable
- You’re healthy and unlikely to need significant care
- The plan includes extra benefits (dental, vision) you actually need and will use
However, the critical risk is the one-way door: if you enroll in Medicare Advantage and later want to switch to a Medigap plan, you may need to pass medical underwriting. That means pre-existing conditions could prevent you from qualifying.
The Role of an Independent Medicare Broker
An independent broker doesn’t work for any insurance company — they compare plans across multiple carriers to find the best fit for your situation. They’re compensated by the insurer, so their help costs you nothing extra. Your premium is the same whether you use a broker or enroll directly.
The right broker will walk you through the real Medicare vs Medigap tradeoffs for your specific health situation, income, and preferred doctors — without steering you toward higher-commission products.
Talk Through Your Medicare Options in Arizona
I’m Andy Orlikoff, an independent Medicare broker in Surprise, AZ. I don’t sell Medicare Advantage. I help Arizona seniors work through the Medicare vs Medigap decision honestly — comparing costs, coverage, and long-term risk.
Call or text: (623) 742-3878
Email: andy@azhealth.us
Fill out the contact form →
Serving Surprise, Phoenix, Peoria, Glendale, Goodyear, Buckeye, Scottsdale, Mesa, Chandler, Gilbert, and all of Arizona.
American Insurance Benefits | 14955 W Bell Rd #8031, Surprise, AZ 85374 | Licensed Arizona Insurance Broker since 2004
As you approach the age of 65, understanding the various Medicare options available to you can feel overwhelming. Two of the most popular choices—Medicare Supplement Part G and Medicare Advantage plans—often cause confusion among beneficiaries. While both plans aim to fill gaps in Original Medicare, they are vastly different in terms of coverage, cost, and flexibility. This comprehensive guide will help you understand Medigap Part G and Medicare Advantage options, making it easier to choose the right plan based on your healthcare needs.
Understanding Medicare Supplement Part G
What is Medicare Supplement Part G?
Medicare Supplement Part G, often referred to as Medigap Part G, is a private insurance plan that works alongside Original Medicare (Parts A and B) to cover “gaps” in Medicare. These gaps include out-of-pocket expenses such as copayments, coinsurance, and deductibles that Medicare doesn’t cover. Essentially, Part G helps reduce the financial burden of medical costs by supplementing Original Medicare’s limitations.
What Does Part G Cover?
Medicare Supplement Part G offers comprehensive coverage, second only to the now-unavailable Medicare Supplement Plan F. It covers:
- Medicare Part A coinsurance and hospital costs (up to an additional 365 days after Medicare benefits are exhausted)
- Medicare Part B coinsurance or copayments
- Part A deductible
- Skilled nursing facility care coinsurance
- Part B excess charges (the difference between what a provider charges and what Medicare will pay)
- Foreign travel emergency coverage (up to plan limits)
The only thing Part G doesn’t cover is the Medicare Part B deductible, which as of 2024 is $226 annually. Otherwise, it covers nearly all out-of-pocket costs for Medicare-approved services.
Pros of Medicare Supplement Part G
- Comprehensive Coverage: You pay very little out of pocket beyond your monthly premiums, providing peace of mind when facing high medical expenses.
- No Network Restrictions: Medigap Part G allows you to see any doctor or specialist nationwide who accepts Medicare, offering greater flexibility.
- Predictable Costs: With Part G, you can anticipate your healthcare costs, knowing that you’ll be covered for most of the expenses not included in Original Medicare.
Cons of Medicare Supplement Part G
- Higher Premiums: Medigap Part G tends to have higher monthly premiums compared to other Medigap plans and Medicare Advantage options.
- Does Not Include Drug Coverage: Part G does not cover prescription drugs, so you’ll need to purchase a Medicare Part D plan separately for drug coverage.
- No Extra Perks: Unlike some Medicare Advantage plans, Medigap Part G doesn’t offer additional benefits like vision, dental, or hearing care.
What is Medicare Advantage?
How Does Medicare Advantage Work?
Medicare Advantage plans (also known as Medicare Part C) are an all-in-one alternative to Original Medicare, offered by private insurers. These plans must provide at least the same level of coverage as Original Medicare but often include additional benefits like prescription drug coverage, vision, dental, and hearing care. Medicare Advantage plans bundle Medicare Part A, Part B, and sometimes Part D into a single plan, offering beneficiaries convenience and potentially lower overall costs.
Types of Medicare Advantage Plans
There are several types of Medicare Advantage plans, including:
- Health Maintenance Organization (HMO): Requires you to use a network of doctors and hospitals, and you need a referral to see a specialist.
- Preferred Provider Organization (PPO): Offers more flexibility by allowing you to see doctors outside of the network at a higher cost, and no referrals are needed for specialists.
- Private Fee-for-Service (PFFS): Allows you to see any provider that accepts the plan’s payment terms, but provider acceptance is not guaranteed.
- Special Needs Plans (SNPs): Tailored for people with specific diseases or conditions, these plans offer specialized care management.
Pros of Medicare Advantage Plans
- Lower Monthly Premiums: Many Medicare Advantage plans have low or even $0 monthly premiums, making them an attractive option for cost-conscious beneficiaries.
- All-in-One Coverage: These plans often include prescription drug coverage (Part D) and additional benefits like vision, dental, and hearing care.
- Additional Benefits: Medicare Advantage plans may offer extras such as gym memberships, wellness programs, and telehealth services.
Cons of Medicare Advantage Plans
- Network Restrictions: Most Medicare Advantage plans have network limitations, requiring you to use specific doctors and hospitals. You may need referrals to see specialists.
- Variable Costs: While premiums may be low, out-of-pocket costs can vary greatly, especially if you need care outside of your plan’s network.
- Limited Nationwide Coverage: Unlike Medigap Part G, Medicare Advantage plans may not provide the same level of nationwide coverage, making them less suitable for frequent travelers.
Medicare Supplement Part G vs. Medicare Advantage: A Direct Comparison
Now that we’ve reviewed the basics of both Medigap Part G and Medicare Advantage, let’s dive into a side-by-side comparison to highlight their key differences.
1. Coverage Options
- Medigap Part G: Covers nearly all out-of-pocket costs that Original Medicare does not, including Part A deductible, Part B coinsurance, and excess charges. However, it does not include prescription drugs or additional perks like dental and vision care.
- Medicare Advantage: Offers all-in-one coverage, often bundling Medicare Parts A, B, and D with extra benefits like vision, dental, and hearing care. However, it comes with network restrictions and varying out-of-pocket costs.
2. Cost
- Medigap Part G: Higher monthly premiums but predictable and stable out-of-pocket costs for covered services. You’ll need to buy a separate Part D plan for drug coverage.
- Medicare Advantage: Generally lower or no monthly premiums, but more unpredictable out-of-pocket expenses, especially if you go outside the plan’s network. Prescription drug coverage is often included.
3. Flexibility
- Medigap Part G: Allows you to see any doctor who accepts Medicare, without worrying about network restrictions. This makes it ideal for those who travel frequently or want the freedom to choose any provider.
- Medicare Advantage: Often requires you to stay within a specific network of healthcare providers. While some plans, like PPOs, offer more flexibility, you’ll still pay more to see out-of-network doctors.
4. Prescription Drug Coverage
- Medigap Part G: Does not include prescription drug coverage. You’ll need to enroll in a separate Medicare Part D plan.
- Medicare Advantage: Most plans include prescription drug coverage, offering convenience and potentially saving you the cost of purchasing a separate plan.
5. Additional Benefits
- Medigap Part G: Focuses on supplementing Original Medicare, so it doesn’t offer additional benefits like dental, vision, or hearing care.
- Medicare Advantage: Often includes these extras, making it a more comprehensive option for those looking for additional non-medical services.
Which Plan is Right for You?
When choosing between Medicare Supplement Part G and Medicare Advantage plans, your decision will largely depend on your personal healthcare needs and lifestyle.
Choose Medigap Part G if:
- You want comprehensive coverage for out-of-pocket Medicare expenses and don’t want to deal with network restrictions.
- You value predictability in your healthcare costs and don’t mind paying higher monthly premiums for peace of mind.
- You travel frequently and need access to doctors and hospitals nationwide.
Choose Medicare Advantage if:
- You are looking for an affordable option with lower monthly premiums, especially if you’re on a fixed income.
- You prefer an all-in-one plan that includes drug coverage and extra benefits like dental, vision, and hearing care.
- You don’t mind using a network of healthcare providers and are comfortable with some unpredictability in out-of-pocket expenses.
Conclusion
Choosing between Medicare Supplement Part G and Medicare Advantage plans is a critical decision that can impact your healthcare and financial well-being. Each plan offers unique benefits, with Medigap Part G providing comprehensive coverage and flexibility, while Medicare Advantage plans are more affordable and offer additional benefits. Understanding the key differences and considering your personal healthcare needs will ensure that you select the right Medicare coverage option that works best for you.
Need Affordable Health Plans in Surprise, AZ?
At American Insurance Benefits, we’re passionate about helping individuals and families in Arizona secure the health insurance coverage they need at a price they can afford. Since 2004, Andy Orlikoff and our team have been dedicated to making the process of finding the right plan as simple and stress-free as possible. If you’re looking for expert guidance tailored to your unique needs and budget, don’t hesitate to reach out to us today. Let’s find the perfect health insurance solution together.
Medicare Advantage chaos is disrupting hospitals, insurers, and seniors across the country. Hospitals are dropping Medicare Advantage contracts, insurers are exiting markets, and seniors are caught in the middle. Here’s what’s happening and what it means for Arizona seniors.
Janna Herron
Hospitals and insurance giants are clashing over wildly popular Medicare Advantage plans as both sides try to protect their profits. Many seniors enrolled in these plans are caught in the crosshairs.
More hospitals and healthcare providers are terminating agreements with insurers that provide these private-sector alternatives to Medicare, citing too many denials, delays, and refusals to pay for care that government-run health insurance would typically cover. The fracas is deepening this year as the federal government issues new guidance on how the plans can be run, posing a major new threat to a profit engine for some of the country’s largest insurance companies.
“We call these knife fights in the industry and I think we’re seeing more and more,” Whit Mayo, an analyst with Leerink Partners, told Yahoo Finance. “And is this something that these insurers are going, ‘OK, this could become a bigger problem for our bottom line.’”
Seniors also have a lot at stake. If more hospitals ditch these plans, seniors who rely on that coverage will be forced to pay higher costs or may even be kept from seeing the doctor of their choice. Many have little recourse if they face these challenges.
“It stinks,” Mayo said. “You’re putting consumers in the middle of these negotiations and they really value being able to know if they’re facing out-of-network costs if they do see a provider that’s not within their network. So the emotional strain that this takes on the people caught in the middle is the worst.”
‘The deck is heavily stacked in favor of MA enrollment’
This year, 33 million Americans have MA plans, representing just over half of Medicare-eligible individuals, according to research from Chartis. They are offered by giant companies like UnitedHealthcare, which is owned by UnitedHealth Group (UNH), as well as Humana (HUM) and CVS/Aetna (CVS).
These MA plans have only grown in popularity since the program’s inception, with enrollment outpacing that of traditional Medicare in the last six years. Two big allures of these plans are their perks and cost.
MA plans provide benefits traditional Medicare doesn’t offer, such as dental and vision coverage and a grocery allowance. Many also offer a low or $0 monthly premium. That’s cheaper than Medicare’s $174.70 monthly premium and any supplemental coverage seniors who choose Medicare often buy.
“MA plans are very well compensated. With that extra money, MA plans are able to offer services that Medicare doesn’t offer,” David Lipschutz, the associate director for the Center for Medicare Advocacy, told Yahoo Finance. “The deck is heavily stacked in favor of MA enrollment.”
Of course, there’s a tradeoff. Depending on the MA plan, enrollees have to go to a network of providers who have contract agreements with the insurer. If an enrollee goes out of network, they either must pay higher costs for the care or may not be allowed to see that provider at all.
The consequences of that tradeoff came to a head in 2022 as MA insurers began denying more coverage for necessary care just as seniors who had delayed elective procedures flooded back into hospitals that were already struggling with major labor shortages.
The practice has infuriated healthcare providers.
“This practice does cost substantial amounts of time and money, but more importantly, it’s not right for our patients who are often caught in the middle or receive coverage that is different than that offered to patients enrolled in traditional Medicare,” wrote a spokesperson for Louisville, Ky.-based Baptist Health Medical Group, which last year terminated its MA agreement with Humana.
Some hospitals move forward with care without prior authorization because it’s an emergency and the appeals process takes too much time.
“There are patients out there that can’t wait. The delay of a cardiac procedure or cancer procedure could be life-threatening,” said Chris Van Gorder, the president and CEO of San Diego-based Scripps Health.
And when the hospital files a claim, “They deny it saying, ‘We didn’t approve it,’” Van Gorder said.
Many healthcare providers are losing money as a result.
Scripps Health lost $75 million last year from its MA-insured patients, Van Gorder said. Scripps Clinic and Scripps Coastal, the medical groups that have exclusive medical service contracts with Scripps Health, tried to renegotiate with MA insurers to reach acceptable terms, but that ultimately wasn’t successful.
The medical groups then withdrew from their MA HMO agreements with UnitedHealthcare, Anthem Blue Cross, Blue Shield of California, Health Net of California, SCAN Health Plan, UnitedHealthcare of California, and Alignment Health last year.
“The last thing in the world I wanted to do is cancel a contract for 32,000 patients. I’m in the business of delivering healthcare, not canceling healthcare,” Van Gorder said. “We just can’t afford it financially.”
In the last 18 months, more than a dozen other healthcare and hospital systems nationwide have dropped out of MA plan networks, many of them citing denial-of-care issues.
“I think we are sadly the vanguard of what is going to be some pretty confrontational contract negotiations between payers and hospitals in the next few years,” Van Gorder said. “I think this is going to get ugly.”
UnitedHealthcare told Yahoo Finance that “each year, we successfully renegotiate the vast majority of our contracts with providers. Our goal is to be a good steward of the resources available to cover our members’ cost of care by ensuring they are charged fair, sustainable prices for the services they need.”
Humana and Centene did not respond to requests for comment.
Still, the tumult also has gotten the attention of the Centers for Medicare & Medicaid Services, which recently put out new rules on processing prior authorizations, patient risk coding, and other reporting and transparency requirements designed to address some of the medical providers’ concerns.
It also adds more pressure on insurers by making it harder to deny claims, potentially forcing insurers to cut back on the perks their MA plans offer.
“The industry is engulfed in just a historically high level of controversies right now. It’s a very tough environment for the plans,” Mayo said. “And I think we’re going to see a sector that’s going to really pull back on benefits.”
In the meantime, seniors who need healthcare are stuck in the middle.
Seniors can opt for a different MA plan or original Medicare during the Medicare Advantage open enrollment period from Jan. 1 to March 31 — and they have been. Plan swapping was up in January and February, Mayo said, based on monthly data from the CMS.
Still, switching to traditional Medicare is no panacea, either. While seniors will have no problem getting Medicare, they may find it harder to get a Medigap policy, a supplemental policy that covers the 20% of costs that Medicare does not cover for medical care.
When a senior first signs up for Medicare at age 65, Medigap policies — which are provided by many of the insurers that offer MA plans — cannot deny or charge a higher premium based on preexisting conditions.
But insurers can deny or charge more for preexisting conditions when someone wants to switch to traditional Medicare down the road. That’s why seniors may choose another MA plan instead, one that could be dumped later by their medical provider.
“That is a danger each and every year,” Lipschutz said. “People don’t have much recourse if their doctor leaves the network.”
Janna Herron is a Senior Columnist at Yahoo Finance. Follow her on Twitter.
If you’re concerned about Medicare Advantage chaos affecting your coverage, consider whether Original Medicare with Plan G makes more sense for your situation. Call Andy Orlikoff at (623) 742-3878 for a free consultation.
