While Original Medicare (Parts A and B) will cover some of your health care expenses, it won’t cover everything. For instance, Medicare Part B covers 80% of your health care costs. You will be responsible for the other 20%. It also won’t pay for any prescription drugs, vision or dental care. You’ll have to cover the cost of those yourself. For many seniors, those items can be some of the most expensive. So, one option is to add supplemental insurance to help with those gaps in coverage. You can add Part D, the Medicare Prescription Drug Plan. And you can add a Medicare Supplement to help with your co-pays, deductibles and emergency coverage when you travel outside the country.
Or, you can choose a better alternative with more coverage: Medicare Supplement. Here are some of the benefits:
If you want lower premiums: Part C plans often have lower premiums than Medigap supplements.
If you want to cap your health spending: Medicare Advantage plans have a $6,700 per year maximum. Once you hit that limit, the plan will pick up all expenses. Original Medicare has no out-of-pocket maximum.
If you want to eliminate the financial uncertainty of 20% co-insurance: Original Medicare Part B only picks up 80% of the cost.
If you want prescription drug coverage included: No need to buy Part D.
If you want dental and vision care: Original Medicare won’t cover these.
If you prefer all-in-one coverage: You’ll get all of your health care needs taken care of from one insurance carrier – so there aren’t so many moving “Parts”. That makes your health care much more convenient and easier to manage.
Medicare Part C: Medicare Advantage
Part C of Medicare refers to Medicare Advantage Plans (MA Plans). These plans are offered by private insurance companies approved by Medicare. When you enroll in a MA Plan your receive your health care from the insurance company, not Medicare. Advantage Plans offer the same benefits as Original Medicare Part A and Part B but they can apply different rules, cost and restrictions than Medicare does. For example, they can require you to get a referral before seeing a specialist.
Medicare Advantage plans have provider networks (HMO or PPO). If you want to go to a doctor or hospital that is not in the network you could be responsible for all cost unless it is an emergency. When you travel out of state you may be out of network. Medicare Advantage Plans must include a limit on your out-of-pocket expenses for Part A and Part B services. The maximum out-of-pocket cost for HMO plans in 2023 is $6,700. If you use out-of-network providers your out-of-pocket cost may be higher.
Most Medicare Advantage plans include Part D prescription drug coverage. These plans can offer additional benefits that Medicare does not cover such as dental, vision and hearing. The benefit levels for these extra benefits can vary among MA Plans. If you enroll in a Medicare Advantage Plan you must continue to pay your Medicare Part B premium.
Medicare Parts A-D
Medicare is a Federal health insurance program that covers millions of Americans age 65 and older, people under the age of 65 with certain disabilities and people with End-Stage Renal Disease (ESRD). The Centers for Medicare and Medicaid Services (CMS) is the federal agency that runs Medicare.
Medicare Part A: Hospital Insurance
Inpatient care in a hospital
Skilled nursing facility care
Inpatient care in a skilled nursing facility (not custodial or long term care)
Home health care
Medicare Part A is free for most people.
Medicare Part B: Medical Insurance
Part B of Medicare covers medically necessary outpatient services and treatments you receive at a doctor’s office, hospital, or clinic. Doctor visits are covered under Medicare Part B and so is preventive care. There is an annual deductible of $229 for Part B medical services. After you have met your deductible Medicare only covers 80% of Part B medical expenses.
You pay a monthly premium to Medicare for your Part B coverage. The standard Part B premium for 2023 is $164.90, but you may pay more if your income is above a certain amount. When Medicare becomes your primary insurance it is essential to sign up for Part B. If you want to apply for a Medicare supplement you have to be enrolled in Part A and Part B of Medicare.
Medicare Part D: Prescription Drug Coverage
Part D of Medicare is the prescription drug benefit that covers outpatient prescription drugs. Part D is offered by private companies that have contracts with the government to offer this coverage. You pay a monthly premium to an insurance company for your Part D plan. You will either pay a copay or a percentage of the drug’s cost. Each Medicare prescription drug plan has a list of covered drugs, called its formulary. Medicare drug plans place medications in their formulary into Tiers 1-5. The lower the tier, the less you pay for the medication.
Unless you have creditable drug coverage you should enroll in a Part D plan when you first go on Medicare. If you delay enrollment you will have to pay a late enrollment penalty.
If you are going on Medicare soon are you overwhelmed with all the information you have gotten in the mail? Call or email me to schedule a Medicare consultation. I offer this service at no cost or obligation on your part. If you need someone to help you make sense out of Medicare, you will find this free service very helpful. Medicare is confusing, and making wise decisions before you go on, Medicare is crucial. I’ll answer your questions and go over your options to help you decide which Medicare supplement plan best fits your needs and budget.
Commonly Asked Questions:
Should you sign up for Medicare if you continue to get your health insurance from your employer?
How much will you have to pay for premiums, deductibles, doctor visits, and hospital stays?
Can you go to the doctors and hospitals of your choice or will you be limited to health care providers that are in an HMO or PPO network?
Will you have coverage when traveling anywhere in the United States?
What are the requirements to see if you can get help from the government to help pay premiums, deductibles, coinsurance, copayments, and prescription drug cost?
Should you choose a Medicare Supplement or an Advantage Plan?
Is Medicare Supplement Plan F the best supplement or should you consider Plan G or Plan N?
Can you be turned down for a Medicare supplement if you have pre-existing health conditions?
Will Medicare cover all your prescription medications, and how much will they cost?
What is the Medicare drug coverage gap (donut hole)?
I want to help you make an educated and informed decision about which Medicare supplement plan is best for you. Call or email me today to schedule your consultation time; I’m ready to help.
What Is Medigap?
Medigap is a supplemental insurance you can get on top of your Medicare Parts A & B. Medicare covers many healthcare costs, but it does not pay for every expense. You are responsible for these costs, sometimes called the “gaps” in Medicare coverage. Medigap helps pay for the gaps, much like retiree insurance.
How Does Medigap Work?
You can buy Medigap from private insurance companies in your state. There are 11 different standard Medigap plans that can be sold in most states. The 11 standard plans are labeled A-D, F, high-deductible F, G and K-N. Each of these plans covers different services.
What Doctors Can I See With Medigap?
With Medigap, you can see any doctor, whether the doctor accepts Medicare assignment or not.
If your doctor “accepts assignment,” meaning he or she agrees to be paid the Medicare-approved amount for a service, your Medigap insurance company usually pays your doctor directly.
If your doctor does not accept Medicare assignment, you may have to send claims to your insurance company and pay the doctor yourself.
Note, however, that Medigap plans generally do not pay for care received outside of the United States, except for medically necessary emergency care that occurs during the first 60 days of your trip.
What Are My Rights With Medigap?
Do you have a specific scenario and want to know your rights when buying a Medigap policy? Learn about your rights.
People who purchase a Medigap policy have certain rights:
Free look periods
Pre-existing condition wait periods
Guaranteed issue rights
These rights can protect you from being denied coverage. They also can protect you from having to keep a plan that is not right for you. If you are thinking about buying a Medigap plan, or if you already have one, keep these tips in mind.
Can I change my mind after purchasing my policy?
Will Medigap cover me for a pre-existing condition?
Do I have the right to buy a Medigap policy outside of Open Enrollment?
Do I have to re-enroll in my Medigap plan every year?
The rights in this section are from Federal law. Many states provide additional Medicare rights. Protect yourself by keeping copies of any letters, notices, emails and claim denials from your Medigap insurance company that have your name on them.
Get in contact with your state about Medigap rules and rights with the state insurance department locater.
Keep any postmarked envelopes that these papers came in. Also, keep any papers that prove the date you bought your new Medigap policy. You may need this paperwork later if you have a problem with your plan.
What’s The Difference Between Medicare Advantage And Medicare Supplement Insurance Plans?
There are different ways that you can receive your Medicare coverage, or add onto that coverage. Medicare Advantage and Medicare Supplement insurance are options that may sound similar, but they’re quite different. They do have one main thing in common: they’re both offered by private insurance companies.
There are two options commonly used to replace or supplement Original Medicare. One option, called Medicare Advantage plans, are an alternative way to get Original Medicare. The other option, Medicare Supplement (or Medigap) insurance plans work alongside your Original Medicare coverage. These plans have significant differences when it comes to costs, benefits, and how they work. It’s important to understand these differences as you review your Medicare coverage options.
Original Medicare, Part A and Part B, is a government health insurance program for those who qualify by age or disability. Part A is hospital insurance, and Part B is medical insurance. There are some out-of-pocket costs associated with Original Medicare, such as copayments, coinsurance, and deductibles. To help with those costs, if you’re enrolled in Original Medicare, you can purchase a Medicare Supplement (Medigap) insurance plan.
Medicare Advantage plans offer an alternative way to receive your Medicare benefits through a private, Medicare-approved insurance company. They must include all your Medicare Part A and Part B coverage (except hospice care, which is covered under Medicare Part A), but may offer additional benefits not included in Original Medicare.
You generally cannot enroll in both a Medicare Advantage plan and a Medigap plan at the same time.
Medicare Advantage Plans
If you have a Medicare Advantage plan, you’re still enrolled in the Medicare program; in fact, you must sign up for Medicare Part A and Part B to be eligible for a Medicare Advantage plan. The Medicare Advantage plan administers your benefits to you. Depending on the plan, Medicare Advantage can offer additional benefits beyond your Part A and Part B benefits, such as routine dental, vision, and hearing services, and even prescription drug coverage.
There are many different types of Medicare Advantage plans, described below:
Health Maintenance Organizations (HMOs) require you to use health-care providers in a designated plan network and may require referrals from a primary care physician in order to see a specialist.
Preferred Provider Organizations (PPOs) recommend the use of “preferred” health-care providers in an established network, and these plans are likely to cover more of your medical costs if you stay inside that network. You don’t need a referral to see a specialist.
Private Fee-for-Service (PFFS) plans determine how much they will pay health-care providers, and how much the beneficiary is responsible to cover out-of-pocket.
Medical Savings Account (MSA) plans deposit money into a “health-care checking account” that you use to pay for health-care costs before the deductible is met.
Special Needs Plans (SNP) are tailored health insurance plans designed for beneficiaries with certain health conditions.
If you decide to sign up for a Medicare Advantage plan, you may want to shop around, because costs and coverage details are likely to vary. We can help you examine your options.
Some of the costs associated with Medicare Advantage might include a monthly premium (not counting your Part B premium, which you must continue to pay as well), annual deductible, coinsurance, and copayments.
To be eligible to enroll in a Medicare Advantage plan, you must be enrolled in Original Medicare, reside in the plan’s service area, and (in most cases) not have end-stage renal disease (ESRD).
Medicare Supplement Insurance Plans
Medicare Supplement insurance, also known as Medigap or MedSup, is also sold through private insurance companies, but it is not comprehensive medical coverage. Instead, Medigap functions as supplemental coverage to Original Medicare. Current Medigap plans don’t include prescription drug coverage.
Medigap plans may cover costs like Medicare coinsurance and copayments, deductibles, and emergency medical care while traveling outside of the United States. There are 10 standardized plan types in 47 states, each given a lettered designation (Plan G, for example). Plans of the same letter offer the same benefits regardless of where you purchase your plan. Massachusetts, Minnesota, and Wisconsin offer their own standardized Medigap plans.
The standardized Medigap plans each cover certain Medicare out-of-pocket costs to at least some degree. Every Medigap plan covers up to one year of Medicare Part A coinsurance and hospital costs after Medicare benefits are used up. But, for example, Medigap Plan G plans don’t cover your Medicare Part B deductible, while Medigap Plan C plans do. So, if you’d like to enroll in a Medicare Supplement insurance plan, you might want to compare the Medigap policies carefully.
While benefits are standardized, the costs are not, meaning they could fluctuate depending on the insurance company offering the plan and location. That is, while Medigap Plan G includes the same coverage no matter where you buy it, the premium for this plan can vary. Also, not every standardized lettered plan is offered in every state.
If you decide to sign up for a Medigap policy, a good time to do so is during the Medigap Open Enrollment Period, a six-month period that typically starts the month you turn 65 and have Medicare Part B. If you enroll in a Medigap plan during this period, you can’t be turned down or charged more because of any health conditions. But if you apply for a Medigap plan later on, you may be subject to medical underwriting; your acceptance into a plan isn’t guaranteed.
No matter whether you enroll in a Medigap policy or a Medicare Advantage plan, you must continue paying your Part B premium.