By Sharon Wagner
It’s not easy getting your arms around the ins and outs of Medicare, Medicaid Advantage, and Medigap. Congress has struggled for years trying to make it all easier to understand and more responsive to the needs of America’s older citizens. However, as you try to make sense of all those supplemental plans, qualifying factors and options, remember that they’re in place to help beneficiaries fill the many gaps in Medicare coverage.
Many low-income Medicare beneficiaries have no need for supplemental coverage. About one in five beneficiaries are eligible for both Medicare and Medicaid, including Medicare enrollees who are eligible for full Medicaid, as well as people who qualify for Medicare Savings Programs aimed at helping low-income seniors pay premiums. Medicaid picks up where Medicare leaves off for dual-eligible enrollees by covering deductibles, coinsurance, and services, such as dental and vision, which aren’t covered under Medicare.
There are different levels of aid available for Medicare beneficiaries who qualify for Medicare Savings Programs. Overall, only one in 10 beneficiaries who are not dual eligible rely on original Medicare solely (these are often people with substantial financial resources of their own).
What It Boils Down to
Essentially, you can choose original Medicare and supplement it with a Medigap plan and/or a Part D prescription plan, or opt for a Medicare Advantage plan, which is a supplemental option available since 1997. Medigap will cover all or part of your deductibles and coinsurance under Medicare, while a Part D plan covers prescriptions. On the other hand, Medicare Advantage covers it all under one plan, with all the benefits of original Medicare (including a cap on out-of-pocket expenses). Most Medicare Advantage plans cover prescriptions as well.
Which coverage path you choose depends on factors such as health, financial situation, the benefits you need and want, plan availability, and more. There’s really no right or wrong — it just depends on your circumstances and which option best meets your needs.
Factors to Consider
Disability: If you’re under age 65 and on Medicare because of a disability, you may not be guaranteed access to a Medigap plan. However, unless you have end-stage renal disease, you can get an Advantage plan if you’re eligible for Medicare, even if you’re under 65.
Conditions: Medicare Advantage Special Needs plans can be a good option for individuals who have certain medical conditions, are institutionalized or have Medicare-Medicaid dual eligibility.
Premiums: There are “zero premium” Medicare Advantage plans in most areas, though enrollees still pay their Part B premiums. Enrollees in Medicare Advantage pay an average of $166 a month, including Part B premiums. A Medicare enrollee with Medigap and Part D coverage would pay an average of about $347 a month, along with Part B premiums.
Out-of-pocket: Enrollees in most Medicare Advantage plans pay copays and coinsurance. Some Medigap plans pay first-dollar coverage for services so there’s little or no out-of-pocket cost.
Missed enrollment: If you apply for Medigap after your initial enrollment period ends, medical underwriting will determine your premium level (Medicare Advantage offers an annual open enrollment period toward the end of every year).
Extra benefits: If you’re interested in extra benefits such as vision, dental, hearing aids, and gym memberships, they may be available in Medicare Advantage, but not in Medigap.
Network size: Most (96 percent) of doctors providing Medicare-covered services participate in original Medicare, with nationwide coverage. However, be aware that each Medicare Advantage plan has its own provider network, which may be limited to a specific region.
Plan availability: Most Medicare enrollees have a wide range of Medicare Advantage, Medigap, and Part D plans available to them; however, availability varies greatly according to location.
A La Carte
Medicare, Medicare Advantage, and Medigap are intended to provide eligible enrollees with an a la carte selection of plan options based on needs, physical conditions, and other factors. It can be an overwhelming task to weed through all the particulars and understand one’s options. Perhaps the best way to approach the situation is based on what makes the most financial and medical sense; in other words, what choices provide the best coverage for the least cost.
For example, two people with similar living and circumstances and demographic backgrounds may choose two different paths based on personal preference — neither one is objectively right or wrong. One might prefer to pay less in premiums and accept higher out-of-pocket costs, while another may be willing to pay more in premiums because they’ll benefit most from a plan with a wider range of network physicians because of a specific medical issue.
Robust Online Resource
MedicareAdvantage.com offers an online resource called the Medicare Plan Finder, which lets you seek out Medicare Advantage (Part C) and Medicare Part D (prescription drug plans) options based on location and other factors. This is an important and valuable resource because Medicare Advantage plans vary widely based on geographic location and plan availability. (Part C and D plans are sold by private insurers, which can make things more complicated as you work to cobble together all of the coverage you need.)
The Plan Finder lets you narrow your selection. Simply enter your zip code to find what’s available in your region. If you wish, contact a licensed insurance agent who has the experience and ability to assess your healthcare needs and help you determine what makes the most financial sense. You can talk to an agent 24 hours a day at 1-877-801-6275. It’s strictly an informational resource; you’re under no obligation to enroll or make any financial commitment.
If you choose to use the online search tool, you’ll be asked for basic information, including name, Medicare number, date of birth, the date your Medicare Part A coverage began, as well as specific information about your existing coverage and any changes you’re interested in making.
It’s natural to want to make the best, most well-informed choices based on your situation and healthcare requirements. However, bear in mind that there’s no wrong or right selection. All that matters is that you find the best options for supplementing your Medicare coverage.
Image courtesy of Pixabay
Sharon Wagner is the author of the upcoming books, The Ultimate Guide to Senior-Friendly Workouts, Fitness Gear, Healthy Recipes, and More. Connect with her at Seniorfriendly.info and she hopes her website and her book can provide inspiration and motivation to seniors seeking optimal health.