How to Get the Best Care from Medicare
Is original Medicare enough?
Those who have paid 10 years of Social Security taxes qualify for Medicare at age 65. They’re automatically signed up if they’re receiving Social Security payments, unless they take steps to opt out. Standard Medicare comes in two parts: A and B. Part A covers a portion of hospitalization expenses, and Part B applies to doctor bills and other medical expenses, such as lab tests and some preventive screenings.
For many lower-income Medicare beneficiaries, there’s no need for private supplemental coverage. More than one in five Medicare beneficiaries are dual-eligible for both Medicare and Medicaid. This includes Medicare enrollees who are eligible for full Medicaid as well as those who qualify for Medicare Savings Programs that help low-income seniors pay premiums and cost-sharing under traditional Medicare.
For dual-eligible enrollees who qualify for full Medicaid, that coverage picks up where Medicare leaves off, covering coinsurance and deductibles, as well as some services not covered at all by Medicare, such as dental, vision, and long-term care.
Is a Medicare Advantage Plan better?
You may want to get a Medicare Advantage Plan instead of original Medicare if you take prescription drugs. Original Medicare doesn’t cover prescriptions unless you pay extra to add Part D coverage. Most Medicare Advantage plans include drug coverage, although in some cases your monthly premium will exceed the amount you’d pay for original Medicare, Part D.
Other reasons for considering a Medicare Advantage Plan include:
- You want a cap on your out-of-pocket health spending. Original Medicare has no out-of-pocket maximum. You keep paying a portion of the cost of services as you use them. Medicare Advantage plans, by law, have an out-of-pocket maximum of no more than $6,700 per year. Once you reach that limit, the plan pays for all covered expenses.
- You want an alternative to enhancing your Medicare coverage with private “Medigap” (Medicare Supplement) insurance. Medigap plans cover or help cover certain deductibles, coinsurance and out-of-pocket costs of original Medicare. Some Medicare Advantage plans, but certainly not all, will be more cost-effective than adding Medigap coverage to original Medicare. Examine carefully the plan details if this is your reason for considering Medicare Advantage.
- You want an alternative to the 20-percent coinsurance charged by original Medicare for most services. Medicare Advantage plans structure costs differently and may offer a lower (or higher) co-insurance, or may charge co-pays instead – which are fixed costs you pay for services. A trade-off could be a higher monthly premium.
You want coverage for vision, dental, assisted living facilities or nursing home care. Original Medicare doesn’t cover these services, some Medicare Advantage plans do.
HMO? PPO? What does it all mean?
Medicare Advantage plans come in two major varieties: HMO plans and PPO plans.
With an HMO (Health Maintenance Organization) plan, you choose a primary care physician from the plan network to be responsible for your care — including directing you to specialists or other services within the HMO’s network for additional care you may need. Only care received from network providers and facilities is covered by the plan.
In addition to health insurance, Medicare Advantage HMO plans often include prescription drug coverage similar to Medicare Part D coverage.
Normally, HMO plans are less expensive than other Medicare Advantage plans. However, they can be more restrictive — all care is referred through the primary care physician, and only services within the plan’s network of providers and care facilities is covered.
Another option for Medicare Advantage coverage is a PPO plan. Preferred Provider Organizations also offer care within a network of physicians and hospitals, with the additional benefit of allowing enrollees a wider choice of provider options. In most cases, you can choose providers outside of the network of physicians and hospitals and still receive coverage; however, you’ll be paying more out-of-pocket when compared to in-network providers.
Compared with a Medicare Advantage HMO plan, PPO coverage may lead to higher out-of-pocket expense for similar care, particularly when using a provider outside the PPO network. Because of less restrictive provider choices, PPO premiums may be more than HMO premiums. Medicare Advantage PPO plans often include prescription drug coverage similar to Medicare Part D coverage.
Review alternative Medicare Advantage plans carefully! Compare both cost and the level of provider choice that you are comfortable with.
For more information on Medicare and Medicare coverage, go to https://www.medicare.gov/