Your Medicare Benefits…The Simple Navigation Guide

Your Medicare benefits…are they really baffling you?  If so, fear not, you are like many seniors I have worked with over the years.   No one likes to deal with insurance.  Yes, understanding Medicare “ins and outs” can be challenging.  The goal here is to put that to rest and lay out what you need to know.  Someday we’ll get a video out.  Until that day, here is today’s post, where I am putting together a simple guide so you have a better understanding of what you need to know to make a good choice for yourself regarding your Medicare coverage.

Medicare Stress?

Medicare publishes a yearly guide.  It is called “Medicare and You”  Here is that guide for reference.  The feedback I get from many seniors is…too much information!!  As a result, people never really get the basics down on what their options/choices really are.  What you need to know is buried in that guide, I can assure you.  This knowledge is also under my belt as a senior benefits specialist.  I will try to reduce it down to what seniors have questioned me on over the years.

I talk to a lot of people turning 65 on an average week.   Sometimes I will get a request if I have some information to send because they just don’t understand it all.  If your one of them, glad that I finally put the basics up on the website for you.  Even many seasoned Medicare recipients don’t understand Medicare and its workings, when they can make changes etc.  That is until they become my acquaintance anyway.

So What is Medicare About?

Medicare is a government run healthcare program you are entitled to once you have 10 years (40 quarters) in the workforce and paying taxes.  Typically, individuals become eligible at age 65.  There are exceptions for those who end up on Social Security Disability.  We will not discuss that here however.  A topic of another future article.

There are 4 actual parts of Medicare you need to be very aware of.  Parts A, B, C, D.  Contact the Social Security office to get your cost and enroll if you are new to Medicare.  You may need some or all of the “Parts of Medicare.”  Part D is found on Medicare’s website.  It can be enrolled after you have set up your Medicare choice thru the Social Security office.

You have 2 major options to choose from with Medicare.  Option 1…Original/Traditional Medicare or Option 2…Medicare Advantage.  You may choose only option 1 or option 2.  You may not have them both. 

What Are My Medicare Benefits?

Now, of the two options you have as a Medicare recipient, Original Medicare is the oldest of the 2 programs and offers access to all Medicare participating providers.  You will have you deepest selection of top healthcare providers under this option.  Your doctor very, very likely accepts Original Medicare.  You do not need special referrals to see any provider under Original Medicare.

Original/Traditional Medicare pays 80% of “Medicare” approved healthcare claim amounts.  The remaining 20% is your responsibility if you do not have a Medigap/Medicare Supplement Policy to fill the “gaps” in coverage ( the 20% of charges unpaid by Medicare itself).

Of the 3 Parts mentioned previously that makeup Original Medicare,  Part A is your hospitalization coverage.  It is automatically available when you go on Medicare.  If Medicare approves your health care claims, they will pay 80% of any and all approved hospital costs covered.

Part B of Medicare is your outpatient care.  This includes Dr. visits as well.  It is sometimes called “medical” insurance.  Care outside the hospital is covered by Part B.  Again, 80% coverage of costs on Medicare approved charges and you pay the remaining 20% out of your pocket unless you have a Medicare Supplement/Medigap policy that handles these uncovered costs.

The last part I roll into Medicare is Part D.  Part D of Medicare is coverage for prescription drugs.  You are able to get a custom prescription plan tailored to your personal needs.  Though this is optional, if you go down the Original/Traditional Medicare path, it is recommended.  Prescription costs are financially devastating for many people, not just seniors on a fixed income.  Part D is your solution though it isn’t free.

Be aware, if you do not (or did not) select Part D when it was first made available, you may be charged a penalty if you later enroll for benefits.

Now, you may have noticed that I didn’t talk about Part C of Medicare.  Why?  Because Medicare Part C is really your 2nd option by itself.  It is better known as Medicare Advantage.  Premiums used to fund you Medicare coverage are combined with option 2, Medicare Advantage.  Those monies are sent to a Medicare Advantage plan option you select and run by a private insurance company.  Your benefits are not from Medicare at this point.  They are fully provided to you by the private insurance company.

Be sure you understand Medicare Advantage (Part C) is a low cost HMO or PPO run by a private company, not Medicare.  It rolls up benefits of Original Medicare Part A, B and even Part D.  These plans must still abide by certain rules that Medicare has in place, but your care is managed by the HMO or PPO the plan is offered by.  If elected, you can tuck your red, white and blue Medicare card away in a safe place.  It does you know good if you elect Medicare Advantage which is outside Original Medicare.

The Pro’s and Con’s of Medicare Advantage

Medicare Advantage (MA) plans will often have little perks that Original Medicare does not have such as Vision Care, a gym membership etc.  You will have various co-payments and coinsurance on these plans.  Be mindful, Medicare Advantage plans are not full coverage like Original Medicare combined with a Medigap plan (Medicare Supplement).  A MA plan is not the same thing and you may be responsible for large claim amounts as it is not required to pay beyond 80% just like Original Medicare.  You cannot purchase Medigap/Medicare Supplemental insurance to go with Medicare Advantage (Part C) plan to cover the remaining percentage.

You must go see providers that are in the HMO or PPO network designed by the specific private insurer.  If you do not, any claim amounts for your care will be 100% your responsibility.  Yes, Medicare Advantage is going to be restrictive for your health care.

Folks, in trying to keep this article simple and to the point,  I am not going to get in depth with all the in’s and out’s of Medicare Advantage plans.  There are quite a variety of different Part C, Medicare Advantage programs.  Some are better than others in terms of overall benefits.

Now, let us get back to Part C of Medicare…is it the plan of choice for you?  Part C is called Medicare Advantage.  The other 3 parts (A,B,D) are often rolled up into Part C.  These plans are offered by private insurers and companies and are funded by your Medicare premiums.  Medicare is not insuring you under these MA plans.  Healthcare decisions are made by the HMO or PPO design of the Medicare Advantage plans in your area.

As you can imagine, the network restricts the availability of providers to only those in the network.  If you go outside the network, 100% of the charges are your responsibility.

Some perks are often included in a Medicare Advantage plan which Original Medicare does not cover.  Vision and Hearing Care, Dental or even a gym membership are often found included.  There may or may not be co-payments for visits to the care provider in a Medicare Advantage plan.  Be aware, high out of pockets expenses are not uncommon in these plans.  Cancer treatments, for example can be thousands of dollars each year.  Keep in mind, there is a considerable trade off for low cost health coverage under a Medicare Advantage plan.

If you are enrolled in a Medicare Advantage program and are dissatisfied, you may change your advantage plan during the yearly Annual Election Period (AEP).  AEP starts October 15th and runs thru December 7 annually.

You may also switch from Original Medicare to “option 2” which is Medicare Advantage during AEP.

AEP is also your time to change or enroll in a Part D prescription drug program you may have previously selected.

Medicare Advantage Disenrollment Period

January 1 thru February 14 is the annual time period when you may change back to Original Medicare if you no longer wish to be in a Medicare Advantage plan.  If you make a change during that time, your new coverage will become effective on the 1st of the following month.  For example: If you disenroll from you MA plan on February 1st, you will revert to Original Medicare on March 1st.  You may or may not have a right to obtain a Medicare Supplement (Medigap Plan) without having to qualify based on your health when revert back to Original Medicare.  You may not change to another Medicare Advantage plan at this time.

Special Election Period (SEP) – Circumstances for Exceptions

There are sometimes mitigating situations that our out of your control that allow you make changes to ensure you are covered.  If you fall into one of these exceptions, you may be able to switch in or out of your Medicare Advantage plan or select Original Medicare to cover you.  There following are those exceptions:

  • You move out of the service area of the MA plan you have
  • You are confined to a nursing home, receiving regular skilled nursing care or confined to a rehabilitation hospital
  • Qualify for low income subsidy program
  • On full Medicaid coverage while eligible for Medicare

Key Issues to Focus on With Medicare

Medicare is a federal insurance program you become eligible for, but is not a free program.  Premiums will vary depending on your income levels and are typically taken out of your Social Security.

While Medicare offers good overall benefits, it does not cover all you approved medical cost.  While that may be very frustrating, it is still very low cost compared to owning a major medical policy thru a private insurer.  A real positive is that Medicare does encourage preventative health items such as mammograms and prostate screening.  They will pay those in full on a yearly basis.  As a recipient however, you should generally be expecting to be pay 20% of the costs the Medicare actually approves unless you have elected Original Medicare and a Medigap/Medicare Supplement plan.

Medicare Advantage (Part C) or what I call option 2 in this article is a very low cost option.  Some Part C, Medicare Advantage programs have no monthly premium beyond what you are paying Medicare as beneficiary.

Why are some free?

Well, actually they are not free.  Medicare uses the premiums you are paying to fund a private company who “manages” your care.

These private networks, Medicare Advantage programs are HMO (Health Maintenance Organizations) or PPO’s (Preferred Provider Organizations).  There are often fringe benefits offered beyond what Medicare would include in its benefits.

The kicker is, these plans do not have to pay in full either.  There are some very high out of pocket costs that are most typical with the zero premium offerings.  It is very important to assess your out of pocket maximums on a Medicare Advantage plan.  As a senior, you must accept the reasonable possibility of requiring hospitalization or ongoing medical treatments.  Could you handle paying up to $6700 a year for regular cancer treatment for example?  Be sure you understand there are some compromises beyond the limited selection of medical providers in those networks.

Medicare Advantage plans do not have to cover any more than 80% of your expenses, just like Original Medicare.  You cannot purchase a Medicare Supplement policy to cover the unpaid charges on a MA plan.  Medicare Supplements only work with Original Medicare to remove your additional risk.

Original Medicare does not pay for dental except in some extreme cases.  An extreme case would not cover routine dental care, crowns and x-rays.  Some Medicare Advantage plans do offer this perk however.

Which Option is The Best?  Medigap vs Medicare Advantage

So how do I answer that?

20 years ago, there was no Medicare Part C or Part D for that matter.  Your Medicare benefits would not have included Part C or D.  Part D has been a blessing and would have been great for most of my clients even 20 years ago.  I remember prescription drugs for Rheumatoid Arthritis running $500 a month at that time!!  All I could offer seniors was a discount drug card if they did not have a expensive Plan I or J Medigap policy (no longer available).  Those discount drug cards were shaky performers at best and did little to really help.

Part C, Medicare Advantage is really for two kinds of people.  The first would be the wealthy.  Someone with a very high fixed income and/or substantial financial resources in reserve.  More specifically an individual who could handle paying up to $6700 a year for cancer treatment or the like (example).  The other group of people who may be best served by Medicare Advantage would be a lower income household that simply cannot afford to pay for Original Medicare (Part A, B, D) and a good Medicare Supplement.  This is the ideal combo as it picks up the remaining costs and allows you to go to any Medicare provider without restriction or referrals.

In having Medigap coverage you must first have Original Medicare.  Medigap policies only work with this option. With the best Medigap plans, you are going to have very little out of pocket even if you require very extensive medical care.  Your medical coverage has less financial risk.  I personally believe the the full access to so many different providers for healthcare that Original Medicare offers is hard to match inside a limited network of providers offered in a Medicare Advantage plan.  Only Original Medicare has options available to fully cover your claim amounts and give you the freedom to fully insure while giving you access to roughly 880,000 healthcare providers.  Further, when it comes to a serious illness such as cancer, you may need access to an Oncologist that is top notch.  Your hands are tied in a MA plan and may be out $6700 each year of treatments.

A question that has come up a lot since the newer and less costly Medicare Advantage became available is what do I recommend?  Folks, I do not know your finances, but I can tell you that my first recommendation is Option 1, Original Medicare.  You should have Part A, Part B and Part D.  Call Social Security to enroll you if are not already receiving your benefits.  Get yourself a Medicare Supplement Plan G and you will have very good health coverage for the worst of times.

If you have good cash reserves, than risking a the high maximum out of pocket each year may be fine with you.  If you are also satisfied with the network of  your Medicare Advantage plan providers than you might be well served.  If your resources cannot afford to take such a loss than you might seriously consider Medigap w/Original Medicare.

Limitations of Original Medicare & Medigap

Since Original Medicare does not really cover dental care, I suggest a senior dental, vision and hearing plan paired with Original Medicare and a Plan G Medicare Supplement.  These separate policies are very reasonable and are available thru a senior benefits agent/broker.  Combining these products gives you the peace of mind that your overall care is covered with limited risk of out of pocket expenses.  You should go here if you want to more about Medicare lack of dental coverage and try this on for size you are thinking about a Plan G Medicare Supplement.

Make sure you find an independent agent that specializes in senior insurance.  Tough health conditions can complicate your options.  You want people in the know, not the agent on the corner who sells auto insurance.  If they are not a senior healthcare specialist you will probably be overcharged.  They just will not be “in the know.”

My second recommendation is Medicare Advantage (MA).  Shop the plan best for your area.  Tuck away some extra funds.  You will thank me later if you end up having cancer treatment in this option. If you reside in a rural area, make sure you understand how far you must go for coverage.  You don’t want to be in an ambulance that needs to go 40 miles to a hospital that participates in the specific MA plan.

There is a 3rd option or a path some seniors go down.  That is not electing anything beyond the base Medicare offering of Part A. Folks, I do not recommend going Medicare Part A by itself and self insuring.  You are asking for financial disaster.  If you have a spouse, how would that affect them down the road?  As terrible as it is to say, the odds are not in your favor to self insure if you have not accumulated a lot to this point.  20% of a $100,000 bill can hurt a lot of people.  A run in with cancer, autoimmune, bypass surgery will run thru a lot of seniors retirement savings like wildfire.  Does not matter if you have been healthy all your life either.

Quick but true story and Conclusion…

My own father missed 1 day of work while I was growing up.  Never even got sick as a general rule.  One day, not long after his retirement, he was struck with an illness called Aplastic Anemia.  An autoimmune illness, the odds of a condition like this are literally 1 in a million.  He lived 10 years with it and it eventually got him.  Died just days before his 70th birthday.  Huge medical bills for 10 years of care folks.  Though my parents were on very solid financial ground, it would have left my mother a lot less financially secure than she is today, period.  Good health care coverage was the key.  My point to you, never ever bank on your past health as a predictor of your future.  Don’t look at family history either.  The body is an intricate machine and was not designed to last forever.  As we age, something in the boiler room is very likely to deteriorate.  Make sure your Medicare planning reflects it.

If your money is extremely tight, you may need to see if you qualify for Medicaid.  Medicaid is a program for low income individuals who cannot afford these 2 recommendations.  Medicaid can provide those who financially qualify with coverage to protect your nest egg and allow you get the treatments you need.

Hope this article has made Medicare seem a little less complicated and given you some clear direction.  Knowing your Medicare benefits is not as complicated as it might seem.  Sometimes it just takes the right guide to put things in perspective for you so you can make the best healthcare choice for yourself.

If you would like some outside opinions, here are some videos on the subject you could use for further clarification.  This may help settle any dilemma about Medigap vs Medicare Advantage you are still sorting out.

While I cannot answer everyone’s questions in this article, feel free to comment below, call or email us.  We’re here to help.  We’ll get back you as soon as possible.

Maple Valley Insurance Group

As an independent, senior Medicare Plan and Life Insurance agency, we are dedicated to helping you make an educated choice on your benefits. We're here when you need us.

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