Understanding your Medicare options can be confusing

The Basics

Your Options

  • Original Medicare (Parts A, B & D)
  • Medicare Advantage (Part C)
  • Original Medicare & Medicare Supplement (Medigap)

Reference: https://www.medicare.gov/sign-up-change-plans/decide-how-to-get-medicare/your-medicare-coverage-choices.html

Original Medicare

Part A - The hospital room; consist of deductible and copay.

Part B - Major Medical (doctor visits, ambulatory services, medications administered in a facility, diagnostics, surgery, durable medical equipment, in patient and out patient procedures etc.). Consist of monthly premium, low deductible and coinsurance (*20% of approved expenses after deductible is met).

Part D - For medications obtained at a pharmacy and administered at home. Choice of most cost effective prescription drug plan for your personal needs. 

Vast amount of doctor and facilities in the U.S. and U.S. territories, covers for what is considered reasonable and medically necessary. 

*20% of approved expenses - 20% of what Medicare approves as reasonable and customary charges for the billed event.

Reference: https://www.medicare.gov/sign-up-change-plans/decide-how-to-get-medicare/original-medicare/how-original-medicare-works.html

Medicare Advantage

Parts A and B  combined (some plans include Part D), may include other benefits that Medicare may not cover such as vision and dental services. 

HMO (in-network) & PPO (in & out of network) - Plans with networks; approvals, restrictions and  limitations may apply. Consist of  premiums (some plans), annual maximum out of pocket limits (higher of out-of-network in PPO), copay and coinsurance.

Prescription drug plan may be built into dependent (MA or MAPD) on which plan your choose.

Some Plans cater for Special Needs and others work in conjunction with partial or full Medicaid that may offer more savings.


Medicare Supplements (Medigap)

Medigap policies can't work with Medicare Advantage Plans. They are designed by Medicare and administered by insurance companies and can only work in conjunction with Medicare Parts A & B. You pay a premium for selected Plan, these Plans dependent on Plan chosen covers your Parts A & B deductibles, copay and coinsurance. These Plans are directly tied to Medicare Parts A & B and therefore utilizes the same vast amount of doctors and facilities in the U.S. and U.S. territories.  

Medigap policies coverage are standardized per plan selected across companies that offer plans. For example: the coverage (payment of deductibles, copay and coinsurance) for the F Plan between one company vs. another company are the same.

Why do monthly premiums differ between Medigap providers if Plans are standardized? The following are a list of factors to consider, to review with your insurance agent and to confirm that these factors are addressed, you have a clear understanding and that they are defined in your policy or certificate:

  • Guaranteed Renewable vs. Guaranteed Renewable for LIFE - In both cases once there is no material misrepresentation and you pay your premium on time or within the grace period you cannot be cancelled *(except for other factors, eligibility requirements and or restrictions that may be dictated in your policy or certificate).
    • Guaranteed Renewable -  As it may be dictated in some policies or certificates *coverage can be and not limited to termination if the group policy (Certificate) terminates and or if there is a change in residence to another State or zip code etc.
    • Guaranteed Renewable for LIFE - Individual policy you have as long as you live.
  • Portability - For some providers if you move residence your coverage can cancel; for some providers it triggers where you can be re-rated based on age, health and or based on community (area) you move to.
  • Affordability - Issue Age, Attained Age or Community Age rated.
  • Rate Stability - Request at minimum 10 to 15 year rate look back. 
  • Tenure - How long has the company been providing Medigap coverage.
  • Service - Are concerns addressed via a customer service number or do you have a local personal agent that can represent you as your advocate.
  • Accountability - Has the insurance company been paying the claims in a satisfactory manner, ask your doctor.

Reference: https://www.medicare.gov/supplement-other-insurance/medigap/whats-medigap.html

Borde & Associates, P.A. are not attorneys and by no means are we giving any legal advise; it is the sole responsibility of the consumer with respect to the above factors. Please read your policy or certificate very carefully, do not rely on anything verbally said  - Have above relevant and or preferred factors shown in writing, attached and or included in the policy or certificate.  Consult an attorney to review your policy or certificate if you do not understand.