By Jose Juarez,
Medicare is a federal health insurance program that is available to U.S. citizens or permanent legal residents, primarily those who are at least 65 years old. Others eligible for Medicare are those with certain disabilities or conditions.
But Medicare coverage can be complex, and it’s not always clear which plan is best for which which person. So, with the annual election period set to begin later this month, here’s a primer to help you out.
What makes up Medicare?
Medicare consists of four parts:
Part A: Hospital insurance that helps cover inpatient care in hospitals, skilled nursing facilities, hospice and home care.
Part B: Medical insurance that helps cover services from doctors, ambulances, lab tests, medical equipment and preventive exams.
Part C: Medicare Advantage, which which is offered by private insurance companies that provides the benefits of Parts A and B, often including Part D.
Part D: Help with the cost of prescription drugs not covered by “Original Medicare.”
Jose Juarez, Medicare Education Specialist, MemorialCare Medical Group. (Photo courtesy of MemorialCare)
Original Medicare, or Part A and B
Part A and B of Medicare make up what is known as “Original Medicare,” covering medical services and supplies in hospitals, clinics or other health care facilities. Part A covers hospital insurance and Part B covers medical insurance, and both are managed by the federal government through Original Medicare.
With Original Medicare, you are generally able to see a primary care doctor, specialist or hospital that takes Medicare in the U.S.
Under Original Medicare, you first pay a deductible, a set amount for your health care. Then, Medicare pays its share while you pay the copayment for covered services and supplies. Since Part B covers more routine services and supplies, you are usually required to pay a monthly premium of around $170.10 for 2022 ($164.90 in 2023) The amount can change each year and could be higher depending on your income.
Medigap is supplemental insurance that helps fill “gaps” in Original Medicare.
Original Medicare pays for most, but not all, of your health care services and supplies. A Medicare Supplement Plan (Medigap) policy can help you pay the remaining health care costs, like copays, coinsurance and deductibles.
Medigap policies don’t cover the following services: Long-term care, vision, dental or hearing aids.
Medicare Advantage, or Part C
Part C, or “Medicare Advantage,” deals with private insurance plans approved by Medicare that provide beneficiaries with Part A, Part B and Part D coverage.
Not all Medicare Advantage plans work the same way, however, so make sure you find and compare the different plans available to you before you join.
In most cases, you’ll need to use doctors who are in the plan’s network, but plans may have lower out-of-pocket costs because of that. Medicare Advantage plans may offer a variety of helpful benefits as well.
All plans that are offered cover the same services and supplies that Original Medicare offers. This will give you access to hospital services, skilled nursing facility care, hospice care and medical services that may be medically necessary or preventative.
In addition to your basic coverage, though, Medicare Advantage plans can offer extra benefits. These benefits vary so be sure to look through each plan to see what benefits would best fit your medical needs. Some of the additional benefits you may find in a Medicare Advantage plan include:
Adult daycare services.
Transportation to health-related services.
Safety devices for use in the home.
Medicare Advantage gives you access to these benefits underneath one single plan. This access to extra benefits also pulls people toward selecting a Medicare Advantage plan over Original Medicare.
Medicare Drug Plan, or Part D
It is very important to understand how your prescription drugs are being covered as well.
Part D, or Medicare Drug Plan, helps with the cost of prescription drugs.
Many Medicare Advantage Plans include Part D at no extra cost. It may be more cost-effective for you to find a Medicare Advantage plan that covers your prescriptions in addition to all the extra benefits the plan may include.
But if you find that Original Medicare or a Medicare Supplement Plan suits your needs better, you may also choose to add a standalone Medicare Drug Plan to Original Medicare.
It is generally recommended that you still enroll in Part D as soon as you’re eligible, so you’re covered if and when you require prescription medication. If you delay enrolling in a Medicare Drug plan, you will most likely need to pay a late enrollment penalty fee, which turns into a permanent cost that is added to your Medicare Part D premium for as long as you use Medicare. Medicare Part D premiums vary depending on your filing status and yearly income.
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Annual election period
The Annual election period is important.
During this time of year, from Oct. 15 to Dec. 7, you can shop around and compare your current plan and decide if there’s something better in your area.
During this period, you can join a Medicare Advantage plan or enroll in a Part D plan, or switch between Original Medicare with or without a Part D plan and a Medicare Advantage Plan.
As you review your current Medicare health and drug coverage, you can make changes for next year depending on how satisfied you are with your coverage.
Even if you are satisfied with your current Medicare coverage, it would be best to look at other options in your area that may better suit your individual needs for the upcoming year.
There may, for example, be other plans in your area that will offer better coverage at a more affordable price or another Part D plan that covers prescriptions with potentially lower prices.
Jose Juarez is a Medicare education specialist at MemorialCare Medical Group. He has years of experience speaking to seniors and educating them about the basics and intricacies of navigating Medicare, finding the best plan for them, and encouraging them to take advantage of the programs and plans available to them.