Medicare is a big decision for any senior. With so many different plans and options, it can be difficult to figure out what’s best for you or your loved one. There are Medicare Advantage Plans that offer additional benefits such as dental coverage, prescription drug coverage, vision care and more while still providing the basic Medicare benefits like doctor visits and hospitalization. Is this right for you? We’ll discuss in today’s blog post!

As R.N. patient advocates, our job is to provide education on health care topics to allow you to make informed decisions. You will need to contact an insurance or Medicare professional to make the final decision on what is right for you.  Besides insurance professionals, many clinics provide staff that specialize in helping you choose the program that is right for you and are knowledgeable regarding what types of plans are available in your area. Our goal here is to give you the knowledge to ask the right questions for your own situation so you can make the right choice for you.  This is not a one size fits all. What is available in your county may not be available in others or even other states, so you have to research what is available in your area.  There are some national insurance companies that have plans nationwide as well as more local insurance companies that provide plans in a specific region. Here is a resource to help you look at Medicare Advantage Plans. How Do I Pick the Best Medicare Advantage Plan for Me? (medicareadvantageplans.org)

Choosing between Medicare plans and Medicare Advantage plans can be tough. Even if you are a baby boomer, the options available to you may not make much sense. The first thing that you need to do is figure out what your needs are. There is no right way, wrong way, only what is best and your way. The plan you choose must meet your financial circumstances as well as your lifestyle choices while taking into consideration your over-all health. Here are some questions to consider:

Do you want something with prescription drug coverage? Is an Advantage Plan with medication coverage for you or paying extra for a regular Medicare Part D or Drug Plan for you?

Do you plan on traveling outside the U.S.? Many Medicare Advantage Plans to not have coverage outside the U.S. or it may cost more for a “rider.” Some do, so this is a big question if you travel.

Do you plan to live part-time in one part of the country and part-time somewhere else? It may be more difficult to be a “snow bird” on a Medicare Advantage Plan because you can usually have only 1 network of providers. This may or may not also impact your ability to get your insured rate on your prescriptions when you are out of your network area. An option may be to have a mail order pharmacy.

Do you want the choice of choosing your own doctor and hospital? Most Advantage Plans have a “network” of specific providers and hospitals that you must stay with to get network benefits.  With Medicare, you can go anywhere that accepts Medicare Assignment.

How much per month are you allowing for Medical Insurance in your budget. Based on income, you may be able to get low cost or no cost plan. Your Medicare Part B premiums are deducted right out of your social security check.

Would you rather pay a small amount each month and a larger amount if you are hospitalized or pay more monthly and pay less if hospitalized?

Do you want coverage that pays for the Medicare deductibles or co-pays? Then a Medicare Supplement might be a consideration Plans E, F, G with an optional “rider” that may need to be added to pay the Medicare deductibles.

What about dental or vision coverage? This is not available with traditional Medicare. Depending on your income you may be able to add these with a Medicaid plan at little or no cost to you.

Once you have figured this out, then it will be easier for you to choose which option best fits your needs. All Advantage Plans must offer all the benefits regular Medicare offers. Some Advantage Plans offer a few more benefits such as Silver Sneakers, Health and Wellness Programs, Meals for a time after being hospitalized, and others.

The Medicare open enrollment period was November 15th through December 7th this year. The decision of whether to enroll in a Medicare plan or go with a private insurance company has become even more difficult and confusing than usual. There are new rules for prescription drug coverage that will affect many people, but there is also confusion about what “Medicare Advantage” plans actually offer. One good thing, is that if you are not happy with your Medicare or Advantage Plans you can make changes during the following annual open enrollment period.

There are lots of choices when it comes to health insurance. You have to decide which one is best for you and your family. There are two main types: Medicare Advantage Plans or Original Medicare (Parts A, B, and D and Supplements or Medigap E, F, G). The decision will depend on what’s important to you in terms of coverage, cost, and other factors such as living location. 

As a baby boomer, the time has come to take control of your health care. As you age, it is important to be proactive in taking care of yourself, and that includes knowing what type of Medicare plan or Medicare advantage plans are available for you. Medicare Advantage Plans and Medicare plans both have their pros and cons.  Make a list of what is important to you for coverage then you can begin to compare.

To begin you have a 6-month window to sign up for Medicare if you are not already collecting Social Security, 3 Months before and 3 months after your 65th birthday. In special circumstances such as disability this may not apply but we will not be discussing that today. There is a penalty if you miss the window to sign up for Medicare Part B.

The first decision you will need to make after applying for Medicare Part A and Part B if you are considering a Medicare Advantage Plan. You do not have to have Medicare Part B if you stay with traditional Medicare but you will limit yourself to coverage as we will discuss later.

Medicare Plan A covers everything that is basic including doctor visits and hospitalization but no other benefits such as dental coverage, prescription drug coverage. If you have worked enough “quarters” in your life to qualify for Medicare part A that is at no charge to you. Medicare was originally intended to be a major medical plan and not to be the end all to coverage. Medicare pays by 60-day episodes. For example, if you are hospitalized you will have a deductible of anywhere between $1400.00-$1800.00 give or take, depending on your income and own circumstances that will be determined by Medicare. If you go into the hospital you will have to pay that deductible and it is good for 60 days. If you come back to the hospital in 45 days you will NOT have to pay another deductible but if you are re-hospitalized in 65 days you WILL have another deductible. If you are in and out of the hospital often, you could pay that deductible up to 6 times. Get started with Medicare | Medicare

In general, Part A covers:

• Inpatient care in a hospital
• Skilled nursing facility care
• Nursing home care (inpatient care in a skilled nursing facility that’s not custodial or long-term care)
• Hospice care-Even if you have a Medicare Advantage Plan you will automatically revert back to regular Medicare for the Hospice Benefit Coverage
• Home health care

• Medicare Plan B Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice including lab tests.
• Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.
• Inpatient Stay in the hospital where you have a diagnosed illness that will keep you in the hospital 2 days or more to treat you before you are well enough to go home.

Part B covers things like:

• Clinical research  
• Ambulance services
• Durable medical equipment (DME)
• Mental health
• Inpatient
• Outpatient
• Partial hospitalization-Observation Stay in a hospital as an extension of an inpatient stay. The provider continues to try to diagnosis or rule out an illness or manage your symptoms while you typically stay in the hospital 24-48 hours. We have a blog post that does go more in depth regarding these two type of admissions, Inpatient vs. Observation, found on our website.
• Limited outpatient prescription drugs

A Medicare Supplement or Medigap Plan is taken to fill in the gaps of a regular Medicare plan and may cover things like copays, coinsurance, or deductibles that are incurred from a doctor visit or hospitalization.

A Medicare Advantage plan takes your budget of Medicare money assigned to you and gives it to the insurance company that provides benefits in addition to Medicare like dental, vision and hearing. You must be enrolled in Medicare Part A and B to qualify for a Medicare Advantage Plan. Medicare, based on your health history will hand over your calculated “bucket” of Medicare dollars to the Advantage Plan to manage the money and provide you coverage. Medicare Advantage Plans can cost you nothing per month or on average up to $150.00 per month and may have dental and or vision extra or included. With a Medicare Advantage Plan, you must also continue to pay your monthly premium for Medicare Part B which is deducted from your social security check if you are already collecting social security payments. So, make sure you take that into consideration when calculating your monthly costs. For the year 2021, the Medicare Part B Premium is $148.50 per month for most people unless you have an above average income. If you are already receiving Social Security, you will automatically be signed up for Medicare Part A and B, and your card will come in the mail. If you are still working and have insurance with your employer, and not collecting Social Security yet, you still have to sign up during your 6-month period to avoid the Part B penalty.  Instructions will come regarding your Medicare if you are still working.  Do I need to sign up for Medicare if I’m still working? (msn.com)  

Medicare advantage plans offer many benefits, but the downside is that you are limited to what providers and hospitals they work with. Deductibles and out of pocket maximums can vary like regular insurance based on the plan and monthly premium you select to pay.  Medicare Advantage Plans are much like regular health insurance plans except they must offer at least the same benefits that straight Medicare covers.  It is then up to them if they want to offer more.

Medicare supplement insurance plans do not have limits on your coverage; it’s just a Medicare plan by another name. A Medicare Supplement gives you more freedom to choose your provider and you are not “locked” in to a small list of doctors and hospitals you may choose from. You pay the insurance premiums again, on top of your Medicare Part B premiums but may have a bit more flexibility but sometimes can be more expensive. You must take the time to compare plans you are considering to know how much you will be paying total every month and what you may expect to pay out of pocket.

A Medicare Supplement might be a good choice if you travel or spend several months away from home. Some Medicare Advantage Plans do not cover world-wide travel and only cover you when you are in the United States. If you travel this is one of the questions you need to ask when considering an Advantage Plan is what is your coverage if you travel outside of your network of providers and if you travel outside the country.

Your Medicare supplement is the same no matter who you choose to get your Medicare benefits from. You will have options with a Supplement again, based on what you are comfortable paying. Based on your income, sometimes the more you pay the better the coverage and less out of pocket costs.  Some Medicare Supplement plans may offer extra benefits such as dental, vision and hearing or they might cover more of what other people call an “extended hospitalization benefit.” Some supplements can have a “rider” attached that you pay extra for to have them pay all the Medicare deductibles you may incur while in the hospital.

We have included our “live” discussion on Conversations with Your Nurse Advocates where we discuss the differences between traditional Medicare and Medicare Advantage Plans.

You’ve learned a lot about Medicare and how to make an educated decision. We hope you found this information helpful and informative, but we also understand that there are many questions still unanswered for you. Make your list of questions and then reach out to a professional to help you select the right plan. Join our “Stay in Touch” list so that we can help answer those lingering questions or keep up-to-date on topics related to aging by subscribing now!

Just a side note: Not all Advantage Plans are equal. As a Case Management/Utilization Review Nurse I work with insurance companies all the time working to get hospitalized patients hospital stays covered and not denied. Insurance companies with Advantage Plans have to make money off of the bucket of money that is given to you by Medicare while trying to offer more benefits to attract you to their company. Please check out your prospective Medicare Advantage Plan, ask around. Ask people in your area if they have ever had any bad experiences with their Plan. Believe me they are not all the same and we have seen the good, the bad, and the ugly!! Research ratings on each Advantage Plan you are looking at. Each Advantage Plan gets a Medicare rating and the highest is a 5-Star Rating. Find out what the rating is before you choose. Understanding Medicare Advantage Plans. This resource will also help you choose and share information on how you can compare Advantage Plans.

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Thank you for taking some of your precious time to spend with us! We look forward to serving you in the future.

Your Team Pam, Mary, and Linda

Your Nurse Advocates, Pam and Linda