Medicare

Medicare Advantage Plans are offered through private insurance companies contracted with Medicare and are an optional election. Advantage plans renew annually and have a similar feel of a group/major medical health plan.

• Copays and/or coinsurance for doctor visits, outpatient services, and hospital stays
• Built-in prescription drug coverage (in most cases)
• Preventive and/or comprehensive dental, hearing, and vision benefits
• A network of providers to choose from (not all providers participate)

Depending on if a Medicare beneficiary elects a Part C Medicare Advantage plan or a MediGap/Supplement plan, out-of-pocket costs will differ.

Most private insurance providers offer plans for beneficiaries with special needs, chronic conditions, and individuals needing additional financial assistance.

• Health Maintenance Organizations (HMO)
• Exclusive Provider Organization (EPO Plans)
• Health Savings Account (HSA Plans)
• Preferred Provider Organizations (PPO)
• Private Fee-for-Service (PFFS)

Accessing prescription drug coverage under Medicare works differently than traditional group, or individual major medical plans on the market today. Medicare’s prescription drug plan program is optional, however, penalties could apply for those who waive coverage and decide to elect at a later time. There are two ways to access drug coverage:

1. Stand-alone Prescription Drug Plan (PDP): These plans add coverage to Original Medicare, some Medicare Private Fee-for-Service (PFFS) plans, and Medicare Medical Savings Accounts (MSA) plans.
2. Medicare Advantage Plans (Part C): You get all of your Part A, Part B, and Part D through these plans. These plans are commonly referred to as “MA-PDs”.

The 4 Phases of a Drug Plan:
Most drug plans have an annual deductible, a 4-5 tier copay/coinsurance schedule, coverage in the gap, and catastrophic phases. Private insurance carriers are required to cover the yearly standard benefit set by Medicare and CMS. In addition, each carrier has their own drug formulary covering at least 2 drugs in each therapeutic class.

Premiums:
Part D premiums will vary by stand-alone prescription drug plans or Part C plans elected. More robust drug needs may warrant a plan with a higher premium but lower out-of-pocket costs at the pharmacy. A standard rule of thumb to follow is your specific drug list will determine the right Part D plan for you. Individuals with higher income may have an Income Related Monthly Adjustment Amount (IRMAA) apply.

How much are your premiums, deductibles, and other costs? How much do you pay for services like hospital stays or doctor visits? Is there a yearly limit on what you could pay out-of-pocket for medical services? Make sure you understand any coverage rules that may affect your costs.

Costs in Original Medicare
There’s no limit on how much you pay out-of-pocket per year unless you have supplemental coverage.

Costs in Medicare Advantage
Plans have a yearly limit on your out-of-pocket costs. If you join a Medicare Advantage Plan, once you reach a certain limit, you’ll pay nothing for covered services for the rest of the year. This option may be more cost effective for you.

Note:
If you’re in a Medicare plan, review the “Evidence of Coverage” (EOC) and “Annual Notice of Change” (ANOC).

How well does the plan cover the services you need?

Coverage in Original Medicare
Medicare covers medical services and supplies in hospitals, doctors’ offices, and other health care facilities. Services are either covered under Part A or Part B.

Coverage in Medicare Advantage
Plans must cover all of the services that Original Medicare covers. Some plans offer benefits that Original Medicare doesn’t cover like vision, hearing, or dental.

Note:
If you’re in a Medicare plan, review the “Evidence of Coverage” (EOC) and “Annual Notice of Change” (ANOC).

If you have other types of health or prescription drug coverage, make sure you understand how that coverage works with Medicare. If you have employment-related coverage, or get your health care from an Indian Health or Tribal Health Program, talk to your benefits administrator, or insurer before making any changes.

Supplemental coverage in Original Medicare
You can add a Medigap policy to help pay your out-of-pocket costs in Original Medicare, like your deductible and coinsurance.

Supplemental coverage in Medicare Advantage
It may be more cost effective for you to join a Medicare Advantage Plan because your cost sharing is lower (or included). And, many Medicare Advantage plans offer vision, hearing, and dental. You can’t use (and can’t be sold) a Medigap policy if you’re in a Medicare Advantage Plan.

Note:
If you’re in a Medicare plan, review the “Evidence of Coverage” (EOC) and “Annual Notice of Change” (ANOC).

Do you need to join a Medicare Prescription Drug Plan? Do you already have creditable prescription drug coverage? Will you pay a penalty if you join a drug plan later? What’s the plan’s overall star rating? What will your prescription drugs cost under each plan? Are your drugs covered under the plan’s formulary? Are there any coverage rules that apply to your prescriptions? Are you eligible for a free Medication Therapy Management (Mtm) program?

Prescription drug coverage in Original Medicare
You’ll need to join a Medicare Drug Plan (Part D) to get drug coverage.

Prescription drug coverage in Medicare Advantage
Most Medicare Advantage Plans include drug coverage. If yours doesn’t, you may be able to join a separate Part D plan.

Note:
If you’re in a Medicare plan, review the “Evidence of Coverage” (EOC) and “Annual Notice of Change” (ANOC).

Do your doctors accept the coverage? Are the doctors you want to see accepting new patients? Do you have to choose your hospital and health care providers from a network? Do you need to get referrals?

Doctor and hospital choice in Original Medicare
You can go to any doctor that accepts Medicare.

Doctor and hospital choice in Medicare Advantage
You may need to use health care providers who participate in the plan’s network. If so, find out how close the network’s doctor or pharmacies are to your home. Some plans offer out-of-network coverage.

Note:
If you’re in a Medicare plan, review the “Evidence of Coverage” (EOC) and “Annual Notice of Change” (ANOC).

Are you satisfied with your medical care? The quality of care and services offered by plans and other health care providers can vary. How have Medicare and other people with Medicare rated your health and drug plan’s care and services? Get help comparing plans and providers.

Travel coverage in Original Medicare
Original Medicare generally doesn’t cover care outside the U.S. You may be able to buy supplemental insurance that offers emergency care when you travel outside of the U.S.

Travel coverage in Medicare Advantage
Plans usually don’t cover care you get outside of the U.S.

Example:
If you’re in a Medicare plan, review the “Evidence of Coverage” (EOC) and “Annual Notice of Change” (ANOC).