When it comes to Medicare, there are various options available to tailor your health coverage according to your needs. Upon turning 65 and becoming eligible for Medicare, the initial step is typically enrolling in Original Medicare. This fee-for-service health plan consists of two parts, Part A and Part B. However, after enrolling in Original Medicare, you have the opportunity to personalize your coverage by selecting one of two paths. At Vision Insurance Group, we assist you in assessing your specific needs and provide guidance to help you determine the most suitable path for your healthcare requirements.
Original Medicare was not designed to provide comprehensive coverage for all hospital and medical expenses. As a result, many individuals choose to enhance their coverage by combining Original Medicare with a Medicare supplement and a Medicare Part D Prescription Drug Plan. This approach usually entails higher monthly premiums, but it offers the advantage of significantly reducing your out-of-pocket expenses when accessing medical services.
After enrolling in Medicare Parts A and B, you have the option to enroll in a Medicare Advantage plan. Medicare Advantage differs from Original Medicare and Medicare Supplement plans. With Medicare Advantage, you can receive coverage for all the services provided by Medicare Parts A and B, usually at lower out-of-pocket costs. This path typically involves low to no monthly premiums, but you will be responsible for paying for medical services as you receive them.
| Original Medicare Path | vs. | Medicare Advantage Path |
|---|---|---|
| You have the responsibility of paying the premiums for both Part A (if applicable) and Part B of Medicare | Premiums | You have the responsibility of paying the premiums for both Part A (if applicable) and Part B of Medicare. Additionally, there will be a monthly premium for the Part C Medicare Advantage Plan, which can be as low as $0 per month |
| Across the entire United States, regardless of location or region | Coverage | You are required to utilize healthcare providers within your local and regional network. In the case of a PPO, you have the option to seek services outside of the network, but it may result in additional costs or fees |
| No limit | Maximum-Out-of-Pocket (MOOP) | For the year 2024, CMS has established a Maximum-Out-Of-Pocket (MOOP) threshold of $8,850. Nevertheless, the majority of Medicare Advantage Plans have set their MOOP limit lower than this amount |
| For each benefit period, there is a Part A deductible of $1,632 (as of 2024) that you will be responsible for. Additionally, there is a Part B deductible of $240 (for 2024) that you will need to pay | Medical Deductibles | Certain Medicare Advantage Plans may include an out-of-network medical deductible |
| You are responsible for the 20% co-insurance of Part B | Co-insurance | There is no co-insurance for the majority of medical services, except for dialysis and Part B drugs |
| Copayments are applicable for hospital stays, diagnostic tests, and emergency visits | Copays | There are predetermined copayments for both inpatient and outpatient medical services |
| You have the flexibility to choose any doctor who is in contract with Medicare | Doctors | You may be required to select a doctor from the network of providers affiliated with the Medicare Advantage Plan |
| Not required | Referrals | If you have an HMO Medicare Advantage Plan, you may need a referral for certain service |
| Original Medicare does not provide coverage for prescription drugs | Prescription Drugs | The majority of Medicare Advantage Plans include Part D Prescription Drug coverage. You may have to meet a Part D deductible and pay copays for your medications |
This is a significant aspect to consider, and determining the answer can be intricate as it varies for each Medicare beneficiary. Several factors come into play, including your financial situation, lifestyle, healthcare needs, access to healthcare providers and facilities, prescription drug requirements, and more.
To assist you in making this decision, we recommend scheduling a meeting with a Vision Advisor. They can provide valuable insights, address your specific needs, and help you navigate through this critical question.
While Part A of Medicare is typically premium-free for most beneficiaries, it does have certain gaps that may impact your finances. This includes a $1,632 deductible (for 2024) per benefit period. On the other hand, Part B of Medicare requires a monthly premium of $174.70 (for 2024), a $240 deductible (for 2024), and 20% co-insurance. It's important to note that there is no cap on your out-of-pocket expenses for the 20% co-insurance. If you anticipate that these gaps in Parts A and B could pose a significant financial burden, you may want to explore supplemental coverage options.
Medicare Part C Advantage plans can be a viable solution to address these gaps. Many Medicare Advantage plans have $0 premiums, no deductibles, and low or even $0 copayments. Additionally, they often provide extra benefits like vision and dental coverage, integrated prescription drug plans, gym memberships, transportation services, over-the-counter benefits, discounts, grocery delivery, and more.
However, if you find Medicare Advantage too restrictive and not suitable for your needs, a Medicare Supplement policy, also known as Medigap, may be a better option to fill the coverage gaps left by Medicare. Medigap policies are offered by private insurance companies and require an additional monthly premium. However, they can significantly reduce or eliminate your out-of-pocket expenses when you receive healthcare services. These policies are regulated by the government, and there are ten different Medigap plans to choose from: A, B, C, D, F, G, K, L, M, and N.
Imagine you currently have Original Medicare consisting of Parts A and B, along with prescription drug coverage from ABC. However, you might be questioning whether your current coverage is sufficient. It's natural to start considering the potential costs associated with doctor visits, hospital stays, emergencies, medical procedures, lab work, preventive services, and more.
As we mentioned earlier, Part A comes with a deductible of $1,632 (for 2024) for each benefit period, while Part B has a deductible of $240 (for 2024) and 20% co-insurance after meeting the deductible. It's important to note that there is no cap on the amount you may spend on the 20% co-insurance for Part B.
Let's say you undergo a coronary bypass surgery with a total cost of $175,000. In this scenario, you would be responsible for paying the 20% co-insurance amount, which amounts to $35,000. However, if you had a Medicare Supplement plan in place, your portion of the cost would be offset by the coverage provided by your Medicare Supplement plan. For instance, if you had Medicare Supplement Plan G, your responsibility would only be the Part B deductible, which is $240. Medicare Supplement Plan G would cover the remaining 20% co-insurance for Part B.
| Medicare Supplement Plan | vs. | Medicare Advantage Plan |
|---|---|---|
| It is your responsibility to cover the premiums for both Part A (if applicable) and Part B of Medicare. Additionally, you are responsible for paying the monthly premium for your Medicare Supplement plan | Premium Cost | You are required to continue paying the premiums for Medicare Part B and, if applicable, Medicare Part A. Additionally, if you have a Medicare Advantage plan, you may need to pay a monthly premium for that as well. When you receive healthcare services, it is typical to be responsible for copayments, coinsurance, and/or deductibles. |
| You will have higher premiums but generally lower out-of-pocket expenses as you receive healthcare services | Out-of-Pocket Cost | You will have lower or no premiums but may have higher out-of-pocket expenses as you receive healthcare services |
| Medicare Supplement plans do not have network restrictions. You have the freedom to visit any medical facility and healthcare provider in the United States that accepts Medicare | Network | Medicare Advantage plans have a network of providers that you must stay within. However, it's important to note that emergency and urgent care visits are always covered when you are traveling within the United States |
| You have the freedom to select any doctor and hospital that have a contract with Medicare and accept Medicare patients | Doctors & Hospitals | You may need to select healthcare providers from the network of physicians and hospitals associated with the plan |
| You can consult with any specialist without needing a referral from your Primary Care Physician | Specialist Referrals | Before seeing specialists, you may need to obtain referrals |
| Prescription drug coverage is not provided and requires enrollment in a separate Part D Prescription Drug Plan, which entails an additional monthly premium | Prescription Drug
Coverage | Prescription drug coverage is typically included within most Medicare Advantage Plans |
| Open all-year-round | Enrollment Periods | There are specific enrollment periods throughout the year that allow you to enroll or switch plans, such as the Initial Enrollment Period (IEP), Medicare Advantage Open Enrollment Period (MA OEP), and Medicare Annual Enrollment Period (AEP). It's important to note that when it comes to Medicare Advantage plans, there is typically no medical underwriting involved, providing you with more flexibility in selecting and changing plans |
| In general, most Medicare Supplement plans do not have a Maximum-Out-Of-Pocket (MOOP) limit, which means there is no cap on your out-of-pocket expenses. However, it's important to note that plans K and L are exceptions to this rule. These specific Medicare Supplement plans, namely Plan K and Plan L, do have their own set maximum limits on out-of-pocket costs | Out-of-Pocket
Maximums | CMS (Centers for Medicare and Medicaid Services) requires all Medicare Advantage plans to have a Maximum-Out-Of-Pocket (MOOP) limit. This means that there is a cap on the total amount you would need to pay out-of-pocket for covered services within a calendar year. The MOOP limit provides financial protection and helps ensure that beneficiaries do not face excessive costs for their healthcare expenses under Medicare Advantage plans. |
| Medicare Supplement plans generally do not include coverage for dental, vision, or hearing aids. However, some insurance carriers offer additional "buy-up" plans that provide these benefits for an additional premium. These buy-up plans can be added to your Medicare Supplement coverage to provide coverage for dental services, vision care, and hearing aids | Vision, Dental, and
Hearing Services | Medicare Advantage plans often provide coverage for a range of additional benefits beyond what is offered by Original Medicare. These can include benefits such as eye exams, eyeglasses, and corrective lenses for vision care. Dental exams, cleanings, and X-rays may also be covered for dental care |
| Certain Medicare Supplement plans offer extra coverage for medical emergencies during international travel. This additional coverage is not available in all Medicare Supplement plans and may vary depending on the specific plan and insurance provider | Foreign Travel | With most Medicare Advantage plans, coverage for services while traveling abroad is limited, typically only extending to medical emergencies |
| During the 6-month Open Enrollment Period for Medicare Supplement plans, you are guaranteed coverage without any exclusions or waiting periods for pre-existing conditions. This means that you can enroll in a Medicare Supplement plan and receive coverage for all your healthcare needs from the start | Pre-existing conditions | You can enroll in Medicare Advantage plans regardless if you have a pre-existing condition |
| Certain Medicare Supplement plans may include a fitness membership program as an additional benefit. This means that in addition to the standard coverage provided by the Medicare Supplement plan, you may also have access to a fitness membership at participating gyms or fitness centers | Additional Benefits | Certain Medicare Advantage plans may include benefits like fitness and wellness programs, transportation services, home modification/
maintenance services, telehealth and social worker teleservices, and more |
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