Showing posts with label differences between medigap and medicare advantage insurance. Show all posts
Showing posts with label differences between medigap and medicare advantage insurance. Show all posts

Friday, October 29, 2021

Medicare Supplements vs. Medicare Advantage Plans - What are the differences?

While chatting with a friend of mine recently, a woman who has been retired for over 15 years, she referred to her Medicare Advantage plan as a Medicare Supplement. She did not know the difference.  This might not have been a serious problem, except she told me that she was giving retirement advice to one of her daughters who plans to retire in a few years, and much of what she was telling her daughter about Medicare was incorrect.  

Signing up for Medicare is more complex than many people expect it to be.  We have so many decisions to make, and they have to be done at exactly the right time, or we can end up paying higher premiums for the rest of our lives!  Often, our personal physicians cannot answer our questions, because they do not do the Medicare billing themselves.  They hire a company to do it for them.  It is important for retirees to do their own research.  While this post cannot answer all your questions, it will clarify some basic information and help you get started on making the best decisions for yourself.

What Medicare Choices Will You Have?

You have more choices in Medicare than you realize, whether you are purchasing it on the open market, or your former employer or union will help pay for your retirement coverage. You may get a good deal through the plans they offer, or you may find just as good a deal on your own, unconnected to your former employer.  You need to evaluate as many different choices as possible, to make sure you get the best plan to meet your healthcare needs.

The age you start Medicare is NOT connected to the age you retire.  They are completely separate. You can retire anytime you are financially able and can afford to retire.  You can start receiving Social Security Retirement Benefits anytime from age 62 or older.  You can retire from some government jobs at an even younger age.  

Regardless of when you retire, you are not eligible for Medicare until you are at least age 65, unless you became eligible for Medicare Disability at a younger age.  In some cases, you can sign up for Medicare if you are older than 65, particularly if you are still working and covered by an employer plan when you turn 65. If you are not working, and you wait longer than three months after you turn 65 before you sign up, you may pay a Medicare penalty for the rest of your life.  The best time to sign up for Medicare is during a time window which consists of the month you turn 65, or the three months before, or or the three months afterwards.  This could change in the future, but currently, the eligibility age is still 65.  It is important that all retirees pay attention to any changes which may be made to Medicare coverage.

If you want to make sure you do things correctly when you sign up for Medicare, and at the lowest possible cost, you will want to read the book "10 Costly Medicare Mistakes You Can't Afford to Make." (Ad)  It is well worth the $10 it will cost you.  

TWO Separate Options for Your Medicare Benefits

There are two different systems for obtaining your Medicare benefits.  There are advantages and disadvantages to both, but research has shown that medical outcomes are the same, no matter which system you choose. 

Whether you choose Original Medicare or a Medicare Advantage Plan, you will still pay your basic Medicare premium.  The amount of the premium changes annually, and is higher for retirees with a higher income.  In 2021, the premium was $148.50 for most people, but the premium rose to $207.90 for people with an individual income of $88,000 or more, and is as much as $504.90 for retirees with an individual income of more than $500,000.  Each year, the basic Medicare premium usually rises a small amount. If you are already receiving Social Security benefits, your premium will be deducted from those benefits.  If you are not receiving Social Security, you will be billed separately.  

These premiums pay for what is known as Medicare Part B.  In return, Original Medicare will pay for 80% of what is they consider normal medical expenses.  If you want coverage for the remaining 20%, which nearly everyone does, you need to decide if you want to keep your Original Medicare and add a Medigap plan and a Part D drug plan OR select a Medicare Advantage Plan which is a single payer system where you deal only with one company, similar to what you are used to doing when you had regular health insurance before you were old enough for Medicare.

What should you know about the two different options, so you can decide which one would be best for you?

Original Medicare plus a Medigap (Medicare Supplement) and a Part D Drug Plan  

What most retirees expect to do when they reach age 65 is sign up for Original Medicare, pay their monthly premium for it, and then purchase an additional Medicare supplement (Medigap) policy, plus a Part D drug plan.  There are many Medigap plans and Drug Plans to choose from, and they all have different premiums and co-pays, in addition to the monthly premium you are charged by Medicare. 

The top Medigap plans (such as Plan G or F) can cost several hundred dollars a month, and this is above and beyond your basic Medicare premium. In addition, you will usually have to sign up for a separate drug plan and, in most cases, a separate plan for certain types of specialty medical care such as dental and vision.  Altogether, depending on your plans, you can end up paying an extra $300 to $500 in monthly premiums, in addition to what you pay for your Original Medicare premiums. 

Medigap plans are available as both HMOs and PPOs.  The premiums are higher for PPOs, but you can choose your own doctor (as long as they accept Medicare).  In addition to the premiums, in most cases you will also have some co-pays and deductibles.  The more you pay in premiums, the greater your choice of doctors, and the less you will pay in co-pays and deductibles, which makes this option attractive to some people.  

Medigap billing can be complicated, because everything has to be billed first to Medicare and then to your Medigap supplement. You are sent copies of all the bills, which can be overwhelming if you are receiving frequent treatments by a number of different doctors, and this is common as you get older. It can also be confusing, if you are uncertain what part of the bill you owe, and what portion of the bill is still being reviewed by Medicare or your Medigap plan. 

This double billing after each medical appointment is different from how things were handled before you were on Medicare, when everything was just billed to your insurance carrier, and then you were billed for any co-pays and deductibles you might have.  Basically, with Original Medicare plus a Medigap plan, you are covered under TWO separate insurance plans ... Medicare and your supplement.  In addition, you may have to deal with one or two other insurance carriers for your prescription drugs and dental coverage, which means you may receive a lot of different bills.  Some people become so confused that they hire people to review their medical bills for them, to make sure they are being billed correctly.

Option 2 is an All-in-One Medicare Advantage Plan 

Approximately 42% of Medicare beneficiaries turn to Medicare Advantage plans, which are generally less expensive and less complicated to use than Original Medicare, plus a Medigap plan, plus a drug plan.  The way Medicare Advantage plans work is similar to the system you were used to when you had medical insurance before you were on Medicare.  You only deal with one company for most things. 

The main difference is that Medicare pays a premium on your behalf to your insurance carrier each month, so that one company can handle all or most of your medical needs.  The Medicare Advantage companies are required to offer you everything that Original Medicare does, but most of them offer much more.  For example, they may offer gym memberships, vision, hearing and dental coverage, and other special services.  You only deal with your insurance carrier, not with Medicare directly.  Billing is much less complicated.  

Medicare Advantage plans are available to ANY retiree. Your choice depends on the state where you live.  For example, Kaiser Permanente Senior Advantage (the plan I use) is available in California, Colorado, Georgia, Hawaii, Maryland, Oregon, Virginia and Washington.  Other states have different Medicare Advantage plans available, such as Scan, United Healthcare, Humana, Blue Cross, or CVS Health.  You will have to research which plans are available in your state.  In particular, you will want to make sure that your local doctors are part of the Medicare Advantage network you want to use, since these plans require that you only use their network doctors and medical facilities in most cases. 

Of course, anyone on any plan can always choose to pay full price and see an out-of-network doctor, anytime they want.  Seeing an out-of-network doctor will cost you substantially more, however, unless it is an emergency.  It is always best to use in-network doctors, whenever possible. 

Do you worry about what will happen if you become sick or get injured when you have a Medicare Advantage plan and are away from your network? Most Medicare Advantage plans, such as Kaiser, will also cover the cost of an out-of-network doctor if you are traveling in another state or if, in an emergency, you have been taken to an out-of-network hospital in your area.  

Just in our family alone, we have had two examples of family members who were treated well, despite using an out-of-network doctor in an emergency:  

When our daughter had a medical emergency, Kaiser covered the cost of the first hospital she was taken to, until she regained consciousness and was transferred to the ICU at a Kaiser hospital.  In fact, because she had a brain aneurysm which needed to be treated quickly, she was flown by helicopter to the nearest Kaiser facility that had an available surgical team and an ICU unit.

When my husband developed bronchitis while visiting a different daughter in Delaware, we were not forced to drive to a Kaiser facility in Maryland for him to get medical care.  We were able to get him treated at an Urgent Care in Delaware, and we were charged the same as we would have been if we had gone to a Kaiser facility at home.  If you are getting a Medicare Advantage plan, make sure you understand what medical care will be available to you when you are away from home.   If you like to travel overseas, find out what care your insurance company will provide, and whether or not you need to purchase a short-term travel medical emergency policy.  Original Medicare does not cover you when you are out of the country.

Most Medicare Advantage plans, like Kaiser, usually have no additional premiums, other than your regular Basic Part B Medicare premium.  In some cases, you may have a very small premium, such as $20 to $40 a month. You may also have some low co-pays and deductibles.  In most cases, using a Medicare Advantage plan is much less expensive than using Original Medicare, plus a Medigap plan, plus a Part D drug plan.  However, some people are willing to pay extra to use Original Medicare plus a Medigap plan and drug plan, because they have a wider choice in doctors.  The decision is entirely up to you.

Billing is simpler with Medicare Advantage plans, because the Advantage plan handles everything.  Doctors do not bill Medicare first, and then your private insurance.  You are only dealing with your private insurance company. Medicare Advantage plans are generally less complicated than using Original Medicare, plus a Medigap and drug plan.  Most people are satisfied with Medicare Advantage plans, as long as they are happy using the doctors in their network. In addition, many Medicare Advantage plans include their own drug plan and dental plan.  

Research has shown that the medical outcomes are virtually identical, regardless of which type of Medicare plan you use. 

Is It Hard to Find a Good Medicare Plan?

When you turn 65, you choose whether you want Original Medicare plus separate Medigap and drug plans, OR if you want to use a Medicare Advantage plan.  All Medicare plans, including Medigap and Advantage plans, HAVE to accept all new retirees regardless of the patient's preexisting conditions.  If you change your mind later, however, Original Medicare still has to accept you, but the Medigap plans can reject you or charge you more for some health conditions.  Once you are on a Medicare Advantage plan, do not cancel it and go to Original Medicare until you are sure a Medigap plan has accepted you at a price you are willing to pay.  

Remember that the above information just covers the basics. You will still want to make sure you do things correctly, and are getting the most for your money, by reading the book "10 Costly Medicare Mistakes You Can't Afford to Make." (Ad)  It was written by a Medicare insurance broker who has seen many people make the same mistakes over and over again, and the book could save you a lot of problems later in life. 

You can find gifts for retirees and others at my Etsy Store, DeborahDianGifts:

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Tuesday, August 30, 2016

Confusing Parts of Medicare

Are you confused about all the different parts of Medicare ... the so-called Medicare "alphabet?"  If so, you are not alone. Whether people are getting prepared to sign up for Medicare for the first time or are already using it, the different parts can seem like a foreign language.  Below is a brief summary of the different parts, as well as a little basic information that everyone needs to know. 

Medicare Parts A, B and D

Medicare is broken up into four different parts and each one has a different purpose and, in some cases, different requirements that determine whether or not you are eligible.

Medicare Part A:  This section will help pay for your stay in a hospital or skilled nursing facility. It might also pay for home health services and hospice care, if the patient meets certain criteria.  If you or your spouse paid into Medicare long enough during your working years, you do not pay monthly premiums for Part A.  If neither you nor your spouse paid into it while you worked, you can still buy Part A services by paying monthly premiums.  Everyone is entitled to Medicare Part A, either free or for a monthly fee.

Medicare Part B:  This section will help pay for doctors' services (whether in or out of the hospital) and outpatient care, including lab work, tests and health screenings.  It can also cover the cost of some types of medical equipment and supplies, under some circumstances, as well as most vaccines or drugs that the doctor gives you in his office.  You do pay monthly payments for Part B.  However, low-income people may quality for state assistance.  There is a seven month window to sign up for Part B ... three months before your 65th birthday month, during your birthday month, and three months after your birthday month.  If you wait too long to sign up, you can still obtain it, but you will pay extra premiums for the rest of your life.  Medicare Part B only covers about 80 percent of their approved costs and the patient pays the other 20 percent.  At the bottom of this article is more information on the two options you have for covering your portion of the bills.

Medicare Part D:  This section covers the cost of prescription drugs that you take at home.  There is an additional premium involved in getting a Part D drug plan, unless you purchase it as part of a Medicare Advantage Plan.

Medicare Supplements and Medicare Part C

Medicare parts A, B and D are frequently called "basic Medicare."  People often believe they are all you need.  However, sometimes they do not realize they need to sign up for Part D to cover their drugs.  In other cases, people do not realize that when they settle for basic Medicare alone, they are still obligated to pay 20 percent of their medical bills ... which can be substantial.

What do people do to solve these problems?  They have two choices.  First, they can get the three parts of basic Medicare (A, B and D) PLUS purchase a supplemental health insurance policy.  Second, they can simply get a Medicare Advantage plan, also known as Medicare Part C, PLUS a Part D plan if the Medicare Advantage plan they choose does not include drug coverage.  Confusing enough?  Below is a little more information.

Supplemental Insurance:  Many insurance carriers offer supplemental policies, sometimes called Medigap policies, including Anthem, Humana and United Healthcare.  There are different rates, depending on the size of the deductibles and co-pays you prefer. The government even has a website to help you compare Medigap policies.  If you decide to get a Medigap supplemental policy, do it as soon as you sign up for Medicare Part B.  If you buy one within six months of enrolling in Part B, the insurers cannot deny you coverage or charge higher premiums because of preexisting medical conditions.  With supplemental insurance, your doctor or hospital will send medical bills to Medicare first.  Once Medicare reimburses the doctor or hospital, next they bill the supplemental insurance carrier.  After that, they will bill you for any remaining costs.  This system sometimes confuses people, because they keep getting statements from the hospital, doctor and the insurance companies for the same procedure.  Sometimes they think they are being double-billed.

Medicare Advantage or Part C:  This is a completely alternative way to receive your Medicare services.  Everything is administered by one private managed care plan.  There are both HMO and PPO options.  These plans are required to cover everything that is offered in basic Medicare, but they may charge lower co-pays and/or offer additional benefits.  Some of the companies that offer these plans are Kaiser Permanente and Scan. The government also has a website to help you learn more about Advantage plans. The plan you buy may also include Part D drug coverage, or the company could offer you a choice of drug plans at a separate price.  Often they offer extra benefits such as dental, vision and hearing care.  In some cases, there are NO premiums, other than what you would pay for basic Medicare.  With other plans, you may have an additional premium.  They may restrict your choice of doctors to only ones who are in their network, or they may charge a higher copay if you go out of network.  Only one company is billed, the Medicare Advantage company, which is less confusing for some people, since they only receive one set of statements and bills for each procedure.

The Medicare Advantage choice is often the least expensive, since there is frequently no premium or only a small premium above the cost of basic Medicare.  However, it is always beneficial to shop around to make sure that you are getting the most for your money, from a reputable insurance company.  Make sure you are aware of all the major choices available in your state.

Summing Up Medicare

To bring it all together, it is important that everyone contact their local Social Security office as soon as possible when they get close to age 65.  In addition, most people will want to attend informational meetings and get more details about the insurance options for both Medicare Supplemental Plans and Medicare Advantage Plans in their state.  Don't make a decision until you have met with two or three different companies and learned about all your choices.

If you start with a company and realize that you wish you had chosen a different company or type of plan, you are not stuck with your first choice.  There is an open enrollment period every year between October 15 and December 7.  During that time, you are free to move to a different plan.

You May Also Want to Find Out About Common Medicare Mistakes

In addition to knowing the various parts of Medicare, you may also want to read the blog post linked below.  It explains the most common Medicare mistakes made by people approaching retirement:


Looking for more information about Medicare, retirement planning, where to retire, common health problems as we age or more?  Use the tabs or pull down menu at the top of the page to find links to hundreds of additional articles.

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Tuesday, July 8, 2014

Should You Get a Medicare Advantage Plan with Your Medicare?

As you approach the age of 65, your first step in obtaining Medicare is to contact the Social Security Administration and sign up.  The ideal time to do this is within three months before you turn 65, during the month you turn 65, or during the three month period afterwards.  You can sign up at a later age, but you will pay more, in most circumstances.

You can read more about how to complete this process by reading my article "How to Sign Up for Medicare."

Once you have signed up for Medicare, your next step is to decide if you want to get a Medigap policy (Medicare Supplement Insurance) or a Medicare Advantage Plan.  In this post I will discuss Medicare Advantage plans, similar to the one I have selected.  You may also want to read my article  "Should You Get a Medigap Supplemental Policy with Your Medicare?"  

Medicare Advantage Plans

When you select a Medicare Advantage Plan you are still using Medicare.  You get your Part A and Part B services directly through your Medicare Advantage Plan.  Your healthcare providers are required to provide you with everything that original Medicare offers except hospice care and research studies.  You will still receive those services; Medicare just covers them directly.

The benefit of getting a Medicare Advantage Plan is that they usually offer extra services in addition to those you would get only from straight Medicare.  Depending on the insurer, these extra services could include vision, hearing, dental and wellness programs.  Some Medicare Advantage Plans charge no premium above what everyone must pay for basic Medicare; others charge a small additional premium.

For example, I have chosen to use Kaiser Permanente in California as my Medicare Advantage provider.  The only additional fee they have is an optional $20 a month for their Plus plan, which includes dental and extra vision benefits.  You need to understand your plan, however, because the fees and services vary from company to company.

All Medicare Advantage Plans must follow Medicare's rules and provide you with the basic services.  However, they can charge different out-of-pocket fees and they may have their own rules about their services, such as requiring you to get a referral from a primary care doctor in order to see a specialist.

Different Types of Medicare Advantage Plans 

There are a wide variety of Medicare Advantage Plans available and choices vary from state to state.  You can choose an HMO, a PPO, a Private Fee-for-Service plan, Special Needs Plans, HMO Point-of-Service plans and Medical Savings Account Plans.

A few months before your 65th birthday, most of the providers in your area will start mailing you brochures about their plans and some will have seminars to explain how their plans work.  Hospitals and senior centers in your community may also sponsor informational meetings.  Selecting the right program for you can be very confusing, so I highly suggest that you talk to your friends who are already on Medicare.  Ask them about the type of plan they are using, what they like about it and what they would change.  It is recommended that you discuss your choices with an agent who represents a variety of insurance companies and types of policies.

You may also need to take costs into consideration.  One of the factors which helped me make up my mind to use Kaiser was the fact that the optional premium was only $20 above the cost of basic Medicare and my out-of-pocket costs were very low ... for example, $10 to $15 for office visits.

On the other hand, the disadvantage was that, when I decided to switch from my prior insurance to Kaiser, I had to change all my doctors.  Some people are so attached to their current doctors that they don't want to make such a drastic change.  My husband was one of those, which is why he chose to use a Medigap Supplemental insurance policy rather than a Medicare Advantage Plan.  Since I am quite healthy and never saw my physician except for an annual medical exam, I did not mind making the change.
There is a lot more information that you need to know about Medicare Advantage plans.  In addition to reading brochures, attending seminars, and speaking with an agent, you can learn more by contacting Medicare directly.  I have included the contact information below. 

Contact Information for Medicare:

1-800-MEDICARE  (1-800-633-4227)
TTY 1-877-486-2048

Questions about Eligibility for Medicare:

Social Security Administration:  1-800-772-1213

To Get Personalized Insurance Counseling:

Call the State Health Insurance Assistance Program which is also called SHIP.  The number is different for each state. The one for California is listed below:

California SHIP:  1-800-434-0222

Regardless of your circumstances, nearly everyone should contact Social Security within three months before or after their 65th birthday and decide what they need to do.  This is the first step you should take in the process.

If you are interested in learning more about preparing for retirement, you may want to check out the tabs at the top of this page.  They contain links to hundreds of articles on family relationships after retirement, the best places to retire in the United States and overseas, financial planning and medical issues.

You may also be interested in reading:

How to Sign Up for Medicare
Should You Get Medigap Supplemental Insurance with Your Medicare?

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Thursday, July 3, 2014

Should You Get Medigap Supplemental Insurance with Your Medicare?

As I mentioned in a recent post, within three months before or after your 65th birthday, it is important that you contact the Social Security Administration to sign up for Medicare.  This is true even if you already have insurance through an employer or the military.

Once you have completed the paperwork for Medicare, the next thing you will need to decide is if you want to get a Medigap policy (Medicare Supplement Insurance) or a Medicare Advantage Plan.  In this post I will go over the Medigap Supplemental Insurance plans, like the one that my husband has selected.  You may also want to read "Should You Get a Medicare Advantage Plan with Your Medicare?" and "How to Sign Up for Medicare." These articles will help you consider all the options available to you.

Medigap Supplemental Insurance  

The reason why someone would want to have a Medigap policy is because Medicare doesn't pay for everything.  While regular Medicare will cover most of your medical expenses when you are over age 65, there are large deductibles and expenses that are not covered.  Medigap policies are designed to "fill the gap" by covering some of those expenses like copayments, coinsurance and deductibles, so that patients do not end up with a lot of large medical bills.   Some of the Medigap policies also cover things that Medicare does not include at all, such as emergencies during foreign travel, although each plan is different so you need to shop around to make sure you are getting the coverage that meets your needs the best.

You will have to pay a premium with a Medigap policy, in addition to the premiums you pay for Medicare.  You cannot have both a Medigap policy and a Medicare Advantage policy.  You have to choose one or the other.

One of the reasons that people sometimes choose a Medigap policy rather than a Medicare Advantage Plan is because they want to stay with their current doctors rather than be limited only to the doctors that are part of a Medicare Advantage HMO or PPO list of approved providers.   

For example, my husband has CKD (chronic kidney disease) and he was very happy with the doctors who were treating him prior to his 65th birthday.   He contacted all the physicians that he sees and discovered that all of them accepted both Medicare and Blue Shield.  As a result, he chose to buy a Blue Shield Medigap policy so he could stay with his favorite doctors. Conversely, I was not that attached to my physician so I chose a Kaiser Permanente Medicare Advantage plan.  My plan is substantially less expensive, but his plan allowed him to stay with his current physicians, which was important to him.

My husband also chose a Plan "F" Medigap insurance policy.  This is the most expensive Medigap plan.  He pays about $275 a month in addition to the $135 that Medicare currently takes out of his Social Security.  However, when he had a heart attack, we paid no deductible or co-pay.  On the other hand, as of 2019, when this article was updated, I only pay the standard $135 a month to Medicare, which is deducted from my Social Security, to cover the cost of my Kaiser Medicare Advantage plan.  However, spending the same amount of time in the hospital and having heart surgery would have cost me at least $1000 in deductibles and co-pays.  In other words, my husband pays an extra premium, but no co-pays and deductibles.  I do not pay an extra premium, but I do have co-pays and deductibles ... although they are quite reasonable.  

Whatever policy you choose, if you are unhappy with it, you should know that once a year in the fall  open enrollment period (between October 15 and December 7) you can select a different plan to use the following year.  However, if you have end stage renal failure (which means you are on dialysis), there are severe restrictions on switching plans.  This is one reason my husband wanted to keep his current doctors.  He did not want to change doctors, end up unhappy, and then be stuck with new doctors he did not like.

You can find a lot more information on the Medicare website.  In addition, as you approach age 65, you will be contacted by a number of Medigap and Medicare Advantage companies in your state.  You may want to attend their seminars and learn about the differences between what the various companies offer before you make a final decision.

Contact Information for Medicare:

1-800-MEDICARE  (1-800-633-4227)
TTY 1-877-486-2048

Questions about Eligibility for Medicare:

Social Security Administration:  1-800-772-1213

To Get Personalized Insurance Counseling:

Call the State Health Insurance Assistance Program which is also called SHIP.  The number is different for each state. The one for California is listed below:

California SHIP:  1-800-434-0222

Related Articles You May Want to Read:

Should You Get a Medicare Advantage Plan with Your Medicare? 
How to Sign Up for Medicare

Regardless of your circumstances, nearly everyone should contact Social Security within three months before or after their 65th birthday and decide what they need to do.  This is the first step you should take in the process.

If you are interested in learning more about preparing for retirement, you may want to check out the tabs at the top of this page.  They contain links to hundreds of articles on family relationships after retirement, where to retire in the United States or overseas, financial planning and medical issues.

You are reading from the blog:

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