All U.S. citizens are eligible for Original Medicare (Part A and Part B) when they turn 65. Some people are also eligible at a younger age if they have certain qualifying conditions.
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In broad terms, Part A covers hospital services and Part B covers physician services. In addition, to offset the high cost of prescription drugs, many people also choose to enroll in Medicare Part D which covers prescription drug costs.
With this amount of coverage, many people wonder if they need Part C coverage as well.
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If you decide that you want enhanced benefits at prices that are lower than regular private insurance, then an MA plan may be right for you.
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Keep in mind that you’ll need to keep Part A and Part B coverage, and you will need to pay an additional premium for Part C coverage. Also, you’ll need to live in a particular MA plan’s coverage area to buy it.
You need to be aware of out-of-pocket costs, too.
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If you have Medicare Part C, the maximum out-of-pocket limit is $6,700 per year for services that Medicare Parts A and B cover if you go to in-network care providers. The limit is $10,000 per year for combined in-network and out-of-network costs. Actual limits may be different because insurers set their own limits, as long as they don’t exceed these maximum amounts.
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Due in part to laws passed in 2018, Part C plans have some flexibility when it comes to benefits. They can cover “daily maintenance” items like wheelchair ramps and home modifications as well as durable medical equipment, home health services, and telehealth.
They can also cover transportation services to help you get to your doctor’s office or pharmacy.
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[av_toggle title=’Home Health Nurses and Telehealth‘ tags=” custom_id=” av_uid=’av-knjf0nd2′ sc_version=’1.0’]
Beginning in 2018, MA plans began to offer coverage for doctor house calls, home nurses or aides to help with dressing and daily activities, over-the-counter pharmacy products, and non-emergency transportation (defined as the ability to schedule a ride to your doctor appointments or in some cases, the pharmacy).
Transportation services are usually offered through third-party companies (sometimes including Uber and Lyft) that your health plan is contracted with, so be sure to contact a company that your plan covers to make sure you’re covered.
MA plans now offer “non-skilled” home care for services that do not require a licensed doctor or nurse practitioner. Those services can include things like home cleanup and meal delivery.
Telehealth services are another new benefit that MA plans can offer. Using telehealth, people who cannot leave their home either for medical reasons or for lack of transportation to easily access healthcare online.
If your plan allows telehealth, there will be a list of telehealth providers you can use that will allow you to speak to doctors over the phone or via video chat.
One of the big advantages to telehealth is that doctors are often able to prescribe medications without you having to travel to their offices. In many cases, you can then have those prescriptions delivered through CVS Pharmacy or any other mail-order pharmacy.
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Original Medicare only covers medical equipment that is considered “durable” which is generally defined as something that must be usable at home for at least three years.
Some examples of durable medical equipment include oxygen equipment, nebulizers, infusion pumps, wheelchairs, and others. However, Original Medicare does not include home modifications.
MA plans can cover this providing coverage for modifications such as wheelchair ramps, bathroom support bars, stair lifts, automatic doors, and other similar items.
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MA plans also often provide fitness benefits, usually as a membership to a third-party program. The two most popular are SilverSneakers and Silver & Fit.
If one of these programs is included in your MA coverage, you will have access to a gym membership and special group fitness classes designed for seniors and Medicare eligible beneficiaries.
Silver & Fit even offers “home fitness kits” for those who need to or prefer to stay at home.
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In most cases, Original Medicare does not cover dental, vision, and hearing services. The exception for these is if they are related to hospital stays for another reason, in which case, Part A may pick up the costs.
Although exact benefits will vary by plan, MA plans can offer a variety of dental benefits such as dental exams and cleanings, x-rays, fillings, extractions, root canals, crowns, and even dentures in some cases. There are usually copayments associated with these services.
MA vision benefits can cover exams, glasses, and sometimes contact lenses.
MA hearing benefits generally include exams and hearing aids.
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When shopping for a MA plan, you can purchase a MA only plan or a plan that also includes prescription drug coverage. These are known as Medicare Advantage Prescription Drug Plans or MAPDs.
You also have the option of purchasing a separate Medicare Part D Prescription Drug plan if you prefer.
However, enrolling in a MAPD plan means that you do not have to enroll in Part D or another form of prescription drug coverage. Instead, all of your coverage will be bundled into one convenient plan.
Like any other prescription drug plan, your MAPD coverage will come with a drug formulary, which is a list of prescription drugs your plan covers. Most formularies are split into tiers that indicate what your co-payment will be for each prescription.
In many cases you may have co-payments for your prescriptions with a MAPD option, but there are $0 premium plans available in some areas.
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People with Original Medicare have access to doctors throughout the United States. It’s estimated that about 93% of all primary care providers accept Medicare.
However, with MA plans, things work a bit differently. Not every doctor who accepts Original Medicare will accept patients with an MA plan, and vice versa.
You may be covered out-of-network for emergency room and urgent care at in-network rates, but things can quickly get complicated on the billing side of things.
Per CMS, all MA plans must include an adequate number of providers and hospitals in their networks. If you have to seek routine care from an out-of-network provider, your insurer may cover services at in-network rates if an appropriate provider is not available in-network.
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Plans you can enroll in vary based on where you are located. Most MA plans are only available in certain states and counties.
Each plan will be customized to its location and will have its own provider network. Your doctors and pharmacists will most likely not accept every plan, so a good place to start would be figuring out which plans your favorite doctors and pharmacies accept.
Service Areas are determined by ZIP Code, region, county, or partial-county (in densely populated areas like Los Angeles, for example).
If you move from one state to another or out of an MA Service Area, and you don’t have access to the same coverage, you will qualify for a Special Enrollment Period so that you can get new coverage.
When you are ready to move, you can ask a Medicare representative for assistance finding a new Medicare plan in the Service Area where you plan to live.
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There are six major types of MA plans and all are commonly referred to as Coordinated Care plans (except for Medical Savings Accounts). Coordinated Care plans offer health care through an established provider network approved by the CMS.
Health Maintenance Organization (HMO) – You select one primary physician. In some cases, you may only receive coverage for that one doctor (unless he or she refers you to a specialist).
Point-Of-Service (HMO-POS) – You’ll select one primary physician, but you’ll have the freedom to visit any specialist in your network for your other needs. You will be charged a fee for visiting specialists.
Preferred Provider Organizations (PPO) – You can see any doctor, but your costs will be lower if you choose one that is in your network.
Private Fee-For-Service (PFFS) – You will not need referrals or a primary physician, but you’ll have to pick a doctor that accepts your PFFS plan.
Special Needs Plans (SNP) – Designed for those who are eligible for both Medicare and Medicaid, live in a nursing home, or have a chronic illness or disability.
Medical Savings Account (MSA) – Works like a tax-free savings account for your medical bills. Medicare will deposit money into your HSA. You can use that account to pay for medical expenses.
Contact Medicare Plan Finder to get in touch with a benefits advisor who can help you select the best type of Part C plan for you and your needs or call now at 833-328-3676.
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Medigap policies help fill in the gap in Original Medicare. These policies are sold by private companies and will help bridge expenses for deductibles, copayments and coinsurance costs.
However, as of January 1, 2020, Medigap plans sold to new people with Medicare aren’t allowed to cover the Part B deductible. Due to this change, Medigap Plans C and F are no longer available to new Medicare beneficiaries starting on this date. If you already have coverage under Plans C and F, you can keep your plan.
A Medigap policy is different from an MA plan. Those plans are ways to get Medicare benefits, while a Medigap policy only supplements your benefits from Original Medicare.
You can’t own both a Medigap and a MA plan at the same time. So, you need to decide which one provides benefits more suited to your needs and buy accordingly if you’re looking for enhanced coverage.
Medigap policies sold after January 1, 2006 aren’t allowed to include prescription drug coverage. If you want prescription drug coverage, get a MA plan that includes prescription drug coverage or a separate Part D plan.
Also consider that Medigap policies generally don’t cover vision or dental care, long-term care, hearing aids, eyeglasses, or private-duty nursing.
Policy choices and coverages can be confusing, so it’s best to have an idea of what kind of coverage you want and then work with a licensed agent to help you find the best plan for your situation.
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