When you’re first eligible for Medicare (Parts A and B), you also have a one-time opportunity to apply for Medicare supplement insurance without having to go through medical underwriting. This benefit, called guaranteed issue rights, is only available once, and the window of opportunity is only 6-months.
In this article we’re going to answer an important question that many seniors ask when they first qualify for their benefits, do I really need supplemental insurance with Medicare? In a word, the answer is yes, but you have multiple options available. We’re going to explain what your options are and how to make the best choice for your personal situation.
What Are Medicare Supplement Plans?
Medicare supplement plans, sometimes called Medigap, are supplemental Medicare policies that help pay some of the shared healthcare costs baked into the Medicare system. Often times people look at the monthly premiums for a Medigap plan and want to know if the extra coverage is really necessary? And more importantly, is it worth it?
The first thing to understand is that Original Medicare (Part A and Part B) is an 80/20 shared cost system. Medicare pays about 80% of all major medical costs and the beneficiary pays the rest. When you realize that a simple visit to the emergency room can cost hundreds of dollars, and a short stay in the hospital runs into the thousands, you quickly come to the conclusion that not having some additional coverage for major medical costs is very risky.
That’s where a Medicare supplement comes in.
There are 10 lettered Medicap plans (A through N). Each plan is standardized and covers the nine gaps in Medicare. These include:
- Medicare Part A Coinsurance & Hospital Costs
- Medicare Part A Skilled Nursing Facility Coinsurance
- Medicare Part A Deductible (per benefit period)
- Medicare Part A Hospice Care Coinsurance or Copayment
- Medicare Part B Deductible (annual)
- Medicare Part B Coinsurance or Copayment
- Medicare Part B Excess Charges
- Blood (first 3 pints)
- Foreign Travel Emergency
Medicare Part A is your hospital inpatient coverage and Medicare Part B is your medical coverage. Without additional coverage, you are responsible for the shared costs listed above.
This surprises many seniors getting their Medicare benefits for the first time. And that’s why it’s so important to understand one basic fact. Healthcare in the United States is very expensive, and most people simply can’t afford to pay their share of hospital costs out-of-pocket.
Why Choose a Medicare Supplement Plan?
Medicare, as originally designed, does the heavy lifting. It covers the bulk of all major medical costs for its beneficiaries. Medicare is the primary payor for all healthcare claims for its beneficiaries. However, from its inception, Medicare was designed to work with other coverage.
At the same time, Medicare was signed into law, the Medicaid program was enacted. This combined state and the federal program provides additional coverage for seniors and disabled persons on Medicare. Similarly, our retired military has TRICARE for Life, and most veterans qualify for VA healthcare. For everyone else, there’s Medicare Advantage or Medicare supplement insurance. Those are your options.
So, why choose a Medicare supplement plan vs. Medicare Advantage? For most people, it comes down to choice and peace-of-mind.
With Original Medicare, which you keep when you have a Medigap plan, you are free to choose your doctors, hospital, and other healthcare providers. With Medicare Advantage, you lose these benefits because these plans restrict you to their network of providers. And, in most cases, they also require you to get a referral (permission) to see a specialist.
The other big difference between Medicare Advantage and supplement Medicare insurance is when you pay your healthcare costs. With Medicare Advantage, you pay most costs when you use services. With a Medigap plan, you pay most costs in advance. This causes great confusion for many people and it gets them in trouble.
Unlike Medicare Advantage, there are no Medicare supplement plans with no premiums. But, there are also no surprises. Here’s why:
- A Medigap plan pays its portion of approved expenses not covered by Medicare, including copayments, coinsurance, and deductibles.
- There is a variety of Medigap plans to meet your needs. Some plans cover all costs allowed by law.
- With a Medigap plan, there’s no network, so you can choose any doctor or hospital that accepts Original Medicare.
- A Medigap policy is guaranteed to renew each year (so long as you don’t commit fraud or fail to pay your premiums).
But is it Really Worth It?
Health insurance, like auto insurance, is a financial tool. We all buy insurance for different reasons, but most commonly we get it to protect us financially. To answer whether or not the cost is “worth it” depends on your personal financial situation.
Many people look at the best Medigap plans and get turned off by the premiums. But, there are more options than Medicare Plan G (the best you can buy today) if your budget can’t afford it.
Related Article: Is Medicare Plan G Better than Plan F?
If you are in good health and believe you’ll stay that way into your 70s, you might be a good candidate for Medicare Plan N. This policy helps healthy people save money on premiums by charging you a small copay when you see your doctor (up to $20) or use the hospital emergency room (up to $50). With Plan N you’re also responsible for excess charges if your doctor does not accept Medicare’s standard rates for services.
There are other Medigap plans that let you share some of the costs so you can get a lower rate. We suggest that you speak with your insurance agent to get more advice, or call 1-855-266-4865 and let a HealthPlanOne agent assist you. There’s no obligation.
Are Medicare Advantage Plans Bad?
Above we talked about the differences between supplemental Medicare insurance and Medicare Advantage, and that may lead you to ask if Medicare Advantage plans are bad? In a word, no, but they are not the right choice for everyone.
Many people aging into their Medicare benefits now are used to employer group health plans that look a lot like Medicare Advantage plans. That’s because group health plans and Medicare Advantage use the familiar HMO (health maintenance organization) and PPO (preferred provider organization) managed healthcare delivery models.
When you and your family were young and healthy, the HMO and PPO style of healthcare delivery saves money. But, as we age, many people discover that their out-of-pocket costs actually go up with an HMO or PPO plan. That’s because people with one or more chronic health conditions see their doctor and need emergency care more frequently, and they end up paying more copayments.
For this very reason, Medicare Advantage has a built-in safety net system, which is a maximum out-of-pocket (MOOP) limit, which is currently $6,700 per year. It can be lower, however, most plans are at the maximum allowed. But, the MOOP does not include your premiums or your cost of medications. So your actual out-of-pocket costs could be much higher.
Also See: How to Choose a Medicare Supplement Plan
In MedicareWire’s opinion, Medicare Advantage plans are only a safe option if you are extremely healthy and have no family history of chronic illnesses later in life, or if you receive assistance paying the out-of-pocket costs. This is the case if your former employer or union offers retiree healthcare benefits, or if you are dual-eligible (Medicare and Medicaid), or if you qualify for a Special Needs Plan (SNP). If none of these situations apply to you, a Medicare supplement plan is the better option.
Speak with Your Agent
It’s important to have a candid conversation with your insurance agent about your health and financial situation. Don’t make this important decision alone. Ask your agent if a Medigap policy is right for you.
If you don’t have an agent, or you want a second opinion, call 1-855-266-4865 and let a HealthPlanOne agent assist you. HealthPlanOne is contracted to service plans from all major carriers in all 50 states, and there’s no additional cost to you, and no obligation, just more choices.