If you’re about to retire or planning for your retirement, you might be considering a Medicare Advantage plan. These are private health plans offered by national and region health insurance companies and healthcare providers. They are similar to Obamacare plans and health coverage you get through your employers, but some features and terminology are a bit different. In this MedicareWire article, we’ll break down all of the various terms and costs associate with Medicare Advantage to give you a better understanding of how they work.
Medicare.gov does a nice job breaking down Medicare benefits into neat grids. They even show a calculation of what you should expect to pay annually if you enroll in a particular health plan. Even so, it’s up to you to understand the difference between deductiblesA deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share., premiumsA premium is an amount that an insurance policyholder must pay for coverage. Premiums are typically paid on a monthly basis. In the federal Medicare program, there are four different types of premiums. , maximum out-of-pocket limits, co-pays, and co-insurance so you’ll know what you will actually pay when you use healthcare services.
Planning Ahead
It’s important to be prepared for your share of the doctor’s bill, but it’s particularly important to understand this stuff when shopping for a new Medicare Advantage plan or a Medicare prescription drug plan. In order to compare plans, you must understand how they are priced and your share of the bill when you use healthcare services.
Medicare Advantage Health Insurance Terminology
There are several Medicare insurance terms that are important to understand:
- Premium: The monthly fees you pay for your health insurance.
- Deductible: How much you must pay first, before the insurer pays.
- Co-pay: A fixed dollar amount that you pay for medications, services, or seeing your doctor.
- Co-insurance: Similar to a co-pay, however, co-insurance is a percentage of the cost.
- Maximum Out-of-Pocket (MOOP): The absolute maximum you’ll pay for inpatient and outpatient careOutpatient Care is medical care that does not require an overnight stay at the hospital. Medicare Part B provides coverage for Outpatient Care. annually, excluding premiums and deductibles.
- Initial Coverage LimitOnce you have met your yearly deductible, you will pay a copayment or coinsurance for each covered drug until you reach the initial coverage limit. You will then enter your plan’s coverage gap (aka, “donut... (ICL): Specific to Part D coverage, ICL is the amount paid by both you and the insurer for your medications before you hit the dreaded donut hole (coverage gapA period of time in which you pay higher cost-sharing for prescription drugs until you spend enough to qualify for catastrophic coverage.).
- Coverage Gap: The phase of a Part D plan when you pay all costs for your prescriptions.
Let’s discuss these factors in a bit more detail.
Monthly Premium
There’s no getting around it, Medicare Advantage premiums are complicated. The reason for the complication is because there isn’t a single premium, there are four:
- Part AMedicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care. Premium (inpatient coverage): Most people don’t pay a monthly premium for Part A. If you buy Part A, because you didn’t work, you’ll pay up to $499 each month.
- Part B Premium (medical coverage): Most people pay $170.10 each month. If you’re a higher-income earner, you’ll pay more.
- Part C Premium (Medicare Advantage): The Part C monthly premium varies by plan.
- Part D Premium (prescription drug coverage): The Part D monthly premium varies by plan (higher-income consumers may pay more).
If you have shopped for a Medicare Advantage plan (Part C) in the past, you already know that some have a zero dollar ($0.00) premium, while others have a premium up to about $500.00 per month. This is the amount above and beyond your monthly Medicare Part B premiumThe Medicare Part B premium is the monthly charge paid by beneficiaries for their outpatient medical care, services, and supplies. A beneficiary's premium may be uplifted by an IRMAA surcharge if their income is above... that you will pay to join a plan.
This might seem confusing at first. However, it’s done this way because Medicare pays the plan between $700 and $800 per month (on average), for each beneficiaryA person who has health care insurance through the Medicare or Medicaid programs. that joins. The amount is variable because Medicare pays more for higher quality plans. A zero-dollar plan is simply one that is able to provide the health insurance coverage offered for the monthly amount it receives from the government.
To further complicate matters, some Medicare Advantage plansMedicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B). include Part D coverage for your prescription drugs, and some don’t. If it includes Part D, the monthly premium for this coverage is included.
Deductibles
Most Medicare Advantage plans do not have a deductible for the Part B (medical) portion of the insurance. If you are accustomed to employer or Obamacare health insurance, this will be a welcome change for you.
Many plans do have deductibles when you use Part A (inpatient) services. However, these deductibles cannot be more than what you’d pay with Original MedicareOriginal Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage.:
- $1,556 deductible for each benefit periodA benefit period is a method used in Original Medicare to measure a beneficiaries use of hospital and skilled nursing facility (SNF) services. With each new benefit period, the beneficiary is charged a new benefit...
- Days 1-60: $0 coinsuranceCoinsurance is a percentage of the total you are required to pay for a medical service. for each benefit period
- Days 61-90: $389 coinsurance per day of each benefit period
- Days 91 and beyond: $778 coinsurance per each “lifetime reserve day” after day 90 for each benefit period (up to 60 days over your lifetime)
- Beyond lifetime reserve daysMedicare Part A covers up to 90 days of inpatient care per benefit period. Beneficiaries get an additional 60 days of coverage known as lifetime reserve days. Lifetime reserve days can be used once. Beneficiaries...: all costs
In most cases, plans deductibles are significantly less than what Original Medicare allows.
Co-Payments and Coinsurance
How a plan structures its Part B co-payments and coinsurance makes a huge difference in what you’ll pay each year when you see the doctor or use other heath services. A co-payment is a fixed amount fee that you pay every time you see a doctor, get lab tests, or use other medical services. Fees vary from service to service. Unlike the fixed amount you’ll be charged for a co-pay, a co-insurance hits you with a percentage of the cost. The maximum coinsurance for any service is 20%, just like Original Medicare.
In general, we like co-pays better than co-insurance. It’s more predictable and it make comparing plans easier.
Maximum Out-of-Pocket (MOOP)
Unlike Original Medicare, Medicare Advantage has a safety net system. It’s the annual Maximum Out-of-Pocket limit, or MOOP. Plans may use the standard MOOP set by Medicare annually, $7,550, or an alternative lower amount.
This is an important number, particularly if you visit the doctor frequently for a chronic condition. When you reach the MOOP amount in annual deductibles, co-payments and coinsurance, you won’t pay any more out-of-pocket for the remainder of the year.
It’s important to note that the MOOP amount does not include your monthly premiums or what you pay for prescriptions (Part D). MOOP only applies to the healthcare (Part C) portion of your plan.
Part D Coverage for Prescriptions
Without a doubt, the most confusing and frustrating of all health insurances is Medicare Part DMedicare Part D plans are an option Medicare beneficiaries can use to get prescription drug coverage. Part D plans provide cost-sharing on covered medications in four different phases: deductible, initial coverage, coverage gap, and catastrophic. Each.... It’s confusing because its a cost sharingAn amount patients pay for their share of the cost of medical service or supply, like a doctor’s visit, hospital inpatient visit, or prescription drug. system with four phases:
- The “Deductible” Phase: If a Part D plan has a deductible, you pay the full price for your prescriptions until you’ve spent the amount of the deductible.
- The “Initial Coverage Limit” (ICL) Phase: Once your deductible is met, you start the ICL phase. In this phase you and the insurer share the cost of your prescriptions based on the plan’s formularyA formulary is a list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Medications not on a plan's formulary are generally not covered.. All covered medication fall into a price tier in the formulary. You pay the amount specified in the price tier until you and the insurer have spent the annual ICL of $4,430.
- The “Gap Coverage” Phase: Once you and the insurer have reached the ICL, you fall into the dreaded donut hole coverage gap. While in the coverage gap, you’ll pay 45% of the plan’s cost for brand-name drugs and 58% of the plan’s cost for generic drugsA generic drug is a prescription medication that has the same active ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs. in 2016. You’re out of the coverage gap once your yearly out-of-pocket drug costs reach $7,050.
- The “Catastrophic Coverage” Phase: If you reach the catastrophic coverage phase, you’ll only pay a small co-payment or coinsurance for covered prescription drugs for the remainder of the year.
The following costs count towards getting you out of the donut hole and past the $7,050 threshold:
- The annual deductible
- Co-payments and coinsurance costs spent by you and the plan during the initial coverage phase
- Co-payments and coinsurance spent by you in the coverage gap (In 2016, this is 45% of the plan’s cost for brand-name drugs and 58% of the plan’s cost for generic drugs)
- The 50% manufacturer discount for brand-name drugs
Wrapping Up
There’s no escaping it, Medicare has a lot of moving parts. What you pay won’t be the same as what your spouse or neighbor pays. Your costs in a Medicare Advantage Plan depend on:
- Whether the plan charges a monthly premium.
- Whether the plan pays any of your monthly Medicare Part BMedicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services. (Medical Insurance) premium.
- Whether the plan has a yearly deductible or any additional deductibles.
- How much you pay for each visit or service (co-payment or coinsurance).
- The type of health care services you need and how often you get them.
- Whether you go to a doctor or supplier who accepts assignmentAn agreement by your doctor to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance. (if you’re in a PPO, PFFS, or MSA plan and you go out-of-network).
- Whether you follow the plan’s rules, like using network providers.
- Whether you need extra benefits and if the plan charges for it.
- The plan’s yearly limit on your out-of-pocket costsOut-of-Pocket Costs for Medicare are the remaining costs that are not covered by the beneficiary's health insurance plan. These costs can come from the beneficiary's monthly premiums, deductibles, coinsurance, and copayments. for all medical services.
- Whether you have MedicaidMedicaid is a public health insurance program that provides health care coverage to low-income families and individuals in the United States. or get help from your state.
The more you bone up on the terminology, the better prepared you will be to make smart decisions about your plan choices.