Medicare health insurance is a very personal product. And, other than a household discount from some Medicare supplement companies, there are no discounts for choosing the same plan as your spouse. In this, the fifth article in our Medicare Mistakes Series, we’ll cover why buying the same coverage as your spouse is rarely the best move.
Key Takeaways
- 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). allow you to exchange your 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. benefits for a private health plan with extra benefits. The best plan is the one that has benefits that you can actually use (and afford!).
- Medicare supplement insuranceMedicare Supplements are additional insurance policies that Medicare beneficiaries can purchase to cover the gaps in their Original Medicare (Medicare Part A and Medicare Part B) health insurance coverage. covers the gaps in your Original Medicare coverage (i.e., deductiblesA deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share., coinsuranceCoinsurance is a percentage of the total you are required to pay for a medical service. , and copaymentsA copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service.). If you have poor health, getting the most coverage you can afford is a wise move. If you are healthy, buying too much insurance may be wasteful.
- 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... covers prescription medications in cost tiers laid out in a 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.. The best Part D plan is the plan that provides your specific medications at the overall best price.
- Al la cart secondary coverage for dental, vision, and hearing may help extend your budget.
When Medicare time rolls around, most couples tend to view coverage jointly even though enrollment is an individual responsibility. This often means that one person or the other does not have optimal coverage.
The best way to evaluate coverage is by the individual. You need to figure out what each person needs and the best way to get it.
It’s quite conceivable that one person will be best served by Original Medicare and a Medigap plan, while the other can get the most through Medicare Advantage. It really all depends on your health, finances, and priorities.
Cover Your Major Medical Needs First
In our first article in this series, we talked about what Medicare costs. As an 80/20 system, Medicare pays about 80 percent of your major medical costs1Medicare.gov, “What’s Medicare?”, Accessed January 15, 2022. How you pay for the remaining 20 percent is up to you. You have three options:
- Pay out-of-pocket
- Buy additional insurance2Medicare.gov, “What’s Medicare Supplement Insurance (Medigap)?”, Accessed January 15, 2022
- Qualify for state or federal assistance3Medicare.gov, “Medicaid”, Accessed January 15, 2022
Contrary to popular belief, Medicare Advantage is not additional insurance. Medicare Advantage plans are still based on an 80/20 split. You pay your 20 percent out-of-pocket when you use health care services. However, with Medicare Advantage, there is a failsafe mechanism that caps your annual 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. on major medical services.4Medicare.gov, “Costs for Medicare Advantage Plans”, Accessed January 15, 2022
Original Medicare does not have a maximum out-of-pocket (MOOP) limit5Medicare.gov, “How Original Medicare works”, Accessed January 15, 2022. However, you can buy additional insurance, called Medigap, to cover some of the gaps in Original Medicare6Medicare.gov, “How to compare Medigap policies”, Accessed January 15, 2022.
With Original Medicare and Medigap, you control your out-of-pocket costs by purchasing the amount of coverage you need. The best coverage is a balance between fixed costs (monthly 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. ) and the long-term benefit (deductibles and copayments covered by insurance).
If you can’t afford your 20 percent share, you are institutionalized, or you have certain qualifying chronic health issues, then Medicare, MedicaidMedicaid is a public health insurance program that provides health care coverage to low-income families and individuals in the United States., and Social Security have assistance programs that can help. We cover these programs in another part of this series.7Medicare.gov, “Special Needs Plans (SNP)”, Accessed January 15, 20228Medicaid.gov, “Health Homes”, Accessed January 15, 2022
How do you know which route is best for you?
In the fourth article in this series, we talked about why people with chronic health issues should not join a Medicare Advantage plan. Unless you are receiving government or retiree benefits that help pay your copayments and/or premiums, Medicare Advantage can be very expensive if you have chronic health conditions. However, healthy seniors can get a lot of value from a Medicare Advantage plan that offers secondary benefits.
The only way to know which option is best for you is to sit down and calculate your estimated costs. How frequently do you see your doctor(s), go to the emergency room, need an ambulance, or have inpatient hospital stays?
Cover Your Medications Second
The pharmaceutical industry in our country is out of control. Fortunately, the Medicare Part D program was put into place in 2003 and has since been reformed again by the Affordable Care Act.9CMS.gov, “History”, Accessed January 15, 2022
When you buy a Part D plan you are able to get your prescription medications at predictable cost based on the plan’s formulary. The formulary is nothing more than a list of covered medications organized into cost tiers.10Medicare.gov, “What Medicare Part D drug plans cover”, Accessed January 15, 2022
If you and your spouse both take regular medications, each of you should shop for the plan with the best overall cost on your medications. It might turn out to be the same plan, and it might not. It might also mean you use different pharmacies because each plan has its own preferred pharmacy relationships.11Medicare.gov, “Using your drug plan for the first time”, Accessed January 15, 2022
If you are enrolling in a Medicare Advantage plan that includes Part D coverage, and you have regular prescriptions, don’t forget to check your costs. People often look at the secondary benefits in a plan, like dental and vision, and forget to see if their prescriptions are covered.12Medicare.gov, “How do Medicare Advantage Plans work?”, Accessed January 15, 2022
If you don’t have any regular prescriptions your choice is easy. Go for the cheapest plan. If you do start taking medications down the road, then you can shop the best plan. However, don’t make the mistake of not getting Part D because you don’t have prescriptions now and want to save money. There are penalties for not joining.13Medicare.gov, “Part D late enrollment penalty”, Accessed January 15, 2022
Cover Your Secondary Health Needs Last
It’s easy to get caught up in looking at our health care needs holistically while our budgets have a different idea of what’s possible. By breaking things up by importance, it’s easier to set priorities and make better decisions based on what we need and what we can afford.
Original Medicare covers medically necessaryServices or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice. health care services, which does not include routine care for dental, vision, hearing, and other minor medical needs14Medicare.gov, “What’s not covered by Part A & Part B?”, Accessed January 15, 2022. If a Medicare Advantage plan meets your major medical needs, and you can find a plan that includes the extra benefits you need, that’s great. If not, you can buy a dental, vision, and hearing plan a la carte through DentalPlans.com. They have over 40+ plans to choose from and offer 1-month free (use promo code 1FREE).
The MedicareWireMedicareWire is a Medicare insurance consulting agency. We founded MedicareWire after seeing and hearing how confusing and frustrating it is to find, understand, and choose a plan. Our services are free to the consumer. staff researched available dental savings plans and recommends looking at what these five plans offer:
- Aetna Vital Dental Savings
- Cigna Preferred Network Access
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- Careington Care 500 Series
- DentalPlans.com (1 Month FREE!)
Need Help Deciding?
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Citations
- 1Medicare.gov, “What’s Medicare?”, Accessed January 15, 2022
- 2Medicare.gov, “What’s Medicare Supplement Insurance (Medigap)?”, Accessed January 15, 2022
- 3Medicare.gov, “Medicaid”, Accessed January 15, 2022
- 4Medicare.gov, “Costs for Medicare Advantage Plans”, Accessed January 15, 2022
- 5Medicare.gov, “How Original Medicare works”, Accessed January 15, 2022
- 6Medicare.gov, “How to compare Medigap policies”, Accessed January 15, 2022
- 7Medicare.gov, “Special Needs Plans (SNP)”, Accessed January 15, 2022
- 8Medicaid.gov, “Health Homes”, Accessed January 15, 2022
- 9CMS.gov, “History”, Accessed January 15, 2022
- 10Medicare.gov, “What Medicare Part D drug plans cover”, Accessed January 15, 2022
- 11Medicare.gov, “Using your drug plan for the first time”, Accessed January 15, 2022
- 12Medicare.gov, “How do Medicare Advantage Plans work?”, Accessed January 15, 2022
- 13Medicare.gov, “Part D late enrollment penalty”, Accessed January 15, 2022
- 14Medicare.gov, “What’s not covered by Part A & Part B?”, Accessed January 15, 2022