How-to Review and Understanding Your Medicare Coverage

In Medicare Mistake #5 we talked about why the best plan for your spouse or friend might not be the best plan for you. In this Medicare Mistakes article, we’ll address the importance of reviewing and understanding your coverage to make sure you’re actually getting what you need.

Key Takeaways

Medicare Advantage and Medigap are easily confused, but they are very different.
Medigap works 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.... to pay some of the 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 copayment 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.....
A Medicare Advantage plan completely replaces Original Medicare with private health insurance that’s approved by Medicare.
If you join a Medicare Advantage plan you pay the plan’s deductibles and copaymentsA copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service.... out of pocket until you reach the annual maximum out-of-pocket (MOOP) limit.
In Original Medicare, a Medigap policy provides out-of-pocket cost protection.

If you qualify for Medicare and don't know where to start, we have licensed Medicare insurance agents^[1] available at 1-855-728-0510 (TTY 711) who can answer your questions and help enroll you in Medicare Advantage, Medicare Supplement Insurance, and Prescription Drug Part D plans.

In the mad rush to get enrolled at age 65, far too many people choose a plan or policy based on the monthly premiumA 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. ... without taking the time to fully understand out-of-pocket costs. And many people get wooed into a plan based on the recommendations of a friend or what they read in the Medicare & You Handbook. Both of these situations can result in a costly mistake if not reversed in time.

Don’t Confuse Medicare Advantage Plans with Medigap Policies

In Medicare Mistake #4 we talk about who should be in a Medicare Advantage plan and who shouldn’t. It’s important to understand if you are a good candidate for private Medicare insurance because if you aren’t it will save you a lot of headaches when comparing plans.

Original Medicare and Medigap coverage are easy to understand. Medicare 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.... covers your hospital inpatient careInpatient care refers to care provided in a hospital or other inpatient facility. Inpatients are admitted and stay at least one night depending on their condition.... and 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... covers your medical care, including doctor visits, lab work, tests, and medical supplies. Both Part A and Part B have deductibles and coinsurance out-of-pocket costs. That’s where Medigap comes in.¹²³

In all but three states (Minnesota, Wisconsin, and Massachusetts) Medigap coverage is standardized into 10 lettered plans (A, B, C, D, G, F, K, L, M, and N). There are also high deductible versions of Plan F and Plan G. Standardization means that a Medicare Supplement Plan FMedicare Supplement Plan F is the most comprehensive Medicare supplement plan available. This plan covers all Original Medicare deductibles, coinsurance, and copayments, leaving you with no out-of-pocket costs on all Medicare-approved services.... sold by AARP is exactly the same as a Plan F policy sold by Humana. The only difference is the monthly premium and how the premium is determined.⁴

Medigap coverage is easy to understand because you can look at a simple Medigap comparison chart to see what a plan covers:

Unfortunately, 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).... are not as cut-and-dry as Original Medicare and Medigap. Even though all Medicare Advantage plan must offer the same coverage as Medicare Part A and Medicare Part B, they are not required to provide hospitalization and medical care the same way as Original Medicare.⁵

Confusing, right?

What that basically means is that each Medicare Advantage plan has the flexibility to determine its shared costsAn 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..... You see, Medicare is an 80/20 system. Medicare pays about 80 percent of all major medical costs and beneficiaries pay the remaining 20 percent. Medicare Advantage plans are no different, and that causes people a lot of confusion.⁶

In Medicare Mistake #1 we go over Medicare costs in detail, so we won’t go into it again here. But, it is important to point out that Medicare Advantage plans are not free, even though a zero-dollar monthly premium makes it appear as if they are. Many people join a low-cost Medicare Advantage plan and later discover they can’t afford the deductibles or copayments.⁷

This is why 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.... offers a PDF download on all of its Medicare Advantage plan pages. Our basic summary of benefits PDF documents will help you see what your costs will be when you use different health care services.

If you have chronic health issues and see your doctor or specialist frequently, or you use medical supplies, you need to know your out-of-pocket costs. There’s no other way to get this information than to gather the deductible and copayment information and do the math.

Find affordable Medicare Supplement Insurance

Failing to Understand Provider Networks

One of the best features of Original Medicare and Medigap coverage is that you are not restricted by provider networks and prior authorizationPrior authorization is a process used by health plans to control healthcare costs. Most HMO plans and some PPO plans require authorization before receiving certain treatments, medical services, or prescription drugs.... approvals. Provider networks are a feature of Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) private health plans.⁸

Original Medicare is a private fee-for-service (PFFS) system. Beneficiaries are allowed to use any healthcare provider that accepts Medicare-assignment. In other words, if a healthcare provider you want to see will give you an appointment, you can see them and Medicare will pay its share. No prior approval is required.⁸

This is not the case with most Medicare Advantage plans. Most of these plans are HMOs or PPOs.⁹

HMO and PPO plans are managed care health plans. This simply means that the insurers negotiate care agreements with providers for their member’s care. Contracted providers make up the plan’s provider network.⁸

If you join an HMO Medicare Advantage plan you are required to use providers in the network. If you go outside of the network you pay all costs yourself. Don’t worry though, if you have an emergency and can’t make it to a provider in your plan’s network, you’re still covered (in the USA and its territories only). Also, most plans have pre-authorization rules that require members to get authorization to see a specialist, get a test, etc.⁵

PPO plans are similar, but with a PPO you can go out-of-network if you choose. However, you will pay higher copayments.⁸

Before joining a Medicare Advantage plan it’s important that you fully understand the plan’s rules and restrictions. A plan’s extra benefits might look really enticing, but if they keep you from seeing your preferred doctor or getting the care you want, it may not be your best option.

Find affordable Medicare Advantage Plans

Failing to Verify Drug Coverage

Most Medicare Advantage plans include a Medicare Part D prescription drug plan as an additional benefit¹⁰. Original Medicare does not cover prescriptions, but you can add a stand-alone Medicare Part D plan¹¹. In most states, Medicare prescription drug plansMedicare 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... start at around $20.

Unfortunately, you can’t assume that every plan covers all medications. They don’t. And you can’t assume that medications cost the same in each plan, either.

Isn’t our pharmaceutical system wonderful?

Why is this? Simply put, every Part D plan negotiates its own costs and preferred pharmacies. And, every plan organizes medications into several tiers on a list called 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 formulary is what determines your costs when you pick up your prescription at the pharmacy.¹²

Can you see how this might complicate choosing a Medicare Advantage plan?

If you have regular prescriptions that you take, it is critical that you compare Part D plan coverage and costs to make sure your medications are covered at the overall best cost to you. Medicare.gov has an online tool that makes this a simple task.

Failing to Review Coverage Annually

Yet another significant benefit of Original Medicare and Medigap is that coverage does not change. In fact, the last time Original Medicare had a significant change was when the Affordable Care Act was signed into law.¹³

Unfortunately, this isn’t true with Medicare Advantage plans.

Each year Medicare Advantage plans are allowed to submit changes to the Centers for Medicare & MedicaidMedicaid is a public health insurance program that provides health care coverage to low-income families and individuals in the United States.... Service (CMS) for approval. Plans must send an Annual Notice of Changes (ANOC) to all plan members at least 15 days before the start of Open EnrollmentIn health insurance, open enrollment is a period during which a person may enroll in or change their selection of health plan benefits. Health plan enrollment is ordinarily subject to restrictions.... on October 15. The ANOC outlines changes in the plan’s benefits, coverage, formulary, premium, and out-of-pocket costs that will take effect on January 1.¹⁴

If you’re in a plan and ignore the plan’s annual notice, you might be in for quite a surprise the next time you see your doctor or have an inpatient stay in the hospital. With health care costs on the rise, one of the many ways plans remain profitable is to increase copayments, particularly those for inpatient and emergency care. In fact, a Kaiser Family Foundation study found that the inpatient out-of-pocket costs in many plans are higher than Original Medicare alone.¹⁵

If you join a Medicare Advantage plan, it’s important to review your coverage every year. If you stay in Original Medicare and purchase 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.... to cover the gaps, you should compare rates each time your policy has a rate increase.

Find affordable Medicare Advantage Plans

When to Make Changes

There are several periods when Medicare lets you change your Medicare Advantage coverage each year. The most well-known period is the Annual Election Period (AEP). This is in the Fall from 15 October through 7 December. During this period you can join a plan, switch plans, or go back to Original Medicare.¹⁶

There is a second enrollment period for people who are in a Medicare Advantage plan. This is called the Medicare Advantage Open Enrollment PeriodDuring the Medicare Open Enrollment Period, Medicare Advantage and Part D plan members can change, switch, or drop a plan they chose during the Annual Election Period. OEP starts on January 1 and ends on... (MA-OEP). It starts 1 January and ends 31 March. During this period you can change plans or disenroll from a plan and go back to Original Medicare. Changes you make take effect on the first day of the month after you make the change.¹⁶

Citations

1
Medicare.gov, ”What Part A covers”, Accessed January 15, 2022
2
Medicare.gov, ”What Part B covers”, Accessed January 15, 2022
3
Medicare.gov, ”Medicare costs at a glance”, Accessed January 15, 2022
4
Medicare.gov, ”How to compare Medigap policies”, Accessed January 15, 2022
5
Medicare.gov, ”Medicare Advantage Plans cover all Medicare services”, Accessed January 15, 2022
6
CMS.gov, ”The 80/20 Rule: Providing Value and Rebates to Millions of Consumers”, Accessed January 15, 2022
7
Medicare.gov, ”Costs for Medicare Advantage Plans”, Accessed January 15, 2022
8
Medicare.gov, ”Doctors, providers & hospitals in Medicare Advantage Plans”, Accessed January 15, 2022
9
Medicare.gov, ”Medicare Advantage Plans”, Accessed January 15, 2022
10
Medicare.gov, ”How do Medicare Advantage Plans work?”, Accessed January 15, 2022
11
Medicare.gov, ”How to get prescription drug coverage”, Accessed January 15, 2022
12
Medicare.gov, ”Costs for Medicare drug coverage”, Accessed January 15, 2022
13
HHS.gov, ”What is the Affordable Care Act?”, Accessed January 15, 2022
14
Medicare.gov, ”Plan Annual Notice of Change (ANOC)”, Accessed January 15, 2022
15
KFF.org, ”Cost-Related Problems Are Less Common Among Beneficiaries in Traditional Medicare Than in Medicare Advantage, Mainly Due to Supplemental Coverage”, Accessed January 15, 2022
16
Medicare.gov, ”Joining a health or drug plan”, Accessed January 15, 2022

Medicare Mistake #8: Not Reviewing and Understanding Your Coverage