Medicare is a federal government program that aims to provide health insurance to people over the age of 65 and also those with certain disabilities or conditions. Over the years, it has helped many Americans who are otherwise uninsured to access basic and essential health care services at affordable cost.
Medicare coverage is divided into four parts: Medicare Parts A, B, C, and D. Part A & B, which covers essential medical needs such as outpatient and inpatient services as well as emergencies care, are together commonly known as the Original Medicare and sign-ups are mandatory for people over the age of 65. While signing up for Part A is free for most people, Part B normally incurs a premium that varies depending on an individual’s income level. The services also incur out of pocket costs.
On the other hand, Medicare Advantage plans, or Medicare Part C, refer to private medical insurance plans that are regarded as alternative to Medicare Part A & B. They are offered by private insurers which have been approved by Medicare and which provide the same benefits as well as additional coverage not available under Original Medicare. Some of the upsides of getting Medicare Advantage include lower out-of-pocket expenses and reduced premiums.
Medicare beneficiaries have to choose whether to go with Original Medicare or a Medicare Advantage plan when they enroll. In this blog post, we will walk you through how this part of Medicare works, and how it can offer you additional protection that are not covered by the other parts of the program. If you have questions at any time while going through this post, contact EASY Insurance to speak with an agent.
What Are The Four Part of Medicare?
To make it easier for both beneficiaries and their families to understand, the four main parts of Medicare (A,B, C, and D) each focuses on providing coverage in one or several specific areas, ranging from emergency care to preventive services to hospital care to prescription drugs. And here they are:
- Medicare Part A: Hospital Insurance -- covers all inpatient hospital stays, care in skilled nursing facilities, hospice care, and some home health care
- Medicare Part B: Medical Insurance -- covers some doctors' services, outpatient and preventive care, and medical supplies
- Medicare Part C: Medicare Advantage Plan -- the private health insurance alternative to the original Medicare
- Medicare Part D: Prescription drug coverage -- covers the cost of prescription drugs, recommended shots and vaccines.
The Basics About Medicare Advantage
Based on rules set by the Government, Medicare Advantage plans need to include benefits that are equivalent to Original Medicare (hospice care maybe an exception). While these plans need to meet certain basic requirements, they may be different in premium levels, copayments, deductibles and other medical service expenses.
Some plans may even include prescription drug coverage and other additional benefits, such as cover the cost for vision, hearing and dental services. Here's a list of some of the items that maybe included:
- Routine dental care and dentures
- Emergency response devices
- Fitness benefits
- Hearing aids
- Prescription drug (Part D)
- Out-of-US emergency care
- Over-the-counter drugs
- Eye exams
The rules for Medicare Advantage plans on how you get services may be different than that for Original Medicare. For examples, for some you may need a referral to book an appointment with some specialists, while some plans may limit the choice of doctors and healthcare providers you can see within a specified network, though these restriction normally won't apply for emergency or urgent care.
What Affect the Costs for Medicare Advantage?
The cost of Original Medicare is set by the federal government who offer these plans. And the only factor that would affect the cost to a person enrolling is what income bracket he or she falls into
Unlikely Original Medicare, Medicare Advantage plans are offered by private insurance companies, meaning that there are plans that carry different features that you can choose from. In general, for both Original Medicare and Medicare Advantage plans, there are four components:
- Premiums: It is the amount the user pay on a monthly basis to enroll in the program. .
- Deductibles: It is a set amount users pay out of their pocket before the providers begin to pay for a service
- Copays: It is a set amount user have to pay at the time they receive the service, such as part of the fee for a doctor's appointment
- Coinsurance: This is a percentage of medical costs an individual is required to pay.
Average Medicare Advantage Plan Premium
In 2022, the average monthly premiums charged by private health insurance companies is $19, though cost vary based on the plan and the provider. Bear in mind that while Medicare Advantage includes coverage for Original Medicare, sometimes the plans charge a supplemental premium for the additional coverage
As the premiums vary from one plan to another, the same principle goes for deductibles, copayments, and coinsurance. But bear in mind that the amount on these may not be the same as the cost-sharing requirement of Original Medicare. Also, for Medicare Advantage plans there is also a cap on your annual out-of-pocket expenses, or your share of covered medical expenses.
Why Should You Get Medicare Advantage?
So if Medicare Advantage generally cost more, why should you get it? Well, there are plenty of reasons. For starter, Medicare Advantage plans usually come with coverage for prescription drug plans and other medical services not included in Original Medicare, such as vision and dental.
Also, because there are many types of Medicare Advantage plans from different providers, the premiums actually varies, with some costing as low as $0. And speaking of cost, many Medicare advantage plans may even come with lower copayments and coninsurance than Original Medicare, as well as limiting out-of-pocket expenses. The latter means you will pay nothing more for the year after you have met the stated maximum. This is very different from Original Medicare, which doesn't set an out-of-pocket limit.
That is why, if you have a condition that may require regular and expensive treatments, the out-of-pocket maximum of a Medicare Advantage plan will help limit your liability. On the other hand, since Original Medicare doesn't offer this protection, you may want to consider purchasing a Medigap policy to help cover the expense, or risk facing significantly higher costs.
Why Shouldn't You Get Medicare Advantage?
At the same time, there are some negative factors which you need to take into consideration when choosing whether to join a Medicare Advantage plan. First, some of these plans may restrict your choice of physician or health care providers to a network designated by them. And that if you need out of network services, you will have to cover your own cost. This is very different from Original Medicare, which covers any service providers who accept Medicare.
Also, not all Medicare Advantage plans are catered to users for the entire nation. Their network of providers may only be available to people who live within a specific region. Plans like these may not be a good fit for people who don't live in a single location all year round. And last but not least, some plans require referrals or authorization from your primary care physicians for certain services or operation, or if you want to see a specialist. Comparatively, it is far less common for Original Medicare to require these.
Enrolling in a Medicare Advantage Plan
If you have decided to enroll in a Medicare Advantage plan for the first time or to make changes to an existing one, you will have to wait for an enrollment period. The first window is called the initial enrollment period, which varies depending on your birthdate and the timing of your enrollment in Original Medicare. This initial enrollment period is a 7-month windows that starts from 3 months prior to your birth month to 3 months after.
Next there is the open enrollment period, which takes place on January 1 to March 31 each year. If you are enrolled in a Medicare Advantage plan already, you can use this period to switch to another plan. You can also withdraw from your Medicare Advantage plan and go back to Original Medicare.
For both the initial and open enrollment periods, the coverage begins on the first day of the month following the month you enroll.
If you have missed the open enrollment period, the next window is the annual enrollment period that runs from October 15 to December 7 each year. For these enrollments, coverage begins on the first day of the following year.
During this period, you can do the following: switching from Medicare Advantage to Original Medicare; switching from Original Medicare to Medicare Advantage; and switching between Medicare Advantage plans.
In certain circumstances, you may be eligible for a Special Enrollment Period outside of the open enrollment period. Qualifying events may include losing your job, getting married or divorced, having a child, or moving to a new state.
Finding a Medicare Advantage Plan
If you are confused about the terminologies and terms in the different plans offered by insurance providers, we are here for you
EASY Insurance Plans is dedicated to helping you find the right Medicare Advantage plan Our experts are available to provide answers and will not rest until your health care needs have been met. Best of all? Our services come at no cost to you! Let us help make sure that you get the coverage that best fits your situation - contact us today!