Medicare Advantage: What to choose?

W. Kevin Watterson, MD

Once Medicare becomes an option, understanding what plans are best for you can be confusing and overwhelming. Hopefully, this will help.

Understanding the parts ….

For clarity, straight Medicare has two parts — A and B.

Part A covers inpatient care in hospitals, skilled nursing facilities, hospice care, and home health care.

Part B is for services from doctors and other health care providers in clinics or outpatient services. Rockwell Physicians services falls under part B.

Part D is an optional prescription coverage.

There is also a Part C. You can think of this as parts A and B combined but provided by a private commercial insurance plan. They usually cover D (prescription drugs) and may even cover items like eye, hearing, and dental that are not covered by Medicare. These plans are called Medicare Advantage Programs.

Medicare Part A

Covers inpatient hospital care, skilled nursing and rehabilitation facilities, home health care and hospice services.

There is an associated deductible that is calculated based on your tax payments to Medicare while you worked. As an example, if you have paid in for at least 10 years there is no monthly premium with a current deductible is $1,556 for a benefit period (calendar year). Coinsurance or copayments vary by the amount of time in care. There is no maximum out of pocket.

Medicare Part B

Covers doctor visit and other outpatient services such as physical therapy.

Standard Part B has a premium of $170.10 a month and a deductible of $233.00. Coinsurance /copay is 20% of most services. Just to note, if you have an income higher than $91,000 then your premium will also be higher. There is no limit for out-of-pocket cost.

Medicare Part C (Medicare Advantage Programs)

These are plans that are offered by private insurers who serve as the intermediary for Medicare who pays them a flat annual fee per covered member and the insurer determines the costs (premiums, deductibles, coinsurance) for Medicare covered services which they are required to cover. They may also provide other features (gym memberships, hearing aids, dental) not typically covered by Medicare.

The Advantage plans typically provide the advantage to those who are relatively healthy. Premiums are typically low. They tend to limit which heath care providers/hospitals that provide care. When you are sick your out-of-pocket cost can exceed the 20% (Medicare’s coinsurance). However, unlike Medicare, they dohave an out-of-pocket limit.

Medigap or Supplemental Plan (sometimes called Part F)

Medigap is a supplemental private commercial insurance plan that covers most if not all of the coinsurance/copays that Medicare does not cover. It is optional at an additional premium cost and is used alongside your Medicare plan. After Medicare pays 80% of the bill, they send the balance to your Medigap insurance plan who then covers most if not all of the balance. Medigap policies will cover services Medicare covers. In some cases, it may even cover services that Medicare does not cover but this is a policy-by-policy feature.

Which plan is best?

That depends on several factors including your current health, number and type of prescriptions you are regularly are taking. For healthier populations, the Advantage plans can be a more affordable options as their premiums tend to be lower than straight Medicare.

If you are managing several chronic illnesses with multiple medications, then having straight Medicare may save you money though we would encourage that this be associated with a Medigap to cover co-insurance costs.

If you are struggling with choosing of the myriad of options, we encourage you to contact an experienced individual with knowledge of the multiple plans and can best fit your individual needs and risk tolerance to an appropriate Medicare option.

Rockwell Physicians can help connect you with those resources. Feel free to reach out!