According to the Centers for Medicare and Medicaid Services (CMS), nearly 1 in 5 Americans are currently enrolled in a Medicare program for senior adults.
A quick breakdown of Medicare Parts A, B, C, and Medigap
People usually receive notification of Medicare enrollment the year they turn 65. Most, especially those already receiving Social Security, are automatically enrolled in Medicare Part A, which covers inpatient hospital care, skilled nursing facility, and hospice.
Medicare Part A coverage is usually free if you fulfill the necessary criteria.
After your Part A enrollment, you can ‘buy’ Medicare Part B coverage. You pay a monthly premium for services such as ambulance transportation, certain drugs and medications, and care equipment like glucometers, walking canes, wheelchairs, etc.
Some people prefer to enroll in a Medicare Advantage plan, which is also known as Medicare Part C.
Then, there are additional coverage options called Medicare Supplement Plans, or Medigap.
Can I get a Medigap policy if I have only Medicare Part A?
No. You must have both Medicare Part A and Medicare Part B.
Can I get a Medigap policy if I have Medicare Advantage (Part C) instead of Original Medicare?
No. Medigap policies are available only to people with Original Medicare (Parts A and B). People with Medicare Advantage, or Part C, cannot buy a Medigap policy.
What is the Medicare Open Enrollment Period?
The Medicare Open Enrollment Period takes place every year between October 15th and December 7th. During this time, senior adults who already have an Original Medicare or Medicare Advantage plan can modify or make changes to their healthcare coverage.
You can add to your coverage, drop part of your coverage, switch between plans, or sign up for an entirely new plan.
When will my new Medicare plan become effective?
The Medicare Open Enrollment Period gives you 54 days to make any changes to your healthcare coverage. Whatever changes you make during this time will go into effect from January 1st of the following year.
For example, if you change your coverage on October 20th, and your spouse modifies their coverage on December 5th, the updated coverage for both of you will start from New Year’s Day of the coming year.
Is Original Medicare better, or Medicare Advantage?
Original Medicare and Medicare Advantage each have their own pros and cons. They have some benefits and features in common, and then there are certain benefits unique to each program.
In very broad terms, a few notable differences are:
- Medicare Advantage plans tend to be a ‘one-stop shop’ and prescription drug plans are often part of the package.
Patients with Original Medicare will need to get the Part D prescription drug plan separately, and may also have to purchase a supplemental policy, like Medigap, for additional coverage at extra cost.
- Original Medicare pays for dental, vision, and hearing care only if they are an integral part of treatment for the health conditions it covers. For instance, a yearly eye exam for diabetic retinopathy is covered, but a routine vision check for eyeglasses is not. You will have to pay 100% of the cost.
Most Medicare Advantage (Part C) plans cover routine dental, vision, and hearing care. They sometimes even include gym memberships. However, you may have to chip in for specialized care. For example, most Medicare Advantage dental plans will pay for preventative care like cleanings, but you might have to pay 50% coinsurance for tooth extractions, root canals, crowns, dentures, etc.
- Medicare Advantage plans tend to have tighter doctor networks. Original Medicare is spread out more. Any care provider across the US who accepts Medicare assignment will see you if you have Medicare Parts A and B.
What is Medicare assignment?
When you enroll in Medicare, you assign, or give it the responsibility, of remembering to pay your doctor. Meanwhile, a doctor who accepts assignment is one who has agreed to send the bill to Medicare instead of you.
- Medicare Advantage has a cap on cost share. Called ‘out-of-pocket maximum’, it is the limited amount of money a plan-holder will spend on deductibles, copay, and coinsurance. When the plan-holder hits this limit, the insurance provider takes over and pays for any further expenses incurred.
Original Medicare does not have such a capping mechanism.
Here is a quick comparison table to help you know what you can get from each program.
How do the plans cover medication costs?
Medicare Advantage plans usually have drug coverage built in. Patients with Original Medicare (Parts A and B) will have to buy the Part D prescription drug plan separately, no two ways about it.
There are multiple Part D plans at different premiums. If you are on the healthier side and don’t need too many prescription medications, or if you’re comfortable taking generic medicines instead of name brand drugs, you can buy a lower-priced plan. Do make sure that the drugs you need are included in the formulary of the plan you buy.
Medicare Extra Help is a benefits program that makes prescription medication more affordable. It is available to all Medicare plan-holders (A, B, and C) who fall below a certain income threshold.
Insulin, vaccines, and drugs for chronic diseases
Diabetic persons dependent on insulin pay only $35 a month for the injectable drug, no matter if they have a separate Part D, or if their drug costs are built into their Medicare Advantage plan.
Most Medicare Advantage plans cover the cost of supplies like syringes and needles. Patients with Original Medicare will have to pay for these out of their own pocket.
Several important vaccines are free for all senior patients, regardless of their coverage plan.
From January 2025, medications for many chronic illnesses will be available at lower prices. These drugs are used to treat illnesses like diabetes, blood clots, heart issues, and autoimmune diseases like psoriasis.
Medicare Open Enrollment Period is the perfect time for a yearly benefits review
CMS updates Medicare benefits and programs annually, making changes as necessary.
Similarly, most healthcare insurance providers revise their Medicare Advantage offerings each year. They may reduce premiums, lower drug costs, add new drugs to the formulary, expand the range of support services, and more.
Just as your Medicare Annual Wellness Visit keeps you informed of changes to your health, an annual review of your healthcare coverage keeps you informed of new benefits you may be able to get and helps you decide if you should make any changes to your healthcare coverage.
I switched from Original Medicare to Medicare Advantage last year. Can I switch back to Original Medicare? Will I be able to get the same Medigap coverage I had before?
You can, but there are some things to consider, especially regarding supplemental policies or Medigap.
When you enroll in Medicare for the very first time in your life at the age of 65 and choose Original Medicare (Parts A and B), you get a 6-month period in which to buy any Medigap policy you want, no questions asked.
This is known as the Medigap Open Enrollment Period. It is also called a guaranteed issue period. This means that no matter what chronic illnesses you have, you have a guaranteed option to buy a Medigap policy.
When you switch from Original Medicare to Medicare Advantage (Part C), any Medigap policies you have will become void.
If you decide to switch back to Original Medicare, there will be no 6-month guaranteed issue period like you had before. You can apply for a Medigap policy, but the insurance provider will require medical underwriting. This is an evaluation of your medical history, pre-existing conditions, and any illnesses you may have developed recently.
Based on this information, the insurance provider may decline to sell you a Medigap policy, or may charge you a higher premium. Your total expenses for healthcare coverage might then be more than what you’re paying for your Medicare Advantage plan.
Is there anyone who can guide me?
Choosing the right Medicare plan can be daunting, but there are several organizations that can help you make a decision.
The Medicare website lets you explore all your options at your own pace. You can also call them at 1-800-MEDICARE (1-800-633-4227). Then, there are State Health Insurance Assistance Programs that let you assess both Medicare and drug plans.
A very good resource is our Patient Relations Team. They can cut down the clutter and save you a lot of time you would spend researching your options.
Our Patient Relations Team can also inform you of benefits you did not know existed, or that you were eligible to receive. These include monetary help with prescription drug costs, rides to the clinic and back, diet and nutrition programs, reductions in premiums and deductibles, and more.
To speak to our Patient Relations Team, call our helpline at (800) 941-1106. Our knowledgeable staff will be happy to guide, advise, and answer all your questions about Medicare.