Aside from learning how Medicare works one of the more difficult aspects of the process is deciding how to insure yourself on Medicare. Once original Medicare A & B are in place you will need to decide how you want to insure yourself. There are two options as illustrated below:
Choosing Medicare Insurance
Basically Medicare Supplements and Medicare Advantage Plans have different program designs. When you buy a Medicare Supplement plan you are still enrolled in Original Medicare which is insurance provided by the federal government itself. Medicare pays the majority of the bills and the supplement, carried by private insurance companies, pays some or all of the deductibles and coinsurance, depending on the plan, associated with Medicare Parts A & B. To this you would then add a stand-alone Prescription Drug Plan (PDP) to cover your prescriptions.
When you buy a Medicare Advantage Plan, you move completely into a private health insurance plan. That means you are no longer insured by Original Medicare provided by the government, the private insurance pays the majority of the bills and you pay a coinsurances or copay per visit. However, you are still in the Medicare program (Medicare Part C) and these private health plans are strictly regulated by Medicare.
Medicare Part C, also known as the Medicare Advantage program, are Medicare health plans offered by private insurance companies that cover your hospital and medical insurance needs. Many of these, depending on the plan, have Part D prescription drug coverage built in at no extra cost. Using this option means that you are not insured by the government insurance Medicare Part A & B, you are insured by the private insurance company you choose based on benefits offered. These plans typically have low or zero dollar monthly premiums but require that you make more significant copayments on the back end whenever you use medical care. This option can allow for significant savings in some situations.
What doctors can I see?
Some plans are HMOs that require you to choose a Medicare-eligible primary care doctor and then utilize a network of physicians with which the plan has a contract with. Today, most HMO companies in Maine have very extensive networks. Other plans are PPOs (Preferred Provider Organization) or PFFS (Private fee for Service) that allow you to choose whatever Medicare-eligible provider you want provided they accept the plans terms, conditions and payment rates.
While Medicare Advantage plans do have appointed service areas, usually the state you reside in, they do offer worldwide coverage for emergencies. If you are traveling and need nonemergency care most national plans have some mechanism for accessing non-emergency care outside the plan’s service area. Some advantage plans use what is called a Point-of-Service Benefit. Sometimes it is a specific dollar amount to receive non-emergency care outside of the plans service area.
When do I join?
These plans require that you be enrolled in original Medicare A & B and then the standard open enrollment dates apply. That is three months before your 65th birthday month (or enrollment dates for Medicare part B if you are over age 65) 23 months after your 65th birthday. (Important: if you worked past age 65 these enrollment dates change, please review the working past age 65 page of this website) Also, if you select a Medicare advantage plan (MA) that does not have prescription drug coverage in it, and you do not have other credible coverage such as the Veterans Administration (VA), then you may be penalized later on. (see the Medicare Part D page)
How much does a Medicare advantage plan cost?
Most of Medicare advantage plans have premiums that vary by county. More populated counties in the southern part of Maine have several zero premium plans available, however the more rural counties usually have a premium. As a general rule the lower the premium the lower the benefit. This type of plan is a good fit for a lot of people but perhaps not for others. We will go over the options with you in detail and you can decide for yourself which plan is right for you.