“My father received a letter about his Medicare Advantage plan ending. Now we need to figure out which plan to pick, and we are confused by the options. Why is understanding Medicare so difficult?” –Linda from Smyrna

Medicare open enrollment takes place every year between October 15 and December 7, so many seniors are getting letters like your father as insurance companies change or drop their Medicare Advantage plans.

Understanding Medicare is a challenge even for people who work in elder care, so it’s no surprise that seniors find it confusing. Before you automatically sign up for a different plan with the same company, let’s look closer at the options to help you decide.

Medicare Basics

Medicare is an entitlement program that can help pay for hospital bills (Part A), physician care (Part B), and some nursing home stays. You usually can see any doctor you want, as long as the practice accepts Medicare.

You do not always need a referral for specialist care, which is a significant advantage for seniors with chronic health conditions. Unfortunately, regular Medicare currently does not cover vision, dental, or hearing exams.

Seniors pay for Part B premiums and may have additional out-of-pocket expenses, and there is no maximum limit to those expenses. Part D of Medicare refers to prescription drug coverage; you do have to sign up for an additional plan for this form of Medicare.

Medicare Advantage

Unlike Parts A and B of regular Medicare, Medicare Advantage plans are administered through private insurance companies. They may work more like an HMO or PPO, where you go to a primary physician who then refers you to specialists.

Where is the advantage in Medicare Advantage plans? This option might cover preventive care as well as dental, vision, and hearing care. They also have an out-of-pocket maximum, which means if your medical expenses are higher than a determined amount, you no longer have to pay the extra not covered by your plan.

Are there any disadvantages? Mental health providers often do not accept Medicare Advantage plans, and this provision of healthcare includes Cognitive decline and Dementias. Medicare Advantage plans sometimes advertise benefits such as discounts on gym memberships or other wellness programs. Often, these extra programs are available to seniors through other programs, regardless of Medicare status, so you should decide how likely your loved one is to use those additional benefits.

Medicare Supplement Policies

Whether you have original Medicare or Medicare Advantage, you or your loved one may still have expenses that are not covered. The remedy for this coverage gap is known as Medigap, or Medicare supplement insurance. These policies can help cover co-payments or deductibles to help seniors better manage their healthcare expenses on a fixed income.

Medigap insurance, like Medicare Advantage, is also one of a private insurance company’s plans. If you opt for Medicare Advantage, you cannot purchase a Medigap policy, but regular Medicare recipients may enroll for this program. Some Medigap policies include prescription drug coverage.

Making the Best Decision

As you can see, understanding Medicare is no small feat. To clarify, you can choose between regular Medicare, a government-run program, or Medicare Advantage, which is like Medicare, only run by private insurance.

Medigap is a supplemental policy to help cover deductibles, co-payments, medications, or other expenses Medicare does not pay. You cannot have Medigap with Medicare Advantage, and it is illegal for an insurance agent to try to sell you both.

How do you know which one is right for your loved one? Usually, it boils down to making an educated guess. Consider what your senior’s needs and out-of-pocket expenses have looked like for the past few years to see if it exceeds what Medicare pays. Next, think about those extra benefits Medicare Advantage gives seniors; do you expect your loved one to use them?

Finally, look closely at the prescriptions your loved one takes to see if they are covered by Medicare Part D plans, Medical Advantage, or Medigap coverage. Unfortunately, plans change every year, and what worked for your senior a year or two ago may not be sufficient for present needs.

Figuring out the best Medicare plan can feel like a full-time job, but you only have a small window to switch plans without penalty. The good (and possibly bad) news is that you get to do it again next year during this same time frame, so if you or your loved one is unhappy with your current plan, you are only locked in for a year.

Good luck!


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