Researching Medicare can be a real headache.
But ultimately, the best plan for you is all about you — the drugs you take, the doctors you see and where you live.
Let’s start with the basics. There are two main ways to get Medicare coverage: Original Medicare (Part A and Part B) or a Medicare Advantage Plan (Part C).
Original Medicare helps cover hospitalization and doctor visits, but not prescription drugs. You can buy separate plans to help pay for the medicines you take and out-of-pocket costs like deductibles and co-pays.
Medicare Advantage Plans, also called Medicare Health Plans, are private insurance policies. They are typically HMOs and PPOs that cover hospitalization and doctor visits. Most include prescription drug coverage.
“For someone who is new to Medicare, start by asking your healthcare providers, your doctors and hospital, if they are going to work with any Medicare Advantage Plans in the coming year, and if so, which ones,” said Kathleen Sarmiento, a liaison with Serving Health Insurance Needs of Elders, known as SHINE, a federally funded, volunteer-based program to help Medicare beneficiaries understand and compare coverage.
The next step is to go to Medicare.gov and use their find-a-plan tool. Input your zip code, the prescription drugs you take and where you buy them to find plans in your area and out-of-pocket costs.
“There are different insurance plans in every county, so if you’re going to retire and move to The Villages, you’ll want to do this same exercise when you move, to see what the best insurance is for you,” said Sarmiento, who works out of the Alliance for Aging in Miami.
Drug costs, plans and providers that accept Medicare can change every year, so even if you are with a plan you like, you should use find-a-plan every year to find the most cost-effective plan for you, said April Washington, spokeswoman for the Centers for Medicare & Medicaid Services. “We encourage people to review their plans every year, because there might be a new plan that fits your income or your health needs better than what you have,” Washington said.
Here are the basics:
Original Medicare is made up of Part A and Part B.
Medicare Part A is hospital insurance. It helps cover inpatient hospital stays, care in a skilled nursing facility, hospice care and some home healthcare.
Costs: If you worked for at least 10 years and paid the required Medicare taxes, Part A is free. Most people fall into this category, but if you don’t, there is a cost. In 2018, monthly premiums cost up to $422 for people who bought Part A.
Medicare Part B is medical insurance. It helps cover certain doctors’ services, outpatient care, medical supplies and preventive services.
Costs: Monthly premiums for Part B depend on your income and when you enroll. In 2018, most people paid the standard monthly premium of $134.
With Original Medicare you can choose any provider that accepts Medicare. Typically you pay a deductible and coinsurance for Part A and Part B services, and there is no out-of-pocket maximum. You can buy supplemental coverage known as Medigap to pay some of these costs. You also can buy prescription drug coverage.
New in 2019: The cap has been lifted on services like outpatient physical, speech or occupational therapy. Telehealth programs, which let patients consult with providers over the phone or internet, will be covered for people with end-stage renal disease or treatment for a stroke.
Medicare Advantage Plans
Medicare Advantage Plans, Part C, are offered by private companies that provide all of the benefits of Part A and Part B plans. Most offer prescription drug coverage. Medicare Advantage Plans include HMOs and PPOs, which cover in-network doctors and facilities.
You typically pay a deductible, copay or coinsurance for covered services. Some plans also offer vision, hearing and dental coverage. Plans have an annual limit on out-of-pocket costs. Once you reach the limit, you pay nothing for covered services for the rest of the year.
Types of plans can vary by where you live. For example, there are HMOs in Miami-Dade and Broward, but not in Monroe County, Sarmiento said.
Costs: If you enroll in a Medicare Advantage Plan, you pay your Part B premium, which depends on your income. In 2018, the standard monthly premium was $134. You also may pay an additional premium for your Medicare Advantage Plan, though many plans are free.
New in 2019: Medicare Advantage plans have the option to cover doctor-recommended home health aides, adult day-care and home safety features like wheelchair ramps.
“We are putting changes in place to allow people to live more independently and stay in their homes to get the care and services they need,” Washington said.
Prescription Drug Coverage
Medicare Advantage Plans usually include prescription drug coverage, but Original Medicare does not. If you have Original Medicare, you may want to buy a prescription drug plan, known as Part D. Monthly premiums vary.
Costs: “Prescription drug co-payments typically change every year. If you’re on a Part D, you want to make sure you’re on the least expensive one,” so you should check the costs of different plans every year using Medicare’s find-a-plan tool, Sarmiento said.
New in 2019: The so-called “donut hole,” the coverage gap for people with high prescription costs, will close for brand-name drugs in 2019. The gap will be eliminated for generic drugs in 2020.
Medicare Supplement Insurance (Medigap)
Medigap policies help pay some of the costs that Original Medicare does not, including deductibles, co-pays and coinsurance. Some Medigap policies also pay for services that Original Medicare doesn’t cover, such as medical care when you travel outside of the U.S.
There are 10 types of Medigap coverage, identified by Plan letters A through D, F, G, and K through N. The plans are standardized, which means every plan with the same letter offers the same coverage, but costs can vary widely by insurance company
“The consumer should buy the policy from the insurance company with the lowest price, because they are getting the exact same product,” Sarmiento said. “Some insurance companies, because they feel they have a better brand name, charge higher prices for the same thing.”
Other Medicare health plans
Demonstrations/pilot programs — Also called research studies, these plans test improvements in Medicare coverage, payment and care. They usually operate for a limited time for a specific group of people in specific areas. People are typically recruited for these studies based on history of care, Sarmiento said. For information, call 1-800-MEDICARE.
Programs of All-Inclusive Care for the Elderly (PACE) — PACE is a Medicare/Medicaid program that provides healthcare to people in their community instead of a nursing home. In Miami-Dade, this is typically for people with dementia who receive services from adult day care at a PACE center, Sarmiento said.
Medication Therapy Management programs — This free program helps people in a Medicare drug plan manage their medications when they take medicine for different medical conditions.
Low-income individuals with limited assets may be eligible for Medicare Savings Programs that help pay premiums, deductibles, co-pays and coinsurance. Extra Help is a Medicare program that helps low-income people pay prescription drug costs.
Medicare: www.medicare.gov/find-a-plan allows you to compare costs and coverage, or call 1-800-MEDICARE (1-800-633-4227), for help in multiple languages. A handbook is automatically sent to anyone enrolled in Medicare before open enrollment begins Oct. 15.
Social Security: www.socialsecurity.gov or call 1-800-772-1213 to find out Medicare eligibility, how to enroll, apply for Extra Help with Medicare prescription drug costs and ask questions about premiums.
SHINE – (Serving Health Insurance Needs of Elders) www.floridashine.org, is a federally funded, volunteer-based program to help Medicare beneficiaries understand and compare coverage. You can make an appointment at a free counseling site, email questions or call 1-800-96ELDER (1-800-963-5337).