Like any massive insurance enterprise, Medicare is confusing. Medicare.gov will give you hundreds of pages of explanation, but luckily, the basics of the program aren’t difficult to grasp. As the cliché goes, however, the devil is in the details.
Medicare has four basic parts – A, B, C and D. If you’re unfamiliar with how they work, read Medicare 101: Do You Need All 4 Parts? Taken together, Parts A (hospital care), B (doctors, medical procedures, equipment) and D (prescription drugs) provide basic coverage for Americans 65 and older. What's relevant for this article is what these parts don't cover – deductibles, co-pays and other medical expenses that could wipe out your savings should you become seriously ill. That's where Part C comes in. Also known as Medicare Advantage, it's one of two ways to protect against the potential high cost of an accident or illness. Here's what could happen.
You Have to Plug the Holes
Let's say you have only Parts A, B and D. Here's what the holes or “gaps” in coverage could do to your budget if you were admitted to the hospital for, say, heart surgery, and complications required you to have a long hospital stay followed by needing regular medication after it:
At the hospital: Because of the Part A deductible, you’d pay the first $1,216. After 60 days, you will start paying a portion of each day's cost.
For doctors and medical procedures (Part B) at the hospital and at home: You would pay 20% of all costs after meeting your $147 deductible. Unlike many other health insurance policies, there is no cap or maximum out-of-pocket amount on what you could owe. The American Heart Association says that the average cost of heart surgery is $62,509 – in that case, your Part B copay would be over $12,000.
Because of how Part D works, you could pay as much as 72% of the cost of some of your prescription drugs if you need enough medication to push you into the notorious doughnut hole: when Part D's full prescription-drug coverage runs out after you've spent $2,850, until your medication costs exceed $4,550 per year. In 2015, coverage will end at $2,960 and begin again at $4,700. During the coverage gap, you'll be responsible for 47.5% of covered, brand-named prescription drugs. In 2015, that will change to 45%.
These coverage gaps mean that a particularly bad health year could leave you with tens of thousands of dollars in hospital bills. That's why most people purchase Medicare supplement insurance – also called Medigap – or enroll in Part C, a Medicare Advantage Health Plan. Both options are offered by private insurance companies. They do, however, have to follow Medicare guidelines in what they are allowed to sell.
Option 1: Medigap
Medicare Supplement Insurance, also called Medigap coverage, will protect people who buy traditional Medicare against many of the costs described above. In return, Medigap charges a premium that is in addition to what you already pay for Medicare Parts A (many people get this free), B and D.
Just to make life truly confusing, the various options offered by Medigap are also sorted by letter. Your choices are Plans A, B, C, D, F, G, K, L, M and N. What these plans include is standardized by Medicare. What you pay for them can vary, however, so it's worth shopping around. Joseph Graves, insurance agent and Founder of “I Hate Buying Insurance,” says many people enroll in Plan F, the most expensive choice, because it covers nearly all the gaps. A person with Plan F coverage will have few or no out-of-pocket expenses. A healthy person living in Florida would pay about $289 per month for Plan F coverage as of 2014, according to Graves.
Medigap policies will cover you whenever you see any doctor or facility that takes Medicare. If the doctor or facility does not accept Medicare patients, Medigap won't cover any of those costs, even though it is a private insurance policy. You can find a Medigap policy here.
Option 2: Medicare Advantage
A Medicare Advantage Health Plan (Medicare Part C) may provide more help at a lower cost than traditional Medicare plus Medigap. Instead of paying for Parts A, B and D, you enroll through a private insurance company that, in many cases, covers everything provided by Parts A, B and D and may offer additional services. You pay the Medicare Advantage premium along with your Part B premium in most cases.
Medicare Advantage Health Plans are similar to private health insurance plans. With most plans, services such as office visits, lab work, surgery and many others are covered after a small co-pay. Depending on what’s available in your area, plans could offer HMO or PPO network plans and place a yearly limit on your total out-of-pocket expenses.
Also like private plans, each has different benefits and rules. Most provide prescription drug coverage; some may require a referral to see a specialist while others won’t. Some may pay some portion of out-of-network care, while others will only cover you for doctors and facilities that are in the HMO or PPO network.
Compare plans by going to Medicare.gov’s plan finder.
Which is Better for You?
It is illegal for an insurance company to sell you both a Medicare Advantage and a Medigap policy. Three things to consider before choosing which one to get:
Cost: Medigap coverage usually has a higher monthly premium, but could result in lower out-of-pocket expenses than some Medicare Advantage plans. Medicare Advantage plans, on the other hand, generally cost less and cover more services, which can be the better option for your budget.
Choice: Medicare Advantage plans generally limit you to the doctors and facilities within the HMO or PPO, and may or may not cover any out-of-network care. Traditional Medicare and Medigap policies cover you if you go to any doctor or facility that accepts Medicare. If you require particular specialists or hospitals, check whether they are covered by the plan you select.
Lifestyle: Medicare Advantage plans often only operate with a certain region. If you’re a snowbird living in more than one state throughout the year, traditional Medicare plus Medigap is probably a better choice than an Advantage plan. This may also be true if you travel frequently: Some Medigap plans provide coverage when traveling outside of the United States and cover you in all 50 states; Advantage plans generally do not.
The Bottom Line
Figuring out the Medicare plan that's most appropriate for your needs is probably not a do-it-yourself activity. Once you understand the basics of Medicare, get some help.
Medicare.gov provides tools that will allow you to compare plans, but the decision is complicated. Insurance agent Graves recommends that you “work with a licensed insurance agent who can show you both Medicare Supplement Plans and Advantage Plans from multiple companies. Each type has its positives.” The questions to cover, he says: “You need to understand the costs, doctor networks, coverage levels and maximum out-of-pocket for each. Enroll in what suits your situation best.” Organizations such as Consumer Reports and the Medicare Rights Center can also help you research your decision.