Enrolling in Medicare is a major milestone in your health journey and you may be wondering, “which Medicare plan is right for me?” Whether you are turning 65 or working towards retirement, choosing a plan that facilitates coverage to maintain optimal health should continue to be a priority. During periods of enrollment, it is important to choose coverage carefully and understand how the available plans can affect both your day-to-day and long-term medical needs. Finding a plan that is suitable for your comprehensive health needs, and also offers access to your preferred primary care provider, can narrow the selection process.
Original Medicare vs. Medicare Advantage
Eligibility for Medicare begins at the age of 65. Initial Enrollment Period is a seven-month period of time that includes the three months prior to you turning 65 and the following 3 months after you turn 65. Subsequently, there is an additional period for open enrollment at the beginning of each year that you can make additions or revisions to your Medicare Advantage coverage.
Once eligible for Medicare, there are three options for coverage: Original Medicare, Medigap and Medicare Advantage.
Original Medicare includes Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). Medicare Part A is for hospital insurance coverage, such as inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. Medicare Part B is for outpatient care, certain providers’ services, medical supplies and preventative services.
With Original Medicare, you pay for services as they are received. You are expected to pay a deductible at the start of each year and will usually pay 20% of the cost (also known as coinsurance) of the Medicare-approved service. While Medicare pays for most costs for covered health care services and supplies, it does not cover all costs.
If you would like a plan for prescription coverage, you can add a separate drug plan (Part D). Additionally, the Medicare Supplement Insurance (Medigap) policy can help pay for some remaining health care costs, such as copayments, coinsurance, and deductibles. Some Medigap policies also cover services that Original Medicare doesn’t cover such as medical care when travelling outside of the U.S.
As an alternative to Original Medicare, you can choose to enroll in a cohesive, all-in-one plan called Medicare Advantage (sometimes referred to as “Part C” or “MA Plans”). To enroll in a Medicare Advantage plan, you must live in its service area and have Medicare Part A and Part B. Medicare Advantage “bundled” plans include Medicare Part A, Part B, and usually Part D. Most MA Plans offer extra benefits that Original Medicare does not cover, such as vision, hearing, and dental care.
While MA plans set a limit on out-of-pocket expenses to protect you from unexpected costs, each plan can charge varying out-of-pocket costs and can also have different guidelines on how you can receive services. In most cases, you will need to visit healthcare providers who participate in the plan’s network and service area for the lowest costs.
Because of these guidelines, if you prefer to continue care with a specific physician or provider, it is important that you ask which MA Plans they accept so you can choose an in-network plan option.
How to Choose Medicare Advantage Coverage
Before you choose the right Medicare Advantage Plan, make sure you choose the right primary care doctor to ensure continuity of care with your preferred provider. With Original Medicare and Medicare Advantage Plans, you have the choice to choose between a Health Maintenance Organization (HMO) Plan or a Preferred Provider Organization (PPO) Plan.
Before enrolling in a Medicare or Medicare Advantage HMO Plan or PPO Plan, ensure your primary care physician is participating in-network with your plan to guarantee continuity of care.
With Medicare HMO Plans, you generally must receive health care and services from providers in the plan’s network, except for emergency care, out-of-area urgent care, and/or out-of-area dialysis. As part of coordinating your health care, you will be able to choose to have a primary care physician who would then refer you to providers and specialists participating in your Medicare HMO plan.
In most HMO Plans, prescription drugs are usually covered, but you can always confirm by asking the plan if your specific prescription is covered. To see a specialist, most HMO Plans require a referral except for certain services, such as yearly screening mammograms, that do not require a referral.
A Medicare PPO Plan typically has a large network of physicians, health care providers, and hospitals that you can choose from to receive medical services and remain in-network. While each plan has flexibility that allows you to receive care from providers and hospitals that are not in-network, it will typically cost you more and you will have to pay the out-of-pocket expense associated with the service.
Can I join, switch or drop a plan?
You can join, switch or drop a Medicare health plan or a Medicare Advantage Plan during the following times:
- Initial Enrollment Period. When you first become eligible for Medicare, you can join a plan.
- Annual Election Period. From October 15 – December 7 each year, you can join, switch or drop a plan. Your coverage will begin on January 1 (as long as the plan gets your request by December 7).
- Medicare Advantage Open Enrollment Period. If you are enrolled in a Medicare Advantage Plan, from January 1 – March 31 each year, you can switch to a different Medicare Advantage Plan or switch to Original Medicare (and join a separate Medicare drug plan) once during this time.
After open enrollment ends, you can only make changes to your health coverage if you have a major life event such as relocating or losing group coverage. These chances to make changes are called Special Enrollment Periods (SEPs). Rules about when you can make changes and the type of changes you can make are different for each SEP. If you missed open enrollment in October, there is a special open enrollment period between January 1 and March 31. For more information on enrollment periods, please visit www.cms.gov or www.medicare.gov.
Ready to Enroll
When you are ready to enroll in a Medicare plan, find a primary care physician before selecting your coverage. It is important to make sure your TopLine MD affiliated primary care doctor is included in the plan you choose.