True or False? Once you enroll in Original Medicare (Parts A and B), the Federal Government will cover and pay for all of your health benefits. False!!
Unfortunately, many people don’t realize this until after they make their Medicare elections. To make sure that you are not missing out on benefits to which you are entitled and need, AND that you are financially protected, we strongly recommend that you call one of our licensed agents at 1-888-766-4448 and thoroughly review your options with them. For those who would like to educate themselves on some Medicare basics before calling, we have prepared the following Medicare “primer.”
THE TWO MOST POPULAR MISCONCEPTIONS ABOUT ORIGINAL MEDICARE
The Medicare system can be overwhelming, both in terms of how it works and the voluminous amount of information that’s available to the public. As a licensed Medicare broker, we hear various misconceptions all the time about Original Medicare — Parts A and B — and how those Parts work (or don’t work) with the other Parts of the Medicare system. Let’s start with the two most popular misconceptions that our licensed agents hear.
Misconception No. 1: Original Medicare COVERS ALL of my health needs.
Although it depends on your specific health needs, this statement is most likely not accurate for most Medicare beneficiaries.
Original Medicare is made up of Parts A and B. In simplest terms, Part A helps cover in-patient stays in hospitals and skilled nursing facilities, hospice care services, and home health care services; Part B helps cover out-patient medical care such as therapy, doctor visits and other medical procedures not covered by Medicare Part A.
Many beneficiaries new to Medicare assume incorrectly that Original Medicare also covers routine dental, vision, and hearing benefits, as well as prescription drug coverage. In fact, Original Medicare does not cover routine dental, vision or hearing services. The only exception is if the service is deemed to be necessary to a Medicare-covered service, at which point it may be covered. What does that mean for you? It means that if you are having a surgery that is covered by Original Medicare, and that surgery requires you to have a tooth extracted beforehand, Original Medicare may cover that procedure.
Original Medicare also does not provide prescription drug coverage; that’s covered in Part D, which costs extra (see FAQ What is Medicare Part D — Prescription Drug Coverage).
Misconception No. 2: Original Medicare PAYS FOR ALL of my health needs.
Original Medicare (Parts A and B) HELPS cover certain hospital and medical services, but it does not pay 100% of all services that are covered by Parts A and B. In fact, Original Medicare only pays for 80% of services covered by Medicare and does not have an out-of-pocket maximum. What does that mean for you? It means that you may be responsible for 20% of all of your Medicare health care costs AND there is no cap on that amount.
I NEED ROUTINE DENTAL, VISION AND HEARING BENEFITS, AS WELL AS PRESCRIPTION DRUG COVERAGE. WHAT DO I DO?
Now that you know Original Medicare does not provide dental, vision, or hearing benefits, nor does it provide prescription drug coverage, what do you do if you need those services? You have two options:
Option 1
Enroll in Medicare Part C, otherwise known as a Medicare Advantage plan; or
Option 2
Keep Original Medicare and purchase a Medicare Part D, prescription drug stand-alone plan from a private carrier (“PDP plan”) AND purchase a dental, vision and hearing stand-alone plan from a private carrier (sometimes referred to as a DVH plan).
Let’s look at each option and compare them.
THE “ADVANTAGES” OF MEDICARE ADVANTAGE PLANS
Let’s start with a Medicare Advantage — Medicare Part C. An “MA Plan” is an alternate way for Medicare beneficiaries to receive their Medicare Parts A and B services through a private insurance company, as well as other benefits and services at little to no extra cost. Let’s look at what you get with Original Medicare versus what you get with a Medicare Advantage Plan.
ORIGINAL MEDICARE v. MEDICARE ADVANTAGE
| COVERS / HELPS PAY FOR / COST | ORIGINAL MEDICARE (PARTS A & B) | MEDICARE ADVANTAGE PLAN (PART C) |
| Hospital stays & in-patient care | Yes | Yes |
| Medical care & outpatient services | Yes | Yes |
| Preventative care & services | Yes | Yes |
| Lab / diagnostic services | Yes | Yes |
| Durable medical equipment (e.g., wheelchair) | Yes | Yes |
| Prescription drugs (Part D) | No | Yes (if Medicare Advantage Prescription Drug Plan) |
| May include dental, vision and/or hearing | No | Yes |
| Has an out-of-pocket maximum | No | Yes |
| May include telehealth services | No | Yes |
| May include fitness benefits | No | Yes |
| Cost | Part A & B premium | Part A & B premium + $0-minimal extra |
| Administered by . . . | Federal Government | Private Insurance Carriers |
MEDICARE ADVANTAGE SEEMS TOO GOOD TO BE TRUE . . . IS IT?
As you can see, for little to no extra monthly premium, Medicare Advantage provides you with many more benefits and services than Original Medicare. And all of those services are provided by private insurance carriers (not the Federal Government) who compete for your business. Thus, it is likely that you will have a few options to choose from, as each carrier tries to offer better benefits at a lower price.
You may be thinking that an MA Plan is too good to be true. Additional benefits beyond Original Medicare with little to no extra cost? That’s not possible! It absolutely is possible. However, much like Original Medicare, there are two popular misconceptions about MA Plans that we routinely hear from our clients.
MA Plan Misconception No. 1: All MA Plans offer top-of-the-line dental, vision, hearing, prescription drug coverage, free transportation, etc.
You may have seen commercials where the person tells you to call about a Medicare plan that will give you “all of the benefits you’re entitled to,” including dental, vision, and hearing benefits, prescription drug coverage, free meals delivered to your home, and maybe even money back in your Social Security check. We know beneficiaries believe this to be the case, because we’ve had multiple beneficiaries call and ask to be enrolled in “the plan from the commercial that has everything.” Suffice it to say, those beneficiaries were not happy when we had to tell them that no such Medicare plan exists. Why not?!
The reason is that insurance carriers only have so much money to pay for a particular Medicare plan’s benefits, so they have to allocate the money across each benefits category. And the way in which a carrier allocates the money can be based on a particular market’s needs, a particular benefit that the carrier believes is most popular with beneficiaries, etc. For example, if you looked at County “A” in State “B,” one MA Plan may have excellent dental and vision benefits and offer free transportation, but may not be as good when it comes to hearing benefits. Another MA Plan in that same county may have excellent hearing benefits and free transportation, but it’s dental and vision benefits may not be that good. Still another plan in that County may offer free meals and transportation, but it’s dental, vision and hearing benefits are lacking.
Thus, before calling a licensed agent to discuss Medicare Advantage options, you need to identify and prioritize the benefits that are most important to you, so that the agent can make sure to look for an MA Plan that offers those specific benefits. Maybe hearing and vision are not a priority right now, but dental and free transportation are very important to you. There may be certain MA Plan options for you. Or maybe dental and transportation are not important to you right now, but hearing and fitness benefits are. If so, there may be other MA Plan options for you.
MA Plan Misconception No. 2: All Doctors Accept MA Plans.
Much like your medical insurance you had before you turned 65, not every doctor accepts every Medicare Advantage Plan. Thus, if keeping all of your current doctors is important to you, you need to make sure that you choose an MA Plan that is accepted by all of your current doctors. Otherwise, you will need to select new doctors who do accept the particular MA Plan that you want to enroll in. Don’t worry though — a licensed agent can assist you with this process.
THE STAND-ALONE PLANS OPTION FOR PRESCRIPTION DRUG COVERAGE, AND DENTAL, VISION AND HEARING BENEFITS
As discussed above, if you only have Original Medicare but need dental, vision or hearing benefits, and/or prescription drug coverage, your first option is to enroll in a Medicare Advantage Plan. Your second option is to purchase a prescription drug stand-alone plan from a private carrier (Medicare Part D, or a PDP plan) AND a dental, vision and hearing stand-alone plan from a private carrier (sometimes referred to as a DVH plan). Let’s look at how this option compares to Medicare Advantage.
| May Include / Helps Pay For / Cost | Original Medicare + Part D + DVH Plan | Medicare Advantage |
| Prescription Drug Coverage + Routine Dental, Vision & Hearing | Yes | Yes |
| Allows you to continue seeing current Primary Care Physician & your other doctors | Maybe (depends on DVH plan) | Maybe (depends on MA plan) |
| Has an out-of-pocket maximum | No | Yes |
| Telehealth services | No | Yes |
| Fitness benefits | No | Yes |
| Costs are paid by plan v. reimbursed | Terms of Part D / DVH Plan apply | Terms of MA plan apply |
| Administered by . . . | Federal government AND 1 or more carriers | 1 carrier |
| Cost | Part B monthly premium $148.50 (2021) + $80-$100 per month* | Part B monthly premium $148.50 + $0-$50 per month** |
As you can see, purchasing a Part D and a DVH Plan to work with Original Medicare would somewhat even the playing field with an MA Plan in terms of benefits. However, an MA Plan may still offer more benefits for less money. Moreover, with Medicare Advantage, you only have to deal with 1 carrier who provides your Parts A, B, D, dental, vision and hearing services. With the Original Medicare + Part D + DVH Plan option, you will be dealing with the Federal Government for your Part A and B services, and at least 1 carrier (possibly 2) for your dental, vision, hearing and prescription drug coverage services.
After comparing the two options, you may be thinking, “Why wouldn’t I go with an MA Plan? What’s the downside? As discussed above in the MA Plan option, not all doctors accept MA Plans. Thus, if you cannot find an MA Plan that all of your doctors will accept, and you want to keep seeing your doctors, the Original Medicare + Part D + DVH Plan may be your best option.
*Part B premium will be increasing for the 2022 plan year. New premium rates should be published in early to mid-September.
**Part B premium will be increasing for the 2022 plan year. New premium rates should be published in early to mid-September.
THE MEDICARE SUPPLEMENT PLAN — THE FINANCIAL PROTECTION YOU MAY BE LOOKING FOR . . . BUT AT A COST.
When we started looking at whether Original Medicare provides you with all of the benefits you currently need, we also looked at 2 misconceptions about Original Medicare, the second one being that Original Medicare pays for all of your costs covered by Medicare. As we explained, Original Medicare only pays for 80% of services covered by Medicare and does not have an out-of-pocket maximum. That means that you may be responsible for 20% of all of your Medicare health care costs AND there is no cap on your financial responsibility.
If you don’t have any chronic medical conditions and don’t anticipate any major procedures in the future, these facts may not concern you. On the other hand, what if you do have a chronic condition and/or anticipate having a major procedure in the future? Or what if your health suddenly takes an unexpected turn? The 20% of Medicare costs for which you are responsible could go from $0 to thousands of dollars in no time. Are you prepared to meet those potential financial obligations? If not, you might consider a Medicare Supplement Plan.
Also known as a “Med Supp” or a “Medigap Plan,” a Medicare Supplement Plan is an offering from a private insurance company that may cover the 20% “gap” of costs that Original Medicare does not cover. Depending on the plan / carrier, a Medicare Supplement can help cover copayments, coinsurance and deductibles. Unlike an MA Plan, however, Med Supp plans do not provide additional services, such as routine dental, vision, hearing, or prescription drug coverage. Similar to both Original Medicare and Medicare Advantage, a Medicare Supplement isn’t the right choice for everyone, so let’s look at the “pro’s” and “con’s” of these plans:
| PRO | CON |
| Helps cover co-payments, co-insurance and deductibles | Monthly premium can be costly and is not refundable if you don’t have any eligible expenses, e.g., if you do not go to the doctor, you still pay the premium |
| Monthly premium may cap your financial responsibility at the amount of the monthly premium + Plan B $203 annual deductible | You will still need to purchase a Medicare Part D plan for prescription drug coverage and pay a monthly premium |
| If you require routine dental, vision or hearing, you will still need to purchase a DVH Plan and pay a monthly premium | |
| Monthly premiums can differ between carriers for the same benefits |
I’M STILL CONFUSED! WHAT DO I DO?!
Don’t panic!! There are beneficiaries who have been in the Medicare system for years who still have questions about how the system works and which option is best for them, so if you’re new to Medicare, you’re going to have questions no matter how much you learn. Based on all of the above, here’s what we recommend as next steps:
Collect the following information and/or think about the following questions:
- if you want to have the licensed agent determine if they are in a particular plan network, gather a list of the doctors you currently see, and the frequency with which you see them;
- whether you want to continue seeing all of your current doctors, or are you open to seeing new doctors;
- whether you need routine dental, vision and/or hearing services;
- if you need dental, vision, and/or hearing services, rank them in terms of importance to you currently;
- self-administered medications that you take; and
- whether you have a preferred pharmacy or would you prefer the convenience of receiving your medications delivered to your door.
Call a Connect One Health Licensed Agent at 1-888-766-4448 and have the above-information ready.
This is what our licensed agents specialize in — they take all of your information and preferences and find the plan that works best for you!
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