Question: I have a Medicare Advantage Plan. My friend says I don’t have Medicare. Is that true?

Answer: You definitely have Medicare Part A & B, you must have both to enroll into a Medicare Advantage Plan of any type. There are multiple types of Medicare Advantage Plans, Health Maintenance Organizations (HMO’s), Preferred Provider Organizations (PPO) are the most common. A type we rarely see here locally is Private Fee For Services Plans, (PFFS), which don’t include drug coverage. There is a Program of All-Inclusive Care for the Elderly (PACE) which provides many services in addition to Health Insurance for those individuals who have Medicare and Medicaid and additional health needs. There are also Special Needs Plans (SNP’s) that are available to individuals who may be in a Skilled Nursing Facility or similar situation.

Once you have Medicare Parts A & B, you can insure two different ways: one path is through Medicare Advantage (MA) Plans. This path usually includes prescription drug coverage. The other path is through Medicare + Medigap Plan. This path usually requires purchasing an additional Prescription Drug Plan. For this discussion I am not going to talk about Part D (prescription Drugs) too much.

The MA Plan path requires that you have Medicare Part A & B. You pay the Medicare Part B premium, usually out of your Social Security check. This year’s premium is $170.10, for most individuals. In 2023 the Part B premium will be $164.90. Once you sign up for the MA Plan your Medicare Part A & B go inactive (no longer your primary insurance). You will always pay for your Medicare Part B premium, but your insurance coverage will fall to the MA Plan. Most of these options include prescription drug coverage, therefore you won’t need to buy an additional plan. The MA Plans can have a relatively low monthly premium and may require copays as you access healthcare. For instance, in 2023, it might be $0 to $10 for bloodwork or $0 to $30 for primary care physician visit and $30 to $50 for a specialist physician visit. It might be $295 per day to $700 per day for a hospital stay. The MA Plans MUST provide coverage for all the benefits that Original Medicare would cover, but can set up its own cost structure for you to pay. So, the MA Plans will pay for a Hospital Stay for Heart Surgery, but it can restrict which hospitals you are allowed to go to and decide how much you pay for the Heart Surgery.

Most individuals who have MA Plan are usually good options for healthy individuals.

MA Plans also often provide benefits that Original Medicare may not provide, examples include paying for hearing aids at specific providers, & this year many have added dental benefits. Some MA Plans include a Fitness Benefit that helps to pay for a Health Club Membership (JCC Fitness, YMCA, Planet Fitness and others). The dental, hearing aids, and health benefits are NOT Medicare Benefits. These additional benefits are above and beyond what the companies are required to provide.

For the person who rarely goes to the doctor, and would enjoy having some extra benefits like a Health Club membership, this could be the perfect plan. On the other hand, if your providers aren’t in the network and your medication isn’t covered, having a reduced cost Hearing Aid may be the wrong incentive to choose that particular insurance.

The MA Plan you choose as we said can limit where you are allowed to go, or could increase the amount you have to pay at that location. Be sure your providers are ‘in the plan’; be sure where you live is part of a useful service network.

The insurance answer is NOT the same for everyone! That is the BIGGEST point I try to make each week.

How you complete your Medicare insurance should to be based on your health and medical needs. You and your friend may both have Medicare, but have different variables, or different criteria you used to make your decisions. An informed decision is a good decision.

Senior Life Matters is a community based program sponsored by Lutheran Jamestown. For questions, concerns or to reach Janell Sluga, GCMC, call 716-720-9797 or email [email protected].

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