Do you stick with Original Medicare (otherwise known as Part A plus Part B), or do you choose Medicare Advantage (also known as Part C)?

Do you need Medigap or Part D?

Deciding what’s best can feel like running a maze.

Don’t worry. This guide has your back.

Your Medicare options: Original Medicare & Medicare Advantage 

The biggest decision one has to make about Medicare is whether to stay with Original Medicare with the possibility to add supplemental coverage to it (if needed) or replace Original Medicare with all-in-one coverage that Medicare Advantage offers.

Replace Original Medicare with Medicare Advantage	Keep Original Medicare and add coverage
Sign up for a Medicare Advantage Plan instead of Original Medicare.	keep Original Medicare (Part A and B)
	If needed: add a Prescription Drug Plan (Medicare Part D) to cover prescription drug costs;
	If needed: add a Medigap (Medicare Supplement) Plan to cap out-of-pocket expenses

Original Medicare:

 This is the traditional Medicare program. It includes:

• Part A (Hospital Insurance): Covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
  
• Part B (Medical Insurance): Covers certain doctors’ services, outpatient care, medical supplies, and preventive services.

Original Medicare does not cover the costs of prescription drugs (Part D) and extras like vision, hearing, or dental checkups.

You can expand your coverage by going for

Medicare Part D: 

This is your prescription drug plan, ideal for those with medication needs. It’s an additional private health insurance policy you can purchase to complement your Original Medicare.

Medigap (Medicare Supplement): 

These plans, offered by private companies, act as a safety net. They cover gaps, like copayments or deductibles, that Original Medicare doesn’t.

By combining Original Medicare with Part D and Medigap, you get broad coverage that includes hospital visits, medical services, prescription drugs, and protection from unexpected out-of-pocket expenses.

Medicare Advantage (or Part C): 

Offered by private companies, this is an “all-in-one” alternative to Original Medicare. It bundles Part A and Part B and often includes extras like vision, hearing, and dental coverage. While not all, many Medicare Advantage plans include Part D prescription drug coverage, which means beneficiaries don’t have to enroll in a separate drug plan.

Note: If you choose Medicare Advantage, you cannot add Part D and Medigap separately to your plan. They’re exclusively for Original Medicare beneficiaries.

However, you can join a separate Medicare drug plan with certain types of plans that:

• Don’t offer drug coverage (like Medicare Medical Savings Account plans)
• Choose not to offer drug coverage (like some Private Fee-for-Service plans)

Original Medicare vs. Medicare Advantage: what’s better for you?

Original Medicare might be a better fit if you prefer the flexibility to choose doctors who accept Medicare (without needing to worry about network restrictions) or already have supplemental coverage that you’re pleased with. You have to purchase a separate Part D plan for prescription drugs.

The downside? It doesn’t offer prescription drug coverage or out-of-pocket maximum, leaving you vulnerable to potentially high expenses.

Medicare Advantage packages everything into one plan, often including prescription coverage, and some even offer dental, vision, and other benefits. You’re also protected by an out-of-pocket maximum.

The catch? You might be restricted to doctors and hospitals that are in the plan’s network and might need a referral to see a specialist, offering less flexibility than Original Medicare.

What questions do you need to ask when choosing a Medicare plan?

Now, ready to shop? Here are some questions to keep in mind:

• What’s the total potential cost of the plan? (monthly premium + estimated out-of-pocket expenses)
• Is my preferred doctor in-network? Especially if you have specialists you regularly see.
• What about my medications? Are they covered under the plan’s drug list (or formulary)?
• Can I get coverage outside of my state or even country?

Let’s dive a bit deeper.

How do I know which Medicare plan is best for me?

There’s no one-size-fits-all when it comes to picking a Medicare plan.

The goal is to tailor your choice to your health needs and budget. 

Not sure how to do that? There are tools that can make it easier for you such as online plan finders, they allow you to see plan details and compare before you make a decision.

What is your current health status?

Think about your health right now. What do you need most?

• Chronic conditions: If you have ongoing health issues that require regular check-ups or treatments, a Medicare Advantage plan may be more beneficial due to its comprehensive coverage. It can reduce your out-of-pocket expenses in the long run.
• Doctor visits: For those who frequent their doctors, a Medicare Advantage plan with a lower co-pay for doctor’s visits could be the way to go.
• Hospital stays: Anticipating surgery or hospitalization? Original Medicare (Part A & B) typically provides solid hospital coverage, but combining it with Medigap can cover additional costs.

What are your medications?

What medicines do you take? Make sure they’re covered.

• List down your regular medications: Start with noting all the drugs you’re on. For generally healthy individuals with minimal medication needs, Original Medicare will be enough. Otherwise, you’ll have to add Part D to your Original Medicare coverage or go for a Medicare Advantage Plan with medicare drug coverage.
• Check coverage under formulary: Medicare plans have a ‘formulary’ or a list of covered drugs. Ensure your meds are on this list. Medicare Part D specifically provides prescription drug coverage, but many Medicare Advantage plans also offer this.
• Consider future medications: Might need new drugs soon? Think about getting Medicare Part D or Medicare Advantage with drug coverage.

How much can you pay?

How much can you spend? Keep your budget in mind.

Monthly premiums

Some plans cost more each month. Medicare Advantage prices can vary, while Original Medicare costs are often more fixed.

Here’s a quick breakdown of the monthly premiums:

Original Medicare: 

Part A: $0 if you or your spouse have paid your Medicare taxes while working; $278 or $505 in 2024 if you haven’t.

Part B: In 2024, the standard monthly premium is $174.70. Depending on your income it could be higher; anywhere from $244.60 to $594.00.

Medicare Advantage: It varies depending on your Medicare Advantage plans – PPO or HMO.

PPO: $17 per month for local PPOs and $46 per month for regional PPOs.

HMO: $14 per month (source: KFF)

Out-of-pocket maximums

If you want a safety net, go for Medicare Advantage plans as they cap your out-of-pocket expenses.

Deductibles

Medigap can help reduce out-of-pocket expenses if you opt for Original Medicare.

Do you travel a lot?

Where do you live and travel? This matters too.

• Local Vs. National: Travel a lot? Consider Medicare Advantage PPO or Medigap for more flexibility.
  Rural or Urban: In the countryside? Most places accept Original Medicare. City folks might have more Medicare Advantage options.

Extras and additional benefits

Some plans offer bonus coverage. Check them out.

• Vision, Dental, and Hearing: Medicare Advantage often covers these; Original Medicare doesn’t.
  Wellness Programs: If you like staying active, some Medicare Advantage plans offer fitness perks.
• Flex cards and premium give backs: more plans are offering this type of benefits.

Feedback and reviews

What are others saying? Their experiences can guide you.

• Star Ratings: Use Medicare’s rating system as a guide. High-rated Medicare Advantage plans indicate good quality.
• Personal recommendations: Gather feedback. Often, peers might highlight the pros of Medigap for covering additional costs or the benefits of Medicare Advantage’s all-in-one approach.

Can you switch your Medicare plan?

Absolutely! Medicare has an open enrollment period each year, from October 15 to December 7. This is your chance to review and change your plan if it’s not quite the right fit.

Who can help me choose a Medicare plan?

Once you have a basic understanding of the different parts of Medicare and have evaluated your needs, choosing a plan becomes a more approachable task. However, you don’t have to do it alone. There are many resources available to help you make this significant decision:

1. Medicare.gov’s Plan Finder: This online tool helps you compare coverage options, costs, and drug prescription coverage for various plans based on your personal needs.
2. Hella Health: website that lists down the Medicare plans available in your area and if you want to use their advisor tool you can create a profile to add details such as your favorite doctors and pharmacies and it will customize the search for you, including calculating estimated costs based on your drugs and doctors. 
3. State Health Insurance Assistance Programs (SHIPs): The SHIP network offers free, impartial counseling on all things Medicare. 
4. Insurance brokers and financial advisors: These professionals can offer expert advice. However, ensure they have comprehensive knowledge of Medicare and aren’t biased towards selling certain plans. 
5. Medicare classes and educational programs: Many local community centers offer classes that break down the complexities of Medicare.
6. Friends, family, and physicians: Often, those close to you or who care for your health can provide valuable insights. 

Wrapping it up: your Medicare game plan

Whew. That was a lot, right? Just remember, choosing a Medicare plan is about finding what fits you.

The process may require time and effort, but the reward is a healthcare plan tailor-fit to your personal needs and lifestyle. It’s okay to seek out help in choosing a Medicare plan. It’s your health at stake, and you deserve to understand all your options to make the best possible decision.