Navigating Your Medicare Options

Should you go with a Medicare Advantage Plan or Original Medicare combined with a Supplement?

Turning 65 marks a significant milestone, and with it comes the important decision of how to manage your healthcare. For many seniors, understanding the nuances between Medicare Advantage (Part C) plans, Original Medicare, and Medicare Supplement (Medigap) plans can be a complex task. This guide aims to clarify these options, helping you make an informed choice that best suits your health needs and financial situation. At Ken Locke and Associates, LLC we offer both options and will assist you in finding the most suitable plan for your individual needs.

Original Medicare: The Foundation

Original Medicare is provided directly by the federal government and consists of two main parts:

• Part A (Hospital Insurance): Covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care.

• Part B (Medical Insurance): Covers doctor's services, outpatient care, medical supplies, and preventive services.

While Original Medicare offers broad coverage, it doesn't cover everything. There are deductibles, coinsurance, and no annual limit on out-of-pocket expenses. This is where Medicare Advantage and Medicare Supplement plans come into play.

Medicare Supplement (Medigap) Plan Options: Filling the Gaps

Medicare Supplement plans, often called Medigap, are sold by private insurance companies to help cover the "gaps" in Original Medicare. These plans help pay for some of the out-of-pocket costs that Original Medicare doesn't, such as deductibles, copayments, and coinsurance.

Pros of Medicare Supplement Plans:

• Predictable Out-of-Pocket Costs: Once you pay your monthly premium, your out-of-pocket costs for covered services are generally very low or even non-existent. This offers peace of mind, especially for significant medical events.

• Provider Choice: With a Medigap plan, you can see any doctor, specialist, or hospital in the U.S. that accepts Original Medicare. There are no network restrictions.

• Guaranteed Renewability: As long as you pay your premiums, your Medigap policy is guaranteed renewable, meaning the insurance company cannot cancel it, even if your health declines.

• Minimal Prior Authorizations: Because Medigap works with Original Medicare, you generally won't encounter the need for prior authorizations for most services, allowing for smoother access to care.

Cons of Medicare Supplement Plans:

• Monthly Premiums: You pay a separate monthly premium for your Medigap plan in addition to your Part B premium. These premiums will likely increase slightly year-over-year as you get older.

• No Extra Benefits: Medigap plans only cover the gaps in Original Medicare. They generally do not offer additional benefits like dental or vision.  In Wisconsin, some plans do enhance their Medigap plans with enhanced preventive care, or possibly a gym membership.

• No Prescription Drug Coverage: Medigap plans do not include prescription drug coverage (Part D), so you would need to purchase a separate Part D plan.

Medicare Advantage (Part C) Plans: An Alternative to Original Medicare

Medicare Advantage plans are offered by private insurance companies approved by Medicare. When you enroll in a Medicare Advantage plan, you are still in the Medicare program, but your benefits are administered by the private insurance company. These plans include Part A and Part B coverage and often include Part D (prescription drug coverage) as well.

Pros of Medicare Advantage Plans:

• "All-in-One" Coverage: Many Advantage plans combine Part A, Part B, and Part D into a single plan, simplifying your Medicare coverage.

• Lower or $0 Premiums: Many Medicare Advantage plans have low or even $0 monthly premiums beyond your Part B premium. Some plans may even include a Part B “Giveback” which may reduce your Part B premium costs.

• Additional Benefits: A significant draw of Advantage plans is the extra benefits they often include, such as routine dental, vision, hearing, gym memberships, and even transportation to doctor appointments.

• Out-of-Pocket Maximum: All Medicare Advantage plans have an annual out-of-pocket maximum, which limits how much you will pay for covered services in a calendar year.

Cons of Medicare Advantage Plans:

• Provider Networks: Most Medicare Advantage plans operate within specific provider networks (HMOs or PPOs). This means you may be restricted to doctors and hospitals within the plan's network, or pay more to go out-of-network.

• Prior Authorizations: Prior authorizations are much more common with Medicare Advantage plans. This means the plan may require approval before you can receive certain services, tests, or procedures, which can sometimes delay care.

• Referrals: HMO plans often require referrals from your primary care physician to see specialists.

• Guaranteed Renewability: While your plan can't drop you due to health, the plan's benefits, costs, and network can change annually.

Key Differences: A Closer Look

Let's break down some of the most critical distinctions:

Feature	Original Medicare + Medigap	Medicare Advantage (Part C)
Guaranteed Renewability	Yes, as long as you pay premiums.	Plan can change benefits, costs, and network annually.
Provider Networks	No networks. See any provider accepting Medicare.	Often restricted to network providers (HMOs/PPOs).
Out-of-Pocket Costs	Predictable, often very low once deductibles met.	Lower premiums, but copays/coinsurance add up to out-of-pocket max.
Prior Authorizations	Few needed.	Often common for services, tests, and procedures.
Extra Benefits	No (must purchase separate Part D).	Often includes dental, vision, hearing, gym memberships, etc.

Scenarios: When Original Medicare + Medigap May Be Better

While Medicare Advantage plans offer attractive low premiums and extra benefits, there are scenarios where the comprehensive coverage and flexibility of Original Medicare combined with a Medicare Supplement plan can be more beneficial, particularly for those facing significant health challenges:

• Cancer Treatment (Chemotherapy, Radiation, Surgery): Cancer treatment is often extensive and can involve numerous doctor visits, specialized tests, and expensive therapies. With Original Medicare and a Medigap plan, your out-of-pocket costs for these services are typically much lower and more predictable, potentially saving you tens of thousands of dollars compared to an Advantage plan where copays for each service can quickly accumulate up to the out-of-pocket maximum.

• Chronic, High-Cost Conditions: If you have a chronic condition requiring frequent specialist visits, ongoing tests, or expensive medications given in a clinical setting, the predictable costs and freedom to choose specialists without network restrictions or many prior authorizations can be invaluable with Medigap.

• Frequent Travelers: If you spend significant time in different parts of the country or even internationally (some Medigap plans offer foreign travel emergency coverage), the ability to see any doctor who accepts Medicare, anywhere in the U.S., provides unmatched flexibility. Medicare Advantage plans are typically regionally or network based and may limit you to Emergency or Urgent Care coverage only, depending on the plan, when traveling outside your area.

• Desire for Unrestricted Provider Choice: For individuals who want the freedom to choose any doctor or hospital that accepts Medicare, without worrying about networks or referrals, Original Medicare plus a Medigap plan is the preferred choice.

Here's an image of a senior woman discussing her health with a doctor, emphasizing the importance of informed choices.

Making Your Choice

Choosing between Medicare Advantage and Original Medicare with a Supplement is a highly personal decision. It depends on your health, financial situation, preferred doctors, and tolerance for potential out-of-pocket costs.

At Ken Locke and Associates, LLC, we understand these decisions can be overwhelming. We're here to help you navigate your options, compare plans, and find the Medicare solution that best fits your individual needs. Don't hesitate to reach out for personalized guidance. Call (262) 536-5155 to start the process with a no-obligation review of your options.