Does Medicare really cover that?
If you are wondering if the commercials promising Medicare coverage for dental, vision and hearing costs are legitimate, the short answer is yes.
However, what the commercials don’t make clear is that they are advertising a different Medicare plan than that offered through the federal government (Original Medicare). They are offering Medicare plans through private insurers; these plans are known as Medicare Advantage plans.
Both Original Medicare and Medicare Advantage plans have the same eligibility requirements, however, the cost and coverage of the plans is quite different.
Read on to learn more about the differences between Original Medicare and Medicare Advantage plans and determine which Medicare plan is best for you.
What does Original Medicare cover?
Original Medicare
Original Medicare consists of different “Parts,” each covering a different aspect of medical care.
Medicare Part A
Medicare Part A covers “acute” situations, like:
- hospital stays
- rehab
- hospice care
- home health for skilled services (i.e. physical therapy, occupational therapy, speech and language therapy or a nurse, typically following a hospital or rehab stay; offered usually for a very limited number of weeks)
If you qualify for Medicare, you get Medicare Part A automatically with no extra premiums or deductibles.
Medicare Part B
Another important component of Original Medicare is Part B, outpatient insurance. In addition to doctors’ visits, Part B also covers:
- Radiology (x rays, outpatient studies)
- Labs
- Outpatient physical therapy, occupational therapy
- Some types of psychotherapy
- Oxygen and some types of COPD supplies and meds
- Durable Medical Equipment
- Wheelchairs, walkers, beds
- Emergency room visits without an inpatient admission
The costs associated with Medicare Part B are a small annual deductible (less than $200, currently) and a monthly premium of approximately $150.
Medicare Part B covers 80% of Medicare allowable costs per doctor’s visit. The remaining 20% is either paid out of pocket, or through a Medigap policy (additional insurance you can purchase).
Medigap policies vary in cost and coverage options.
For those who are low income (defined differently in each state), you may be eligible to have your Part B premiums paid by the government through the Qualified Medicare Beneficiary Program (QMB). In addition to paying for the cost of Medicare premiums, QMB also covers the 20% that Medicare Part B doesn’t cover.
Medicare Part D
Original Medicare’s optional prescription drug program is referred to as Part D. There are various Part D plan options with different costs and coverage levels. Determining which Medicare Part D plan is best for you will depend on how much and what types of medications you take.
Part D prescription drug coverage can be confusing (how much the insurance covers of your medication costs and when), but you can read more about Medicare Part D cost sharing.
[You may also be interested in learning about additional strategies for reducing prescription medication costs.]So far we’ve discussed Original Medicare Parts A, B, and D.
Did you notice I skipped right over Part C? What’s with Part C? Part C is not part of Original Medicare. Part C is actually Medicare Advantage (you know the one that offers all those benefits you hear about in the commercials).
How do Medicare Advantage plans differ from Original Medicare?
The most important points to know about Medicare Advantage / Part C are:
- It is actually private insurance offered by companies who contract with Centers for Medicare and Medicaid Services (CMS) to provide Medicare-like services
- Most Medicare Advantage Plans combine Parts A and B and usually Part D of Original Medicare and often offer additional benefits like dental, vision and hearing as well as Silver Sneakers.
- The plans often set a limit on your out-of-pocket expenses annually for covered services so you may be protected from unexpected costs.
- That all sounds pretty good, I imagine, but what they don’t usually mention in the commercials is that:
- You will likely have to use health providers who participate in the plan’s network. You may have to go to specific participating hospitals too. Some plans may allow for out of network coverage, but at a higher cost.
- Medicare Advantage companies get a certain amount of money from the Federal Government to take care of you and if they spend less than that, they keep the difference as profit.
- Also, while Medicare Advantage plans typically consolidate the costs that someone with Original Medicare would pay for Parts A, B, D and any Medigap costs, there may be additional fees charged by Medicare Advantage, including copays for specialist visits and drug deductibles.
- Additionally, certain Medicare Advantage plans may only be offered in specific areas which could be problematic should you move. This is different from Original Medicare, a federal program, that offers the same coverage across the country.
Who can help compare Medicare plans?
If you are considering a Medicare Advantage plan and want to compare the different plans, check out The Centers for Medicare & Medicaid Services (CMS) Five-Star Rating System. The CMS star rating measures Medicare Advantage programs on factors like: management of chronic conditions, availability of care, overall experience and complaints of members, customer service, and drug pricing. These star ratings are updated by CMS every year.
If you need more personalized assistance with comparing Medicare plans and deciding what insurance makes the most sense for you, you can contact your local State Health Insurance Program (SHIP). Each jurisdiction has a SHIP, offering “trusted, unbiased one on one counseling and assistance” to navigate the complexities of Medicare.
The bottom line when it comes to Medicare and Medicare Advantage is that you really need to do your research. You may appreciate some of the additional coverage “perks” that Medicare Advantage offers, but it’s important to know what you may be giving up too. Whatever option you choose, the good news is, it’s not irreversible. You can always switch (back to Original Medicare or to Medicare Advantage) during the next open enrollment period.
