If you are feeling confused or overwhelmed by your Medicare coverage, please know that you are not alone! It is, however, important to learn as much as possible so that you can make informed decisions that best meet your specific healthcare needs.
Original Medicare includes Part A (hospitalization), Part B (outpatient medical) and Part D (prescription drug) coverage. If you are enrolled in Original Medicare, your medical benefits are administered directly through the federal government and you have the option of purchasing a separate “stand‐alone” prescription drug plan from a private insurance company. When accessing medical services, beneficiaries are responsible for a deductible and will then pay a 20% coinsurance for the remainder of the year. One major advantage of Original Medicare is that beneficiaries can see any provider who accepts Medicare. They also do not need referrals to see specialists. On the contrary, one major disadvantage is that Original Medicare generally does not cover dental or vision services.
If you opt to get your coverage through a Medicare Advantage Plan, also known as Medicare Part C, you still have Medicare coverage; however, both your medical and (generally) your prescription benefits will be contracted through a private company. You may or may not be required to pay an additional premium for your plan. Patients are usually responsible for a set copay for services, rather than a coinsurance. The coverage varies from plan to plan but all Advantage Plans must, at a minimum, cover the same medical and prescription benefits covered by Original Medicare. They oftentimes offer additional perks such as hearing, dental & vision coverage, transportation to medical appointments, and health club memberships.
It is important to remember that with Advantage Plans, you may be required to choose and stick with a Primary Care Physician. You may also need a referral from your PCP to see a specialist. Provider networks for these plans are more limited then with Original Medicare. You will need to be sure to see providers who are in‐network for your plan or you will likely face higher out‐of‐pocket costs or possibly even no coverage at all.
If you have questions, please contact or set up an appointment with a member of the AbsoluteCARE social work team.
Bethany Weikart, Care Manager