Facing New Health Problems? How to Make Sure You Have the Right Medicare Coverage

Victoria Burke by Victoria Burke | Licensed since 2011
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This article was updated on: 10/06/2018

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When your health is good, you might not have to worry about the details of your Medicare coverage. But if you start developing health problems, that’s a different story. You might want to take a close look at your Medicare coverage and make sure you have the coverage that’s best for you.

How does Medicare cover your health problems?

First, let’s look at Original Medicare coverage (Part A and Part B). Part A is hospital insurance, and generally covers your care and medical services and supplies when you’re a hospital inpatient. There’s a deductible to pay before Medicare coverage starts, and you generally pay coinsurance or copayment amounts.

Part B is medical insurance, and may cover doctor visits, preventive care, certain screenings for diseases, and other medical services. Part B also has a deductible and coinsurance to pay (20% for most services).

But Original Medicare offers only limited prescription drug coverage. It won’t cover most medications you take at home, although it may cover those administered to you in inpatient and outpatient settings.

Also, Original Medicare doesn’t have an annual out-of-pocket maximum spending limit. That means that, for example, if you’re hospitalized for a long time or multiple times in one year, your costs could be high. If you have health problems, keep reading to learn about other types of Medicare coverage.

Can Medicare Supplement insurance help pay your Medicare costs?

Medicare Supplement (Medigap) insurance might interest you if you have health problems and expect many doctor visits. That’s because Medicare Supplement insurance plans may help pay for your Medicare Part A and Part B out-of-pocket costs, like coinsurance, copayments, and deductibles. There are up to 10 standardized Medicare Supplement insurance plans available in most states. Each of these plans, identified with a lettered name such as Medicare Supplement Plan A, may cover different portions of Medicare costs. Each plan of the same name has the same basic benefits. For example, Medicare Supplement Plan A (not to be confused with Medicare Part A) covers the same basic benefits no matter where you buy the plan. But since different private insurance companies sell these insurance plans, plan costs may vary from one company to another.

So, if your health problems mean that you might spend some time in the hospital – or have many doctor visits – you might want to look into Medicare Supplement insurance. All of the standardized plans available in most states generally cover at least part of your coinsurance costs for doctor visits under Part B, as well as up to 365 days of hospital costs when your Part A benefits are used up. (Under Medicare Supplement Plan N, you might have to pay a copayment up to $20 for some office visits, and up to $50 for emergency room visits if they don’t result in hospital admission.)

However, if you don’t buy Medicare Supplement insurance during your Medicare Supplement Open Enrollment Period, there’s a chance you could be charged more for this insurance if you have health problems. You could have to undergo medical underwriting, and your acceptance into a plan is not guaranteed. Also, be aware that Medicare Supplement insurance plans sold today don’t include prescription drug coverage.

What are my other Medicare coverage options if I develop health problems?

Let’s say you can’t buy Medicare Supplement insurance, or you decide it’s not what you want. You might want to consider a Medicare Advantage plan.

Medicare Advantage plans do have yearly out-of-pocket spending limits. That means that if your Medicare-approved medical costs reach a certain amount within a calendar year, your Medicare Advantage plan may cover your medical costs for the rest of the year.

Medicare Advantage, also known as Medicare Part C, provides a way to get your Original Medicare (Part A and Part B) benefits through a private, Medicare-approved insurance company. Hospice benefits are still covered under Part A. Most Medicare Advantage plans include prescription drug coverage, and many plans include extra benefits, like routine dental care. You must continue to pay your Medicare part B Premium. Learn more about Medicare Advantage plans.

Please note that Medicare Supplement insurance plans don’t work with Medicare Advantage plans.

If you decide to stay with Original Medicare, you can generally sign up for a stand-alone Medicare Part D Prescription Drug Plan to help with your prescription drug costs. It may be a good idea to make a list of your medications and make sure that any plan you’re considering includes those drugs in its formulary (list of covered medications). A plan’s formulary may change at any time. You will receive notice from your plan when necessary.

I’d be happy to explain the various Medicare coverage options in more detail. You can arrange a phone call with me or have me send you customized information by email by clicking on the links below. To check out plans in your area at your convenience, just click the Find Plans or Compare Plans buttons on this page. You can also call and talk with me or another Medicare.com licensed insurance agent.

The formulary may change at any time. You will receive notice when necessary.

Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.

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