Why Do I Need Another Plan in Addition to Original Medicare?

The Difference Between Medicare Supplements and MAPD Plans

Original Medicare allows you to see any doctor, and go to any hospital if they accept Medicare meaning Medicare has allowed them to become a recognized provider.

Medicare is the only insurance that does not have a maximum out of pocket so the 20% which is your part of the bill goes on in perpetuity. This means you pay the 20% regardless of how high the bill is. With traditional underage insurance, all have a maximum out-of-pocket meaning once you hit that maximum the remainder of the year is covered by your insurance. You still have to pay your monthly premium.

So, when you go to the doctor for the first time ask if they take Medicare. If they say yes, ask if they take Medicare Assignment of Benefits. Assignment of benefits means they bill Medicare directly and accept what Medicare pays and they write off the rest of the bill. If the facility does not take assignment of benefits, they can bill you what Medicare disallowed. So, you pay 20% and any balance which equates to about 15%.

When you have Original Medicare, these are the most important concepts to understand. Secondly, you need to understand that if the doctor does not take the assignment of benefits, they can bill you what Medicare disallowed along with the 20% they didn’t pay as stated above.

The solution is either a Medicare Supplement or a Medicare Advantage plan. We will review the Medicare Supplement first and then discuss the Medicare Advantage plans.

There are many Medicare Supplement plans to choose from but the most popular is plan G which has a small annual deductible for outpatient services and the plan picks up the balance of all bills for the year. The other plans have varying deductibles and maximum out-of-pocket costs.

Medicare supplements do not cover drugs, so you need a stand-alone drug plan in addition to the supplement plan. Having a drug plan is mandatory for all Medicare recipients, even if you do not take any medications. In Nevada, the supplemental plans allow you to change plans between the month of and the month after your birthday. As an example, if you currently have a plan G you can change to another plan G or lower but moving to a plan F is not allowed. You can do that annually. I have a plan F and the cost is $350 per month, I found another plan F, but the premium is only $240 per month so I will use the birthday rule to change plans and save over $100 per month.

The other option is a Medicare Advantage plan or MAPD. The popularity of these plans is because they offer additional benefits to attract clients like dental, vision, a prepaid debit card for over-the-counter items, etc. Each plan tries to outdo the other so each year there are new items to consider when choosing a plan.

The plan usually has fixed copays for all services until you reach the plan’s maximum out-of-pocket. Then you pay nothing for the remainder of the year. You are required to use their network of doctors and hospitals. They all offer nationwide coverage in the event of an urgent or emergency. Some plans allow you to see doctors anywhere in the country, but those plans choices are few.

There are HMOs that require a referral to see a specialist and some that don’t. Each has its benefits. All PPOs have a nationwide network, but you are paying for that privilege in higher copays and maximum out-of-pocket costs.

When I meet with a client, I need to obtain the following items to proceed: the doctors they see and the medications they take. Once I have that information, I can determine the best options for them to decide which plan they want.

Since I represent all Medicare insurance companies the choices are plentiful. All Medicare Advantage plans pay the same commissions, so it is easy to be neutral. I prefer the client to choose their option rather than leading them to a particular plan. When the client chooses the plan, they want they will typically remain on that plan.

With 84 different Medicare options in Clark County, picking the right plan is difficult but having the right information necessary to sort through the maze helps reduce that number to a manageable few.

Without the necessary training it is almost impossible to understand the differences between these MAPD plans so using a broker makes sense. These brokers (of which I am one) cannot charge you for their services so using one you can trust will help make your decision easier.

So, the differences between the Medicare Supplement which I would like to refer to as an additional plan that completes your Medicare and allows you to see any doctor, any hospital that takes Medicare versus the MAPD plans are simple.

One is private insurance (Medicare Supplements) with the freedom to choose where you get services versus a plan ultimately paid for by the government with restrictions on doctors and hospitals.

These MAPD plans have networks of doctors and hospitals that you must use but they usually do not have a monthly premium so are very attractive to seniors living on a fixed income. The MAPD plans are well thought out and provide ancillary services as an enticement to choose their plan over the others in the market.

The decision can be based on your doctors and medications, thus finding the best plan for you can be as simple as you want or difficult based on your medical needs.

As many of you may know, I have Rheumatoid Arthritis which requires a monthly injection that costs $4000 per month. For me, the decision was an economic one meaning the supplement picked up what Medicare didn’t pay versus going on an MAPD plan where the cost of that shot because it falls under outpatient services or Part B would cost 20% or $800 per month. My decision was easy as the supplement’s monthly premium is almost ½ the cost of the shot. All this means is you need a broker to decipher the differences between plans to get the best bang for your hard-earned bucks.

Am available for a consultation either in person or over the phone to assist you in choosing the best plan for you.

I hope this information is useful and if anyone has questions, please contact me via phone or email and I will respond quickly.

Also, if you need Medicare information, take a look at Medicare 2023 Information.

The Barend Agency

The Barend Agency Inc.

Len Barend, Broker

Email: len@insurance4unevada.com