Health Tips: Medicare Plans, Medicare Advantage: Fundamental Differences – InsuranceNewsNet

It’s Medicare open enrollment season, Oct. 15-Dec. seven. And the air is filled with advertisements for “Medicare” plans that we old-timers can buy. TV stations repeatedly broadcast circus advertisements telling you that their plans are such a big deal. The billboards display the same messages. And the newspapers come with clever flyers spouting the same thing. An editorial recently appeared in the Minneapolis Star Tribune with the headline “Good deals on health plans abound again in 2023. A day later, a letter to the editor by a doctor, labeled “Only a ‘good deal’ if you squint,” had contrary thoughts.

This is a chronicle on medicine. But paying for medical care and illnesses is a crucial part of medicine. So, as neutral as possible, I’m going to give an extremely simplified comparison of the original Medicare (OM) and Medicare Advantage (MAP) plans in this short space.

On July 30, 1965President Lyndon Johnson signed into law the bill that led to Medicare, medical assistance for the elderly, and Medicaid, medical assistance for low-income people. Health insurance plans were defined as Part A (hospital care) and Part B (office care). In 1972, arrangements were gradually put in place to allow private insurers to subscribe to certain people. In 2003, the Medicare Prescription Drug Improvement and Modernization Act made the biggest changes to Medicare in 38 years.

Medicare-approved private health plans have become known as Medicare Advantage Plans (MAP), or Part C, because they include both Parts A and B of OM. It also expanded Medicare to include an optional prescription drug benefit, Part D, which came into effect in 2006.

As a reminder, the fundamental structure of OM is part A for hospitalization and part B for other medical expenses excluding medication, vision, hearing and dental care. It pays 80% of the allocated amount decided and accepted by the health insurance “providers”. The benefits are the same from person to person. Almost all doctors/providers accept Medicare patients. There is therefore no limited “network” of suppliers. You must pay the remaining 20% ​​of the fees out of pocket with no limit to this amount per year. To compensate for this, supplemental Medicare insurance plans from private companies, called Medigap plans, like blue crossetc., can be purchased.

MAPs are intended to be all-in-one alternatives. They pay for parts A and B and often, but not always, have drug, dental, hearing, and vision plans. These are sold by private companies, which receive a set amount from Medicare for accepting you. These can be confusing and confusing, as private companies can set rules to set all sorts of different fees, depending on your age, pre-existing conditions and even zip code.

The advertisements broadcast by the MAPs sound VERY good. Zero monthly premiums and maximum annual disbursements of $7,550 from now are selling points. But the benefits are different from diet to diet. You still have to pay your Part B premium. A big downside is that you are in a limited doctor network and usually need to be referred to a specialist! If your doc/supplier leaves the network, you need to find a new one. Another disadvantage of MAPs is the high cost per uncovered service. That means the plan is cheap if you’re not sick and don’t ask them to pay. But the outlays for many expenses not covered by MAP can be exorbitant and not worth it. These plans can change the rules from one year to another, unlike OM.

If you sign up for a MAP, don’t like it and want to come back to OM, it may not be easy, especially finding a Medigap plan.

Keep in mind that this is exactly what private “health” insurers do, insure your health, but not so much your illnesses. They make money from your bonuses, not by paying your bills. Charities they are not. I have a skewed perspective of battling insurers when I was in full-time practice. They fight tooth and nail to avoid or delay payment. It’s not a secret. The columnist MD recalls that “health debt is the number one cause of personal bankruptcy” in WE In addition, healthcare/medical care in the WE is about twice as expensive as in other developed countries. It’s hard to end with anything humorous. Remember, when you read those glowing offers and see TV commercials with smiling, perfectly healthy, attractive geezers getting sales pitches, if that sounds too good to be true, think about it. Buy with care. It can be really difficult to understand. Good luck. And take some Tylenol before you go talk to the salesman.