Healthcare is a vital part of life and can often be one of the most expensive. Understanding the expenses involved in treatment and how coverage pays those expenses in your Medicare health plan can help ease this burden.

If your plan doesn’t cover vital needs, there are approaches you can take that help ease the financial burden.

Know the Facts

Knowledge is power, especially regarding complicated matters like health insurance. Once you understand the core elements of different Medicare health plans, you will also understand why your needs are not being met and how to fix that.

Plan Overviews

Understanding what Medicare covers start with understanding the different plan types that makeup Medicare coverage. At its simplest, Medicare breaks down plans into Original Medicare and Medicare Advantage (Part C). The specific coverage areas are organized by Part A, Part B, Part C, and Part D. There are also Medigap plans that will be discussed later.

Original Medicare

Original Medicare includes Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). You can also join a separate Medicare drug plan (Part D) to receive prescription Medicare drug coverage.

Part A coverage includes inpatient hospital stays, skilled nursing facilities, home health care, and hospice care. Part B covers medically necessary health care provider services, durable medical equipment, home health care services, ambulance services, preventative care, therapy, mental health care services, x-rays, lab tests, and certain prescription drugs.

Medicare Advantage

Beyond Original Medicare, you can benefit from a Medicare Advantage Plan. This is also known as Part C and overlaps a great deal with Original Medicare as it includes Part A and Part B coverage. Most Medicare Advantage plans are perfect for individuals with a history of coverage gaps.

Some areas that Medicare Advantage may cover that Original Medicare does not include fitness programs and some dental, vision, and hearing services. There is flexibility between plans to allow patients to choose an option that best covers the areas most relevant to their needs and concerns.

Not all Medicare Advantage plans are the same. It’s critical to note the details in rules, costs, and restrictions as they may vary, particularly as you will still have to pay monthly Part A and Part B monthly premiums where applicable.

Part D

Finally, Medicare Part D is the area concerned with prescription medication coverage. Most commonly, this is offered as a standalone plan through employment or included in specific Medicare Advantage plans. Prescription drug plans are vital when you need regular medication.

Most vaccines not already covered by Part B are covered through Part D. Patients can also expect coverage of at least two drugs from each drug category. All antidepressants, antipsychotics, HIV/AIDS treatments, immunosuppressants, anticonvulsive treatments, and anticancer drugs are also covered services.

Smart Research

Nearly 64 million patients are currently enrolled in Medicare plans, meaning there will be many nuances to understand. Optimizing your research and knowing what to look for is the only way to ensure that you make the best healthcare decisions. Otherwise, you could quickly sink a lot of time into a complex topic with little to show.

More than a quarter (26%) of respondents in a recent Medigap poll stated they were only “somewhat familiar” with their plan’s coverage. This means there is a possibility there are gaps they are not addressing.

The first step in conducting thoughtful research is to take inventory of what is most important to you and your health. For example, if you know you will likely need aid in prescription medications, it’s in your best interest to search for plans (like Part D or Medigap plans) that will cover them.

Once you’ve established your needs, it will be easier to know when to change plans or what to change. From here, you can move to thoroughly understand the different types of Medicare coverage and, eventually, real solutions to your gaps.

Solutions to Coverage Gaps

The best way to combat coverage gaps in your healthcare is simply shopping around for a better plan. Switching plans comes with various factors, but once you are comfortable with your research, you can take the next step.

The main methods patients use to address their coverage gaps include:

 

  • Job-based insurance: The benefits that come with full-time jobs typically include healthcare. If you or your spouse is working, you should consider whether the health insurance tied to that job is primary or secondary to Medicare. Primary insurance pays first on a claim for care, while secondary insurance pays after.
  • Retiree insurance: Some jobs fill gaps in Medicare coverage through insurance plans for their retirees and spouses. This pays secondary to Medicare.
  • Veterans Affairs (VA): VA benefits don’t work with Medicare. If you qualify for VA benefits, this may be the cheapest option for healthcare and prescription drugs, particularly regarding services not covered by Medicare.
  • Medigap: Medigap policies provide insurance through private companies. They are designed to fill in gaps in Original Medicare caused by deductibles, coinsurances, and copayments. Premiums will vary depending on the specific plan and where it’s purchased.
  • Medicare Advantage: Compared to Medigap, Medicare Advantage plans are great for generally healthy individuals. They provide the same benefits found in Original Medicare but with additional coverage and different rules, costs, and restrictions. Premiums and service costs will often vary between Medicare Advantage and Original Medicare or Medigap solutions, so attention to details about your circumstances is critical.
  • Part D: These plans are relevant for prescription Medicare drug coverage. Part D is the addition to Original Medicare that details which drugs are covered. You may be responsible for a premium penalty if you don’t sign up for a Part D prescription drug plan when first eligible.

Switching Plans

Once you have established a solid knowledge of Medicare plans, you can decide whether switching plans is right for you.

Employment

Healthcare and employment are deeply intertwined in the United States. This can be both a relief to employed individuals and a nightmare to the unemployed. That said, if you do have a job, it’s vital to research what options you have regarding job-based insurance policies.

Larger businesses with 20+ employees provide employer coverage as the first payer, with Medicare as the second. Smaller companies often involve Medicare as the first payer and employer coverage for the gaps.

Plan Enrollment

Once you have found the right plan for you, enrollment is the next step. While many Americans are intimidated by the Medicare enrollment process, it’s much easier than one may think.

Understanding enrollment periods is the first step to undertaking this goal. It’s essential to keep this in mind when switching plans to avoid coverage gaps that could be devastating in the event of an emergency or illness.

Medigap

One of the best solutions to gaps in coverage to consider is Medigap. Medicare Supplement plans are designed to individualize healthcare and cover gaps patients find in more generalized programs.

If this is the exact solution you are looking for, you can request a quote to weigh your options better.

FAQs

What will Medicare not pay for?

This depends on the specific Medicare plan you have. For example, you would not receive Part D (prescription drug) coverage if you only have Original Medicare. Some other areas not covered by Medicare include dental care, dentures, hearing aids, eye exams, cosmetic surgery, long-term care, nursing homes, and massage therapy.

Is there a Medicare Supplement that covers everything?

Short answer, no. As Medicare plans don’t cover all areas of healthcare, there will not be a plan to cover everything. That said, finding the right Medicare Supplement insurance or Medigap plan can help cover many of the gaps you would otherwise encounter.

What is a Medicare “gap,” and how do you avoid it?

Essentially, Medicare gaps refer to gaps in coverage where you will have to face out-of-pocket costs. Beneficiaries can avoid this by choosing a health plan that works best for the areas they anticipate needing coverage. Medigap plans can help to bridge gaps that you may otherwise encounter.

What is a Medicare Advantage Plan?

The Medicare Advantage Plan, or Part C, means that you have the coverage provided by Original Medicare and some added areas. This is a private health plan that will include monthly Part B premiums as well as applicable Part A premiums. Since not all Medicare Advantage plans will be identical, it’s essential to see the details in the rules, costs, and restrictions laid out in your plan.

What is Medigap?

When choosing between Original Medicare and Medicare Advantage plans, there are many areas where individuals wish to seek a balance. Medigap plans, sold by private health insurance companies, help fill those gaps for affordable prices by assisting with out-of-pocket costs that aren’t covered by Part A or Part B.

Requesting a Quote

Healthcare is essential, and it’s stressful when your Medicare plan doesn’t cover your needs. Fortunately, there is a range of options regarding the specifics of your Medicare coverage that can help you secure a plan that works best for you. Request a quote today to learn about potential programs that benefit your health and wallet.

Written By:
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Lindsay Malzone, Lindsay Malzone is the Medicare editor for Medigap.com. She's been contributing to many well-known publications since 2017. Her passion is educating Medicare beneficiaries on all their supplemental Medicare options so they can make an informed decision on their healthcare coverage.
Reviewed By:
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Rodolfo Marrero, Rodolfo Marrero is one of the co-founders at Medigap.com. He has been helping consumers find the right coverage since the site was founded in 2013. Rodolfo is a licensed insurance agent that works hand-in-hand with the team to ensure the accuracy of the content.