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Listen closely, because you’re going to want to know this. Almost everyone thinks they have “the best health insurance.” Really, truly, almost everyone I’ve ever met. Well, guess what, not everyone has the best insurance coverage. Don’t be lazy and not learn the difference between these things, because then you will be losing out on coverage or money or left high and dry. Learn the difference, and then you really may get the best. ;)
One of the biggest perks of turning 65 is enrolling in Medicare! At last, government-sponsored health insurance coverage! Medicare is often the best payer, and so it’s often the last insurance to be dropped when a doctor is trying to cut costs. Medicare doesn’t try to “play doctor” (i.e., practice medicine without a license) by requiring prior authorizations before MRIs or CT scans. They don’t delay diagnostic tests. It’s truly a great insurance for the patient to have. The deductible is very little (this year $185.00 for the whole year!), and most services are covered. Medicare does not have exclusive “networks” either – so, if your doctor wants to accept Medicare, they will. Very few doctors “opt out” of Medicare (meaning they will not bill Medicare – they bill their patients directly, and the patients cannot use Medicare funds to pay those bills), and that is a topic for a different day. MOST physicians, even if they do not “participate” with Medicare (meaning they accept the amount that Medicare will pay them), will still bill Medicare and thus you the patient would only be responsible for any excess charge above the Medicare-allowable fee. Again, topic for another day. Most doctors participate.
Let’s discuss what Traditional Medicare alone covers, as far as doctor’s visits (i.e., “Part B;” remember, Part A is hospital coverage, Part B is doctor's visits, and Part D is drugs.). After the yearly $185 deductible, Medicare covers 80% of the office visit fee. The other 20% is the “coinsurance,” which is the patient’s responsibility. There are no other flat copays to pay per doctor’s visit.
Most people will pay extra for a SECONDARY, aka SUPPLEMENTARY, or “MEDIGAP” Plan. These are all synonyms for the same thing. These are plans from private, commercial insurers, to SUPPLEMENT, or CLOSE THE GAP, on what Medicare will cover. These are plans from companies such as United American or AARP from United Health. There are many others. They will always have a LETTER associated with it – for example, Plan A, Plan B, etc. Like your primary traditional Medicare plan, these do NOT have exclusive networks. That means that if your doctor accepts Medicare, he or she will get paid and you don’t have to worry about finding someone who “accepts Blue Cross” or is “in network with United.” The visit is covered no matter if the doctor is in network with your secondary insurance company or not. SOME of these plans will have a deductible (usually Plan “HDF” has a “high deductible” which is what the HD stands for) before their benefits kick in; it may be thousands of dollars (I think this is silly – whatever small amount you’re saving on your premium to get this plan is NOT WORTH the thousands you will be left paying if you need healthcare coverage – it really makes it almost like you don’t even have the secondary coverage, because you have to pay thousands of dollars first!). However, most of these secondary plans do NOT have a deductible. They should not have a copay, either. So what do they cover? SOME cover the Medicare Part B deductible of $185. And some cover the 20% coinsurance that Medicare expects you to pay. So with the right secondary coverage, you don’t have to pay a dime to any Medicare doctor, ever. Which plans are which? It’s actually pretty simple to figure out because no matter your secondary insurance company, they all follow the same rules. https://www.medicare.gov/su…/how-to-compare-medigap-policies is the CMS website where you can learn about the different secondary plans.
Now, if you have secondary coverage with a GROUP under your EMPLOYER, and you don’t have the words “Medicare Supplement Plan” or “Plan X” where X is a letter such as A, B, C, F, etc anywhere on your insurance coverage, then you do NOT HAVE A MEDIGAP PLAN. Your private commercial insurance is just acting as “secondary” without all the benefits of having a Medicare Supplementary Plan. That means you’re paying premiums for LOWER coverage. GROUP health plans do NOT have to cover services by all doctors that accept Medicare. That is, they have their own exclusive networks that the doctor MUST participate in in order for your visit to be covered. If your doctor accepts Medicare only, but is not in network with Blue Cross, for example, your 20% Medicare coinsurance will NOT be covered. IF you have out of network benefits on your specific group plan THEN PART of that 20% MAY be covered, but usually only after you pay another high deductible. Or you may be responsible for that amount up front, and then submit to the insurance company for reimbursement. The good news is that 20% of the bill is not usually that high – for office visits, the most you would be responsible for this year would be around $45. But for some people who think they have the best coverage and they should not be paying a penny for their healthcare, they will be sorely mistaken.
Now, one more distinction. Traditional Medicare, which is what we’ve been talking about to this point, is different from “MEDICARE ADVANTAGE PLANS,” which really should be considered Medicare REPLACEMENT Plans, because they replace Traditional, government-sponsored Medicare, with private Medicare. If you do not have a MEDICARE insurance card with the words PART A and PART B on it, you do NOT have Traditional Medicare. You still pay premiums, but not to the government. THESE plans DO have exclusive networks. That means that sometimes your doctor wants to provide care to these patients, but the company “closes the panel” and does not admit the doctor into their network, meaning, of course, their services will not be covered under your plan. Also, these companies are NOT generally good payers, meaning, they will find any excuse not to pay your doctor, they will require prior authorizations before any testing which delays diagnosis, they will pay much lower fees than the Medicare rate, they will require special referrals from your primary doctor before allowing you to see other doctors, etc., etc. Many, many doctors are not “in network” with these plans, leaving patients with Medicare Advantage plans high and dry (i.e., they have to pay for their medical expenses themselves). These plans are advertised as “better than Medicare,” but truly, in my experience, they are not.
Remember all of this is separate from Medicare “Part D” which is the prescription drug plan. That is completely a separate plan unfortunately. Neither Traditional Medicare nor Medigap plans cover prescription drugs – you have to purchase that as separate coverage, and make sure you check that all your current medications are covered under that plan, too, or you’ll be left with massive prescription drug prices!
So, that’s it in a nutshell. I hope you understand your Medicare health insurance a little bit better. Share with anyone who you think needs to learn more about their Medicare coverage. Have questions or comments? Drop a line below and I’ll try to get to them when I can.
[By the way, this is all what I’ve learned since completing my medical training and starting my own practice, with the help of my awesome biller and mother Astra Shraybman, my many private practice colleagues, as well as in consultation with internet research. If any of this is incorrect, please correct and educate me and my readers!]