The Complete Guide

A lot of seniors we meet with really are confused about what Medigap and Advantage plans cover and how they differ in benefits and what is covered or not covered in each plan.

Seniors choosing a Medicare Advantage plan must realize they are giving up Medicare as their primary insurance.

The Advantage plan takes over for Medicare and makes all the rules regarding your health care and sets forth cost sharing, such as copays for doctor and specialist visits, impatient hospital care which can usually cost a couple of hundred dollars each day you are hospitalized, X-rays, lab services, outpatient procedures, ER visits, radiology etc.

When choosing an Advantage plan you would obviously want to sit down with a BGA Insurance agent because there are an abundance of plans to choose from and they vary widely regarding monthly premiums, deductibles, cost sharing and network providers. When I say network providers, you want to make sure whatever Advantage plan you settle on, all your doctors accept the plan you choose.

Each Annual Enrollment Period from October 15th to December 7th these plans change as far as costs so you want to make sure you contact your BGA agent to make sure you are prepared for the upcoming new year.

Let’s outline what is covered in these plans and how they can change from year to year.

Each company that sells Advantage plans have a few plan selections to choose from varying in pricing and covered providers.

For example:
Usually you pay a monthly premium to keep the plan you choose in force throughout the year. Sometimes when a new plan hits the market they have no monthly premium for a year or two. In a few cases as we have seen this year some plans may have a deductible.

That means you reach a certain limit out of pocket before the plan even starts paying benefits.

For example, if you purchase a plan that has a $1000 yearly deductible that would be the amount you would have to pay out of pocket before the plan starts paying benefits. Sometimes routine doctor or specialist visits are exempt from that deductible.

The other thing that is usually standard on Advantage plans are an Out of Pocket Maximums. That is the sum of money you could pay out of pocket for cost sharing. Usually on HMO plans that number is $6700 yearly and if you reach that number the rest of the year the plan would pay 100% of the remaining cost share for that year until your anniversary date.

Most HMOs require referrals for specialist visits. That means you would need a referral from your primary care physician before you can see a specialist for a specific condition. If you purchase a PPO Advantage plan they do not require referrals needed to see a specialist.

Another condition that you and your doctor need to take into consideration concerning Advantage plans is that if your doctor suggests you need an MRI or any other specialized test to further treatment, your doctor needs to get it approved with your Advantage plan so the benefit is paid for.

The one problem I find with Advantage plans is that they only cover 80% of the cost for cancer treatments such as chemotherapy and radiation therapy, the other 20% is the responsibility of the insured.

If you purchase an Advantage plan, contact your BGA agent regarding a cancer, heart attack and stroke supplement plan to pay for that 20% gap.

Call (855) 494-0097 for help with your plan if you live in New Jersey, PA, or Delaware.

The plans are great and very affordable.

The usual cost sharing benefits that may require a copay are doctor visits, specialist visits, emergency room visits, routine chiropractic services and outpatient surgery. Although hospital inpatient care is a copay most plans charge you the specific copay each day up to a certain amount of days. For example if you are hospitalized as an inpatient you could be charged a copay days 1-6 which could be a couple of hundred a day, but the copays do vary from company to company and plan to plan.

Some Advantage plans offer different kinds of preventative dental, vision, and hearing care for a small monthly added cost.

There is cost sharing involved with regards to cleanings, x-rays, eye exams, eyewear and hearing aids etc.

Another nice benefit you may offered with purchasing an Advantage plan is a fitness program for example Silver Sneakers. If you join a participating health club and use it for a certain amount of days throughout the year, the plan will pay your membership. This is another example of Advantage plans being about preventative care.

Most Advantage plans have drug plans built into the plan, meaning you don’t need to purchase any additional prescription coverage.

Of course, they have tiers and you pay a certain copay for a prescription depending on which tier that script falls in.

The model for it usually looks like this:

Deductible/no deductible

Preferred retail cost sharing (preferred generic/generic/preferred brand/non-preferred brand/coinsurance specialty drug)

Standard retail cost sharing (preferred generic/generic/preferred brand/non-preferred brand/coinsurance specialty drug)

Initial coverage limit – A maximum of $3700 in total drug cost.

Coverage gap – The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs. Once you and your plan have spent $3,700 on covered drugs, you’re in the coverage gap. This amount may change each year.

Also, people with Medicare who get Extra Help paying Part D costs won’t enter the coverage gap.

Catastrophic – Once you’ve spent $4,950 out-of-pocket, you’re out of the coverage gap. Once you get out of the coverage gap (Medicare prescription drug coverage), you automatically get “catastrophic coverage.” It assures you only pay a small coinsurance amount or copayment for covered drugs for the rest of the year.

Most Advantage plans will offer a mail order benefit so you can purchase a 90 day supply.

Other benefits that usually require cost sharing that you should know about are:

Urgent care – Ambulance – Rehabilitation services – Mental health – Podiatry – Skilled nursing facility – Durable medical equipment – Prosthetic devices – Wellness programs – Part B specialty drugs – Radiology services – Cat scans – MRI’s – Surgery

Medigap Plans

Also known as Medicare supplement plans is where Medicare A & Medicare B is your primary health insurance and you then purchase a Medigap plan to cover the gap Medicare doesn’t pay for. Basically your A & B covers about 80% of hospitalizations, ER visits, doctors and everything else “medically necessary”.

For example, if you suffer a stroke and you’re hospitalized for 10 days, your Medicare A&B will cover about 80% of the cost and depending on which Medigap plan you purchase it should cover all or mostly all the 20% gap.

Something else to think about when purchasing your Medicare insurance. Unlike Advantage plans where your doctor has to get approval to treat you for certain tests outlined earlier, under Medicare if your doctor says you need the treatment, it’s usually covered as long as your doctor codes your treatment correctly when submitting billing to Medicare.

Medicare usually abides by what your doctor says you need, which means you are in control of your own health care. In short what it usually comes down to regarding Medicare and your Medigap plan is if your medical doctor feels you need it, it is usually covered.

If you purchase a Medigap plan you have an open network throughout the United States, meaning if the doctor, specialist, or hospital accepts Medicare your Medigap plan is automatically accepted.

Medicare or your Medigap plan do not require referrals when needing to see a specialist. If you have an issue that you can only see a specialist for you just book the appointment and go, you do not need special permission or approval from your primary doctor or Medicare.

Benefits covered under Medicare and Medigap plans for example are:

Doctor visits – Specialist visits – Inpatient hospital care – ER visits – Outpatient procedures – Urgent care – Ambulance – Rehabilitation services – Mental health – Podiatry – Skilled nursing facility – Durable medical equipment – Part B specialty drugs – Radiology services – Cat scans – MRI’s – Cataracts – Glaucoma – Surgery – Blood – Hospice care

Earlier I talked about cancer treatments such as chemotherapy and radiation therapy and that Advantage plans only cover 80%. With Medicare as your primary, chemo and radiation therapy is covered and your supplement plan will pick up the other 20%.

Medicare or your Medigap plan does not have built in drug coverage like an Advantage plan has. If you decide on Medicare as your primary insurance you need to purchase a stand-alone prescription plan at an additional monthly premium.

A lot of folks we meet with are confused when trying to figure out which Part D plan is right for them so we take away that burden. As their BGA broker we will sift through all the various drug plans and find the one that will save them the most money each year.

Not only will we do it the first time but every year after that. It’s a free service BGA agents provide their clients because we really do enjoy when we can save them money each year.

The model for the Part D program is the same as I outlined earlier when talking about Advantage plans. In this case, you have a choice which plan to choose from which best fits your needs.

Monthly premium
Deductible/no deductible

Preferred retail cost sharing (preferred generic/generic/preferred brand/non-preferred brand/coinsurance specialty drug)
Standard retail cost sharing (preferred generic/generic/preferred brand/non-preferred brand/coinsurance specialty drug)

Initial coverage limit – A maximum of $3700 in total drug cost.

Coverage gap – The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs. Once you and your plan have spent $3,700 on covered drugs, you’re in the coverage gap. This amount may change each year.

Also, people with Medicare who get Extra Help paying Part D costs won’t enter the coverage gap.

Catastrophic – Once you’ve spent $4,950 out-of-pocket, you’re out of the coverage gap. Once you get out of the coverage gap (Medicare prescription drug coverage), you automatically get “catastrophic coverage.” It assures you only pay a small coinsurance amount or copayment for covered drugs for the rest of the year.

Medicare or your Medigap plan does not cover routine dental or routine eye exams. However if you have a medical condition such as cataracts or glaucoma it is covered under Medicare and your Medigap plan. BGA Insurance does offer additional coverage for dental, vision and hearing that is inexpensive and would be separate from your Medicare.

Do you have questions about Medicare Advantage or Medigap in 2019?

Contact us! Philadelphia, New Jersey, and Delaware agents can help.

Joe Bachmeier

(855) 494-0097

info@bgainsurance.net