American Retired Seniors

Original Medicare or Medicare Private Health Plan, Do You Have the Right One

By Medicare Rights Center                                                 

Sept. 13, 2008 – Every year, between November 15 and March 31, everyone with Medicare can change how they receive their Medicare benefits – to Original Medicare or to one of the private health plans (also known as “Medicare Advantage” plans). It is a good time to review your current coverage and remind yourself of your coverage options.If you are unsatisfied with your current plan, you should consider making a switch during the enrollment season. And remember that private health plans can change their rules, provider networks and costs every year.

So even if you are happy with the coverage you have now, review how your plan will be changing to make sure it will still cover your health needs at a cost you can afford next year.

Most people who have Medicare stick with Original Medicare, the traditional fee-for-service program run by the federal government. People who have Original Medicare are covered to go to virtually any doctor, specialist or hospital in the country, without ever having to get special permission (prior authorization) or a referral.

You also have the choice to get your Medicare benefits from a Medicare private health plan. Medicare private health plans have contracts with the government and are paid a fixed amount to provide Medicare benefits.

They must cover at least the same inpatient (Part A) and outpatient (Part B) services covered by Original Medicare. However, they can offer that coverage with different rules, costs and restrictions. Some plans may offer additional benefits, like dental or vision care, that Medicare does not cover. Many also offer Medicare prescription drug coverage (Part D) as part of their benefits packages.

Private health plans often charge a premium in addition to the Medicare Part B premium. They also generally charge a fixed amount called a “copayment” whenever you receive a service. The most common types of Medicare private health plans are health maintenance organizations (HMO), preferred provider organizations (PPO), and private fee-for-service (PFFS) plans.

Whether or not you change your health coverage now, once the enrollment periods are over, you will be locked into your choice until the end of the calendar year. Because of this, it is very important to use this opportunity to review your options now. Here are some things to consider before you decide which option is best for you.

Before you sign up for a Medicare private health plan, make sure you will be able to see the doctors, specialists and hospitals that you prefer. Private health plans often have provider networks, and may restrict you to seeing in-network providers.

Some plans require that you get a referral from your primary care doctor before you can see a specialist. Your doctor may also have to follow certain rules, such as seeking the private health plan’s approval before prescribing a treatment or admitting you to the hospital. These limitations may make it difficult for you to get urgent care or care that you need when you travel outside your private health plan’s network.

Make sure you can afford a private health plan before you enroll in it. Some charge higher copays for certain types of care, such as cancer care. If a plan says it has an annual cap on how much you will have to pay out of pocket, ask if all services count toward the cap.

It is important that you understand the private health plan’s rules in advance, because you may have to pay up to the full cost for services when you do not follow the rules. Keep in mind that different types of plans have different rules (for example HMOs v. PPOs), but even plans of the same type (two HMOs) may not work exactly the same way. Always check with the plan you are interested in directly for exact coverage rules.

If you choose Original Medicare, it is best to also have supplemental coverage, which helps cover health care costs that Medicare does not cover. If you do not have coverage from an employer to supplement Original Medicare, you can buy a supplemental plan known as a Medigap plan.

You can also buy a stand-alone Medicare private drug plan (PDP) that works with Original Medicare to give you Medicare prescription drug coverage (Part D).

People with Medicare who have limited incomes may be eligible for Medicare Savings Programs that help with the out-of-pocket costs of Original Medicare, and Extra Help-a federal program that helps with the costs of Medicare prescription drug coverage.

To read more about Medicare private health plans, Medicare prescription drug coverage, supplemental coverage and programs that can help you pay for health care costs,  log on to Medicare Interactive Counselor at www.medicareinteractive.org.

Information provided by source:

Medicare Interactive is a resource provided by the Medicare Rights Center, the largest independent source of health care information and assistance in the United States for people with Medicare.

Investigate and research Medicare Supplemental Plans, not all Plans are the same.  Humana Health Insurance heavily markets its Plan however the actual HMO medical service they provide is significantly lower than many other plans.  Remember the bottom line for HMOs is to make a profit, they do this at the expense of the health of many American Seniors. 

Filed under: Medicare and Health Insurance