The Medicare Maze

A health care worker holding a business card that says "MEDICARE"

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The Medicare program is the answer to your prayers, an opportunity to sit back and relax and let the federal government take care of all your medical and pharmaceutical needs, at a cost far less than what you’ve been paying for most of your life. Once you reach the age of 65, you’ll never have to make another health care decision.

Well, not exactly.

While it is true that your health care premiums probably will be much more affordable once you are eligible for Medicare, without professional help, you still might get lost in the maze of options that confront you every year. Should you go with original Medicare and add a supplemental plan that will cover the difference between your health care costs and the amount Medicare reimburses to doctors and hospitals? Or would you be better off with a Medicare Advantage plan offered by private insurance companies? How do you choose the drug plan that’s right for you? And how will the COVID-19 pandemic and the resulting emergence of telehealth affect the way you receive and pay for medical care?

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You’ll have to make the bulk of those decisions during Medicare’s annual enrollment period, which opened Oct. 15. Until Dec. 7, you’ll be able to make unlimited changes to your health care options. You can jettison your Medicare Advantage plan and opt for original Medicare or change your Part D drug plan. From the first of the year until March 31, you can swap one Medicare Advantage plan for another.

Confused yet?

Have you figured out whether you should choose original Medicare with a supplemental plan from a private insurance company that picks up most of your out-of-pocket health care costs? If you do, you’ll then have to choose from among eight options, each offering different levels of coverage. Or maybe you should sign up for a Medicare Advantage plan that is probably more affordable and might offer extras that pay for dental, vision and hearing services and even gym memberships. Keep in mind that with a Medicare Advantage plan, you’ll be responsible for co-pays and, if you want to keep seeing your specialists, you’ll have to make sure they are in the plan’s network.

Which is the better option?

“That’s the advantage of using a broker,” explained Nicole Stewart, a licensed agent with HealthMarkets Insurance Agency in Charleston. “There are literally hundreds of options. It’s overwhelming. Many people don’t know where to start. Our services are free, and we do all the legwork. What we do would probably take the average person three months.”

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Can Stewart definitively answer the question of whether the Medicare Advantage route is more advantageous than the original Medicare/supplemental option? Not really.

“It depends. Everyone’s situation is different,” she pointed out. “I wouldn’t say one is better. They are different. They function differently.”

Stewart cited three major issues should help determine the best option for Medicare beneficiaries who choose a Medicare Advantage plan: the prices offered by various companies for drugs the beneficiaries are taking; any co-pays that would be charged to see a specialist; and the co-pays for inpatient hospitalization services.

She went on to say that the only major change in the Medicare program in South Carolina this year from last is that the Medical University of South Carolina is now in many more Medicare Advantage networks than in the past, adding that some plans have reduced the deductibles for certain drugs. For most plans, she said, the annual out-of-pocket maximum for beneficiaries has increased from $6,700 to $7,550. She pointed out that the COVID-19 pandemic hasn’t changed the health insurance situation much.

“Telehealth has been in these plans, but it was never a frontrunner for people because they wanted to see their doctors. Now telehealth has been pushed to the forefront.”

She added that all insurance carriers are covering the cost of COVID-19 testing, though some of them are not necessarily paying for the cost of treatment.

“Treatment might or might not be free. It depends on the carrier,” she said.

In the end, the amount you pay for your medical care might depend on whether you try to figure out Medicare on your own or seek professional help.

“We look at this stuff all day, every day. We’re familiar with it. More importantly, we have the technology that allows us to enter certain information and come up with the top three or four options. The average person doesn’t have access to that type of technology,” she concluded.

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