A Quick Guide to Insurance Programs

4 min read

Navigating insurance programs and plans can be a tricky and confusing experience. Here is a quick comparison of Medicare and Medicare Advantage and how they match up to what long term care insurance offers.

Bottom Line

Original Medicare:
  • With Original Medicare you can receive treatment virtually anywhere but you have to pay additional premiums for different plans. If your premium covers services and supplies you do not have to request it. You are not covered for care outside of the U.S. unless you buy a Medigap policy
  • Cost:
    • Plans set the amounts they charge for premiums, deductibles, and services
    • You pay 20% of Medicare-approved amount after you have reached your deductible
Medicare Advantage: 
  • With Medicare Advantage you must stay within the network and may require referrals to see a specialist. Out of pocket costs vary with services and if you pay a premium or not but there is a limit for part A- and B-covered services that when met will not cost you anything for the rest of the year. Plans cover the same things as Original Medicare plus more services such as vision, hearing, and drug coverage. Medicare Advantage also covers more assisted living than Original Medicare to include daily assistance in the home, respite, and transportation.  Plans do not normally cover outside of the U.S. or emergency situations handled outside of the network.
  • Cost: 
    • Plans set the amounts they charge for premiums, deductibles, and services
    • You have to pay the Part B premium. In 2019, the standard Part B premium amount is $135.50 (or higher depending on your income). 
    • Out Of Pocket varies on what plan you pick, whether you stay in network, how much you pay for copay, and the type of health care you receive and how often. 

Original Medicare

Doctor and Hospital Choice

  • You can go to any doctor or hospital that takes Medicare, anywhere in the U.S.
  • In most cases you don’t need a referral to see a specialist.

Cost

  • For Part B-covered services, you usually pay 20% of the Medicare-approved amount after you meet your deductible.
  • You pay a premium (monthly payment) for Part B. If you choose to buy prescription drug coverage (Part D), you’ll pay that premium separately.
  • There’s no yearly limit on what you pay out-of-pocket unless you have supplemental coverage (like a Medigap policy).
  • You can get supplemental coverage(like a Medigap policy) to help pay your remaining out-of-pocket costs (like your 20% coinsurance). Or, you can use coverage from a former employer or union, or Medicaid.

Coverage

  • covers most medically necessary services and supplies in hospitals, doctors’ offices, and other health care settings
  • can join a separate Medicare Prescription Drug Plan (Part D) to get drug coverage.
  • In most cases, you don’t have to get a service or supply approved ahead of time for it to be covered.

Travel

  • Original Medicare generally doesn’t cover care outside the U.S. You may be able to buy a Medigap policy that covers care outside the U.S.

Medicare Advantage

Doctor and Hospital Choice

  • In most cases, you’ll need to use doctors who are in the plan’s network (for non-emergency or nonurgent care). Ask your doctors if they participate in any Medicare Advantage Plans.
  • You may need to get a referral to see a specialist.

Cost

  • Out-of-pocket costs vary—plans may have lower out-of-pocket costs for certain services. 
  • You may pay a premium for the plan in addition to a monthly premium for Part B. (Most include prescription drug coverage). Plans may have a $0 premium or may help pay all or part of your Part B premiums.
  • Plans have a yearly limit on what you pay out-of-pocket for Medicare Part A- and B-covered services. Once you reach your plan’s limit, you’ll pay nothing for Part A- and Part B-covered services for the rest of the year.
  • You can’t buy or use separate supplemental coverage.

Coverage

  • Plans must cover all of the medically necessary services that Original Medicare covers. Most plans may offer extra benefits that Original Medicare doesn’t cover–like vision, hearing, dental, and more. Plans can now cover more of these benefits than they have in the past.
  • Prescription drug coverage is included in most plans.
  • In some cases, you have to get a service or supply approved ahead of time for it to be covered by the plan.
  • Assisted Living coverage-
    • Assistance with everyday activities, such as cleaning, cooking, dressing and personal grooming
    • Adult day care services
    • Installation of grab bars, ramps or stair lifts
    • Respite care
    • Personal safety devices and medical alert systems
    • Transportation for medical and non-medical purposes
    • Massage therapy, acupuncture or other alternative therapies
    • Meal delivery for homebound seniors

Travel

  • Plans generally don’t cover care outside the U.S. Also, plans usually don’t cover non-emergency care you get outside of your plan’s network.

Long term care insurance

Long term care insurance is health insurance whose focus is to aid in chronic illness often attributed to aging. Services generally cover care in your home, nursing homes, assisted living facilities, and adult day care centers. This type of insurance is important for covering long term stays, on-going care, and in-home health that most insurances do not. 

Medicare only covers short nursing home stays or a limited amount of home health care. Assistance with daily living is not covered by Original Medicare though some aspects are covered by Medicare Advantage. 

Learning about benefits and what is available to you is an important step in ensuring care now and in the future. Here are some thoughts to consider when picking what benefit to use:

Keeping track of your benefits

  • The best way to avoid running through benefits is knowing what you have access to and comparing them to ensure you are using what you need and not what you don’t. 
    • This is especially important when you have multiple types of insurance
    • Example: having both Medicare Advantage and long term care insurance. Some services are covered by both so determining what resources you have and which are best to use now versus later. 
    • Long term care insurance has lifetime benefit limits so preserving benefits are important for consistent chronic care

Staying current

  • Insurance changes and new plans may offer different benefits
    • New plans may be a better fit for you and your situation at lower out of pocket costs
  • Premiums and out of pocket expenses:
    • Some insurance benefits are better to use before others and can help save money and prevent stress in the long run
    • With Original Medicare in particular you must opt into additional premiums such as Part D for drug coverage, determining the plans that fit you can reduce overall cost
  • What benefits do you need to stay healthy:
    • This can include as little as normal check-ups or as much as 24 hour care, you know your situation best and what you need to be comfortable and healthy
  • Getting help
    • Insurance is confusing and can be frustrating. Most insurances have specialists in plans and benefits that can help navigate the most practical way to 

In conclusion, determining what coverage you need for your specific situation and what insurance would provide you the best treatment at the most affordable cost is pivotal to staying healthy and independent for as long as possible.


Medicare Annual Election Period is Oct 15 – Dec 7. Shop 2021 

Contact information for Medicare Advantage plans

Aetna: 1-855-335-1407 (TTY: 711)7 days a week, 8 AM to 8 PM. 

Cigna: 1 (877) 268-9688 (TTY: 711), 8:00 am — 8:00 pm 7 days a week

Humana: 1-844-321-5843 TTY:711 5 AM – 8 PM, daily

United Health Care: 1-844-876-9189, TTY 711 Hours: 8 a.m. to 8 p.m., 7 days a week

AARP: 1-800-850-6807, (TTY 711), Hours: 8 a.m. – 8 p.m., 7 days a week

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