Deciphering the Complexities of Medicare Insurance Options – By Guest Blogger Stephanie Goldstein, BSW, LBSW

Posted on


Years ago, once you turned 65, you applied and were granted your Medicare benefit. Some opted to pursue Medigap (supplemental) insurance to help cover the cost of items and services that Medicare didn’t cover. Medigap is optional and because of the monthly premiums many older adults went without supplemental coverage.

With the evolution of healthcare reform and people living longer, many things have changed. Medicare remains the primary insurance for those over 65, but with attempts to keep costs down, Medicare Advantage Plans have emerged. These plans are also known as “Managed Medicare Plans.”

What’s the difference? What are the pros and cons? How do you know what is best? If you are a caregiver, how do you know how to help and advise? Many questions surround these plans and the process of understanding and applying for these programs as well as traditional Medicare.

Medicare Advantage Plans (MAPs) follow Medicare guidelines. Let’s be clear: these plans are not in conjunction with Medicare–they are in place of Medicare– which is the most common misconception. These plans are designed to be more attractive than traditional Medicare. For example, MAPs tend to have lower premiums and lower copays. They also cover what traditional Medicare does not– i.e. hearing aids and dental. So what’s the downside?

As with any insurance, there are restrictions and limitations. The goal of MAPs is to keep costs down. One way they do this is to restrict options and offer less flexibility with providers and services covered. Not all physicians participate with all of these plans. Additionally, they might have lower premiums and upfront costs as well as lower prescription drug copays; however, some necessary services are not covered. There is a higher copay for a hospital stay or skilled nursing center than with traditional Medicare. Certain drugs may not be covered either. Another aspect to consider is that Medicare is a federal program accepted in all states—this is an issue if you need medical care while traveling. Many MAPs are state- specific or do not contract with certain providers if more extended care is needed. These plans also require authorization for services whereas Medicare does not have that stipulation.

Again, how do you know what to do? The main point is to understand what the MAP does/does not offer and/or cover. Before you sign up for any plan, make sure your physicians accept the insurance. You can log onto www.Medicare.gov and compare plans based on your medications to see what the copay and coverage would translate to. You can also use it to simply compare plans in general. Know yourself and your situation-Do you travel out of state often? If so, take that into consideration.

steph-headshotStephanie Goldstein, BSW, LBSW, has been in healthcare for over 15 years. Her experience includes both working directly with patients and as a manager in mental health and long term care. She is passionate about educating patients and families on options while promoting self-determination for those with complex physical, cognitive or mental health diagnoses. A frequent guest lecturer for Johns Hopkins University’s Certificate on Aging program, she also loves teaching professionals about best practices in working with older generations.

Leave a Reply