The first decision you need to make when you join Medicare is whether to go through Original Medicare or not. This is a critical decision because Original Medicare does not cover prescription drugs, dental, vision, and other non-major medical services. If you opt for Original Medicare, you can visit any doctor for your health care. You can also choose your primary care physician. And prior authorization is not required.
How Original Medicare works
When you’re eligible for Medicare, you’ll need to choose which type of coverage you want. There are two main types of plans: Original Medicare and Medicare Advantage. Each has its own limitations and benefits, and you’ll need to do some research before choosing one. Fortunately, Original Medicare has few restrictions.
The Medicare system has four parts. Medicare Part A and Part B are what make up Original Medicare.
Medicare Part A covers most hospital costs. Medicare Part B covers most routine medical services, such as doctor visits and lab tests. Part A and B don’t pay for every service, but it pays a large percentage of these expenses. However, this coverage isn’t unlimited, so you will have to pay a deductible before Medicare begins paying its share.
Original Medicare does not cover outpatient prescriptions. For this Medicare beneficiaries can add a Part D plan. These plans cover prescription drugs. In most cases, Medicare Advantage plans (Part C) provide Part D coverage as well.
Can I get my health care from any doctor?
When you’re eligible for Medicare, you can see any doctor you’d like, as long as they accept Medicare. Original Medicare, which consists of Part A and Part B, usually covers most medically necessary services. However, you’ll need to pay out of pocket for some services, like routine exams and prescriptions. You may want to consider getting Medigap coverage to cover these costs.
Original Medicare does not cover medical care outside the U.S. However, Medicare Supplement Insurance may cover emergency or urgently needed services outside the country. You may want to check with your health plan about your specific coverage before visiting a doctor or hospital outside the United States.
You can also enroll in Medicare Advantage, which bundles Part A and Part B coverage into one plan. Medicare Advantage plans have more benefits than Original Medicare and may have a network of doctors and hospitals. In addition, some plans have different rules about when and where you can get a certain service. Medicare Advantage plans may cover urgent care and emergency care, but will typically charge more for this service.
Are prescriptions covered by Original Medicare?
In most cases, Original Medicare does not cover prescription drugs. To get coverage for these medications, you can purchase a stand-alone prescription drug plan (also called Medicare Part D). A stand-alone Part D plan complements the Original Medicare coverage and offers a way to protect yourself from expensive drug costs. Additionally, you can purchase a Medicare Supplement plan that will cover out-of-pocket costs.
Generally, Medicare Part D plans cover most outpatient prescription medications. They can be purchased separately or as part of a Medicare Advantage Plan. It is best to enroll in a plan when you first become eligible. Delays can lead to coverage gaps and enrollment penalties. Part D plans also have a formulary that you must adhere to. Occasionally, you will need to request an exception for a certain medication.
Do I need to choose a primary care doctor?
If you have Medicare, you are not required to choose a primary care doctor with your original plan. However, if you wish to change your physician, you must notify your health insurance provider. Some insurers even allow you to change your primary care doctor online.
While you don’t have to choose a primary care physician, you may want to schedule a wellness visit at your new provider. Medicare plans cover preventive services like wellness visits, such as yearly wellness exams. The visit provides an opportunity to get to know your doctor and evaluate the facility. You can also look for things such as scheduling convenience, staff friendliness, and the overall environment. Although Original Medicare doesn’t require you to choose a primary care physician, it is a good idea to choose one that works well for you.
Primary care doctors can refer you to specialists if needed. Although they are not trained to treat complex health issues, they are useful in addressing common health goals and coordinating preventive care.
Do I need a referral to see a specialist?
Most Medicare beneficiaries don’t need a referral to see a specialist. However, some private insurance plans require a referral from a primary care doctor. This may restrict the scope of coverage for certain conditions. For example, you can’t see a podiatrist for diabetic foot ulcers unless your primary care physician orders it.
You should check with your primary care provider for referral guidelines. Some specialists do not see patients without a referral, and others require a co-pay or payment upfront. In these cases, it’s best to call ahead to make sure the specialist has your relevant medical records.
You can also check with your insurance provider. Many plans cover the cost of a referral to a specialist. In general, EPOs and PPOs do not require a referral, but HMOs and Point of Service plans do. It’s always best to check with your health plan representative to see what is covered for your condition. You can also choose to see a specialist who accepts other insurance.
Do I need Medicare Supplement Insurance?
Medicare Supplement Insurance is a kind of health insurance plan that helps you pay for expenses not covered by your original Medicare plan. These policies are offered by various insurance companies. You can choose the one that best suits your budget and medical needs. There are 12 standard plans available for this coverage. Some of the plans (Plan C and Plan F) are limited to people who became eligible for Medicare before the end of 2020.
Medigap policies pay most of the out-of-pocket expenses that Medicare doesn’t. Some plans may even pay for Medicare deductibles (except the Part B deductible). Medigap policies have varying premiums, depending on the provider. Some companies calculate premiums based on your current age, while others use your issue age or attained age.
The first step in purchasing a Medicare supplement insurance plan is to enroll in Medicare Parts A and B. This is required by law. Part B covers hospice care. Part C, or Medicare Advantage, is run by private insurance companies contracted with the government. While Medicare Part C plans must provide the same benefits as Medicare Part A and B, many of them offer added benefits and features to help beneficiaries with specific healthcare needs.
Original Medicare out-of-pocket costs
Original Medicare does not have any limits on out-of-pocket costs. However, most enrollees still maintain supplemental health insurance coverage. More than half get this through Medicaid or employer-sponsored plans. These supplemental health plans, which are commonly referred to as Medigap plans, pay a portion of the out-of-pocket costs.
Original Medicare out-of-pocket costs vary based on which part you are using (A or B). Generally speaking, out-of-pocket costs can be as low as 20 percent of the total cost of health care services. Usually, the costs are covered by coinsurance or deductibles. However, with Original Medicare, there is no maximum out-of-pocket limit.
If Original Medicare out-of-pocket costs concern you, you may want to consider Medicare Supplement Insurance. These policies cover your Original Medicare out-of-pocket costs and are a good option for people who want more coverage. Medicare Advantage plans offer lower premiums than Medigap policies, and most have additional benefits, including Medicare Part D prescription drug coverage, but out-of-pocket costs may be higher.
Original Medicare vs. Medicare Advantage
When deciding which type of Medicare plan to select, it’s important to understand what each one offers. While Original Medicare includes coverage for Parts A and B, Parts C and D provide additional benefits. These benefits can include prescription drug coverage, vision and dental care, and hearing aids. Medicare Advantage plans also have a network of healthcare providers. Original Medicare may not cover dental care, vision, or hearing care, so you should make sure that Medicare Advantage covers those services.
Original Medicare also comes with monthly premiums and coinsurance for certain services. However, Medicare Advantage plans let you choose the coinsurance percentages you pay for each service. Some plans charge higher coinsurance than others, requiring you to pay more out of pocket for different services. Original Medicare has no out-of-pocket limit, but Medicare Advantage plans may have a maximum amount that you must pay. You may also need to pay a yearly deductible and select a provider network. If you need to visit a doctor who does not participate in your plan’s network, Medicare Advantage plans may charge higher coinsurance.
The primary difference between Original Medicare Advantage is the provider network. Original Medicare allows you to see any doctor in the United States who accepts Medicare, while Medicare Advantage plans limit you to doctors in a network. Most insurance companies have a website where you can find out which doctors are in their network. You can also call the insurance company or doctor directly.