Interpreting insurance benefits can be confusing at any age, but understanding healthcare options for those 65 and older can be even more difficult. Once most adults reach the age of 65 are entitled to Medicare coverage, or earlier if you qualify for certain disabilities. There are two options for Medicare health coverage: Original Medicare, most often paired with a supplement plan, or a Medicare Advantage Plan. Medicare Advantage plans provide 100% outpatient coverage, while Original Medicare only covers about 80% - which is why they are often paired with a supplemental plan to reach full coverage. One of the main differences between the plans is the cost structure: when you pay and the size of your payments.
Throughout the year on each plan, you may spend the same amount of money. With a Medicare Advantage Plan, you pay less monthly, but pay a copay when you see the doctor and a large copay when you go in the hospital. If you have Original Medicare and a supplement, you pay a monthly premium and a small yearly deductible at the beginning of the year, but all care is without copay or co-insurance.
Another key difference between the plans relates to in-network providers. With Original Medicare Plans, you are covered at any doctor or hospital in the United States that accepts Medicare. Most Medicare Advantage Plans have two coverage options: HMOs (Health Maintenance Organizations) and PPOs (Preferred Provider Organizations). On an HMO, the plan specifies a network of providers that are covered. A PPO also has a set network of providers, but you can still get partial coverage at many providers outside the network, at a cost.
Since Medicare Advantage Plans are offered by private companies, they have more freedom and motivation to include extra benefits; like vision, gym memberships and more. They also have the opportunity to work on a local level with local providers, to create plans that best suit the community’s needs. Each plan has its benefits, which is why it’s important to understand what your needs are, and choose a plan that best fits your lifestyle.
Dr. Jim Osborne is the Primary Care Medical Director for Triad HealthCare Network and internal medicine specialist in the Triad. He received a Bachelor of Science in zoology from North Carolina State University in 1978 and completed medical school at the University of North Carolina School of Medicine in 1983. Dr. Osborne completed his residency in Internal Medicine at the University of Iowa in 1986.