Frank Bures: Deciphering options for Medicare

Frank Bures: Deciphering options for Medicare

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’Tis the season to think about the holidays (which seem to start right after Labor Day), and, if you’re a member of that susceptible target age group, get dunned and harassed by Medicare Advantage medical insurance companies.

On our caller ID we’ve had four or five unsolicited calls from the medical insurance giant company Humana, which I purposely haven’t answered. In the mail, we have received a few missives from United Health pedaling its version via AARP.

Even if you aren’t yet ready for that, but are still doing battle with your own private medical insurance company, which it seems everyone is forced to do, this is relevant information, because someday you just may be old enough (if Medicare is still available and not taken away to pay for a tax cut).

The primary difference between Medicare, which came into being in 1965 as a blessing for so many older folks on tiny, limited incomes, and Medicare Advantage Plans (MAPs) is that the U.S. government manages Medicare, and MAPs are sold by private insurers to substitute for Medicare, under some rules set by the government. The private company contracts with Medicare to sell the plans. It is paid a monthly fee by Medicare for each patient enrolled.

Medicare is an alphabet soup. It has four basic parts: A, B, C and D. Part A pays on hospital care. Part B pays on doctor visits, procedures and equipment. Part C is Medicare Advantage. Part D pays on prescription drugs. Original Medicare A and B has patients pay some deductible amounts before it starts to pay, but these are not very high. After the deductibles, it pays all but 20%, for which you are responsible. There is no upper limit to that, which can ring up some pretty hefty totals if you are really sick and utilizing docs and hospitals.

Enter Medicare supplement insurance sold by private companies, or called Medigap insurance, or MAPs to protect against the sky’s-the-limit expenses and bankruptcy. Half or more of all personal bankruptcies today are from medical costs. What a sad social commentary.

To make something not simple even worse the Medigap plans allowed are labeled A, B, C, D, F, G, K, L, M and N. (What happened to the letters in between?) These are supposedly standardized, except if you live in Massachusetts, Minnesota or Wisconsin, where they are standardized differently. Aren’t we special? The coverages differ by letter, as well as the premium amounts.

MAPs are similar to private insurance plans. Each has different benefits and rules. For 2020, there are more than 3,100 plans offered around the country. Most of them have restrictions on which “providers” you can see, and require referrals to specialists, unlike Original Medicare. To get truly boggled, you can look up the different plans on the’s plan finder. Too much for this small column. MAPs were originally created in 1997 as Medicare+Choice with the name change in 2003 to Advantage.

MAPs automatically cover essential Part A and B benefits, except hospice services. The plans’ benefits and fees vary widely. They tend to cover everything with a co-pay, which is set by the company, not according to any government rule. Their main selling attraction is that they often cover (at least in part) eye and hearing exams and prescription drugs, so there is no need to buy Part D drug coverage separately as with Medigap plans.

Key differences are Medigap plans may have higher premiums but no co-pays, while MAPs have lower premiums, even zero or nothing, but higher co-pays. If you are healthier in general, MAPs may have an “advantage” monetarily. But they generally limit you to doctors and facilities within their Health Maintenance Organization or Preferred Provider Organization. They often operate only in a region. If you are a “snowbird” living in more than one state per year, Original Medicare plus Medigap may be better coverage than a MAP.

The best thing to do is to try to find a live human you can trust who is selling more than one plan, so he or she isn’t biased toward only one company, which they will always say is the best one. It was a lot easier when you could make a house call on your bike, and get a pie or a bag of fresh vegetables for the visit. There, now didn’t I make it simple to understand?


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