Not All Medicare Is Created Equally
How to Evaluate Which Medicare Part is Right
Medicare is the federal program funded primarily from payroll taxes, that provides health insurance for people 65 and older or people between ages 18 and 65, that have been approved for Social Security disability benefits.
Here are details about Medicare and ways you can evaluate the right fit for yourself or a loved one:
What are the Different Parts of Medicare and What do They Cover
Medicare is comprised of Parts A through D.
Parts A and B are considered “traditional” Medicare, and the annual deductibles and co-payments arising under Parts A and B are the financial responsibility of the Medicare beneficiary, unless they purchase a Medicare Supplement Plan (also known as “Medi-Gap” plans),
Part A covers inpatient hospital services, up to 100 days of skilled nursing and skilled rehabilitation services, some home health services, specialty rehabilitation hospital care, inpatient mental health services and hospice.
Part B covers outpatient services, physician services, laboratory, diagnostic and x-ray services, wellness/prevention services, home health services, palliative care services, and Durable Medical Equipment (DME).
Medicare Part C is the Medicare Advantage program, which consist of Medicare HMOs, that cover the same services as Parts A and B, but at a lower cost and with no need to purchase a separate Medicare Supplemental Plan.
Medicare Part D is the Medicare Prescription drug program, that is administered by hundreds of private companies, such as Aetna, AARP, SilverScript, and many more, that provide prescription drug coverage for a monthly premium (in most plans) and cost-sharing for prescription drugs.
Understanding Which Medicare Part is Right for You or a Loved One
Part A or B (Traditional Plans)
If someone becomes ill and develops an ongoing need for medical care, a Traditional Plan may be best.
Medicare Advantage Plans offer comprehensive services, at a cost that is more economical than traditional Medicare plans, if a Medicare beneficiary’s physicians and other preferred health care providers are in the Plan’s network.
However, if a chronic condition develops that requires hospitalization and rehab care, Medicare Advantage Plans can become problematic because they scrutinize utilization of services much more stringently than traditional Medicare (Plans A & B). Most importantly, they have networks of providers from whom Medicare Advantage plan participants must obtain their care*.
* Example: If a Medicare Advantage Plan member lives in a nursing home and after a hospital stay needs Medicare covered physical therapy, they must go to a facility (that provides Medicare rehab services) within their Medicare Advantage Plan’s network.
If the patient goes back to the nursing home where they were living, but it is not “in network”, the Medicare Advantage Plan will not pay for rehab services.
Similarly, if the patient goes to a facility in their Plan’s network, but it is not the facility in which they live, they or their family will likely need to pay a “bed hold” fee to ensure the patient can return to their room at the facility they have been living in, or risk losing their room.