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Piecing it Together: Making Your First Decisions as a Medicare Enrollee

If you’re approaching age 65, you’re probably anticipating having your healthcare needs provided for as a new Medicare enrollee. And while you can rely on Medicare for many aspects of care, there are complexities and coverage gaps you’ll need to understand and be prepared to work around. Initial enrollment in Medicare takes place over the three months prior to your birth month, during your birth month, and throughout the three months following your birthday, so you have some time to research coverage options and understand what your financial responsibilities will be.

While Medicare can be a daunting system to comprehend, with a dizzying list of details and conditions, taking it a step at a time and proceeding carefully will eliminate much of the anxiety. Still feeling lost? Start out by breaking it down into three separate parts, presented below by the Lifestyle Medicine Summit.

Step I: Original Medicare (Parts A and B) or a Medicare Advantage plan alternative?

If you elect to go with Original Medicare, which is coverage administered by the government, you’ll have coverage for most aspects of hospital care (Part A) and medical care (Part B). You can choose from a broad list of doctors, hospitals and other providers who accept Medicare. Be prepared for a monthly premium under Plan B, which is based on your income level (premium amount is $135.50 as of 2019). You’ll also be responsible for co-pays and deductibles, though these may be covered if you add supplemental coverage under Medigap.

If you go with Medicare Advantage (Part C), you’ll have coverage tantamount to Parts A and B, under a private plan with an insurance company approved by Medicare. As such, you’ll probably be restricted to providers within your plan’s network. Though you’ll be responsible for a monthly Advantage premium, you can expect lower out-of-pocket costs, often a deciding factor for seniors. Also, many Advantage plans offer hearing, vision and dental coverage, which aren’t generally available under original Medicare.

Step II: Determine if you want prescription coverage

This is a major factor for many seniors, particularly those undergoing treatment therapies or coping with chronic conditions, such as cardiovascular issues. If you need prescription drug coverage, you will select a Medicare Prescription Drug plan (Part D), which generally comes with a monthly premium and is run by a private Medicare-approved company.

If you have insurance coverage through some other source, like an employer, you’ll need to determine how it will impact your coverage under Part D. It is a bewildering process for new enrollees. If it leaves you confused and frustrated, make frequent use of this resource, which includes definitions of key terms and explains common Medicare terminology.

If you currently have some other form of prescription drug insurance, do some research to find out how it will function with Part D. (If you’re covered under a government-sponsored insurance plan such as Federal Employee or Veteran’s Benefits, it’ll probably be to your advantage to stay with your original coverage.)

Step 3: Decide if you want supplemental coverage

As previously mentioned, Original Medicare will not cover many aspects of healthcare, such as copayments, deductibles, coinsurance, dental, vision and hearing. If those gaps will leave you responsible for more than you can handle financially, consider acquiring supplemental coverage through Medigap. But be careful. If you join a Medigap plan and a Medicare drug plan offered by the same company, you may be required to make two premium payments. Get clarification from your insurance provider.

Those enrolled in a Medicare Advantage plan aren’t eligible for supplemental coverage (some Advantage plans have lower out-of-pocket costs than original Medicare). Always assess your needs and circumstances carefully so you understand exactly the various costs and what options can help you.

The Medicare system is flexible enough to provide sufficient options to fill in coverage gaps. Many seniors are concerned with controlling costs while still getting the coverage (care and prescription drug insurance) they need to remain healthy and active. Whatever plan, or combination of plans, you choose to enroll in, keep close tabs on any changes in your coverage, which often occurs. For example, certain Medicare Advantage plans are sometimes eliminated altogether, so stay well informed.

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