1 min read
20 Apr

You know how I love Medicare and truly believe that it is the greatest, transparent, universal medical coverage period... but you may be picking up on a little frustration with the words and definitions. 

MEDICARE advantage is NOT PART OF ORIGINAL MEDICARE. Making matters even more confusing is to refer to it as PART C when it is not PART of Original Medicare and if someone chooses it, the whole alphabet order changes. Don't get me started on "advantage" but if you do.... you may recall this little nugget including Five DISadvantages of Medicare Advantage

Medicare Advantage is private health insurance contracted with the government to manage care. It is not a part of original Medicare and you can not have it if you want to keep original Medicare. Medicare Advantage or Part C is an ALTERNATIVE to original Medicare. In most cases, they combine hospital, medical, and prescription drug coverage in one HMO or modified regional PPO. They are not only state specific, but county specific in where they are offered and sometimes where their networks exist. 

They have to cover what A and B would without any supplemental and they can do so with in the limited means of their own restricted managed coverage. What exactly does that mean? 

Let me tell you a story about Bobby, Suzie, and Annie. Bobby and Suzie have original Medicare and a Medigap. Bobby and Suzie both need XYZ surgery. XYZ surgery is defined and covered by Original Medicare and it is public information how much of XYZ surgery will be paid by Medicare. It is also public information how much Bobby and Suzie will need to pay, but since they have medigap coverage, each patient can be whole.  Medicare pays their part, their Medigap pays the rest. It is even public information if the facility accepts medicare assignment. Bobby and Suzie are entitled to the exact same care at the exact same cost and it is public information. 

Annie with her Medicare Advantage Plan needs XYZ surgery. Annie's plan could say, "we will cover XYZ surgery if: 

     Annie gets prior approval

     Annie gets a referral

     Annie gets to go through step therapy 

     Annie goes to a specific network approved facility

     Annie still has to pay the out of pocket left

Purchasing a Medicare Advantage plan means someone surrenders their right to Original Medicare. Medicare does not pay any claims if someone has a Medicare advantage plan. All coverage is not universal, which also means that the beneficiary cannot buy a Medigap to pay the parts their plan does not pay. 

None of us can be absolutely certain that we made the exact right choice for us until we pass... so please don't get confused or stressed about this special rite of passage when you get to choose coverage. Take a deep breath, consider your options, and consider using the free services of a professional who gets to know you personally. 

You worked your whole life for this. Protect your retirement.

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