■ Editor’s note: This week starts a regular series of health-related articles titled “Thinking About Health.” Funded by a grant from The Commonwealth Fund and distributed through the Nebraska Press Association member newspapers including The Imperial Republican, the goal of the Rural Health News Service is to provide area residents with unbiased health-related information, designed to help better understand the health issues facing our communities, state and nation.
By Trudy Lieberman
Rural Health News Service
Filling the gaps in Medicare coverage is not a one-size-fits-all proposition. Instead Medicare offers people a number of options to meet their healthcare needs.
And, those on Medicare have from now until Dec. 7 to assess the coverage they have and decide whether they should make changes for the coming year.
Each fall during open enrollment some 50 million Medicare beneficiaries get the chance to choose new coverage to plug the gaps in Medicare and review their prescription drug benefits.
Medicare doesn’t cover everything. There are deductibles for hospital and doctor services and a lot of coinsurance to pay for physician visits, outpatient hospital care and lab tests—20 percent of the bill to be exact. So most people buy insurance to cover those expenses.
In the last five years, the options for doing that have multiplied making the task of choosing a plan much harder. Joe Baker, who heads the Medicare Rights Center in New York City, says that about one quarter of beneficiaries don’t even know about open enrollment, and others are scared or confused by all the choices. What to do?
If you have a retiree plan from your employer, you probably want to keep it. Although rarer than they used to be, they do a great job of covering the gaps and usually offer very good drug coverage.
Next come the traditional Medigap policies, still the gold standard for most people. Designated by letters of the alphabet, each one offers somewhat different coverage.
The most popular plans, F and C, cover just about all the gaps. Seniors still must buy separate prescription drug coverage, but Medigaps allow you the freedom to choose your own doctor and there aren’t a bunch of rules about staying in a network of providers to get care.
In the last few years, private insurers have begun selling Medicare Advantage (MA) plans, which are managed care plans with lots of rules about which doctors you can use. They often include drug coverage and may offer extra benefits like gym memberships or some dental or vision coverage.
They may be cheaper than a Medigap policy, which makes them attractive. However, only about 12 percent of Nebraskans have bought these plans.
“Cheaper doesn’t mean better coverage,” Baker cautions.
When you choose a Medicare Advantage plan, you give up your traditional Medicare benefits, which are instead provided by the insurer (The federal government gives them money to do that). Even though benefits must be equivalent, in a technical sense, you may find accessing those benefits is another matter.
“All of the MA plans have their limitations,” says Bonnie Burns, a policy specialist with California Health Advocates, a Medicare advocacy group.
“Some are very structured; others are more generous. With a Medigap plan you just go to the doctor when you need to. With an MA plan you would need permission to go to the doctor,” she said.
Baker says people who are new to Medicare—those in their 60s—choose Medicare Advantage plans because they are relatively healthy and don’t think about the time when they won’t be. Then they get sick and find their MA plan doesn’t provide the coverage or let them see the doctors they need.
They can go back into traditional Medicare during a special window between Jan. 1 and Feb. 14, 2013, but buying a Medigap policy to go with it could be dicey because companies don’t want people with pre-existing conditions. The Obamacare law that lets people with pre-existing conditions buy insurance no matter how sick they are doesn’t apply here.
If you now have a Medigap policy with stand-alone drug coverage, as most Nebraskans do, the next few weeks to assess whether the drug benefits still work for you especially if your medicines have changed.
Is the plan making you try cheaper drugs first? Do those drugs work? Can you afford the copayments? Some are very high. Are all your medicines covered?
I have always thought choosing Medicare coverage comes down to your tolerance for risk. You can pay a higher premium each month for more freedom to choose your health care and have no surprises when you do get sick.
Or you can take a chance with an MA policy. Pay less up front and hope you have no large medical bills. But if you do, know that some things might not be covered, and you’ll have to pay out of pocket.
In a future column, I will talk about how changes to Medicare being discussed in Washington may affect your coverage and what you may pay for your benefits.
If you have topics you would like me to address in future columns, you can email me at