Decoding Medicare: Your Guide to Better Coverage for Caregivers

Are you a caregiver feeling a little overwhelmed by the complexities of Medicare options? Navigating the program can be tricky, but don’t worry, we’ve got you covered. Mass Care Link is here to help you decode Medicare and find the best coverage for you and your loved ones.

Did you know that while 94% of Medicare beneficiaries are satisfied with their quality of care, there’s still a chance of facing high out-of-pocket expenses? Let’s dive in and make sure you have all the information you need to make the best decision for your loved one’s health and your wallet.

What is Medicare?

What’s the difference between Medicare and Medicaid? Is MassHealth a form of Medicare?

It can be confusing. Medicaid is a federal and state program based on income. MassHealth is the state administrator of Medicaid. If you are caring for a loved one at home you may be eligible to receive assistance through MassHealth. 

Medicare is the federal social health insurance program for:

• People who are 65 or older
• Certain younger people with disabilities
• People with End-Stage Renal Disease

Types of Medicare Coverage

Medicare offers two main coverage options: Original Medicare and Medicare Advantage. Additionally, you can access three additional, or supplementary options.

Original Medicare

Includes Hospital (Part A) and Medical (Part B) insurance.

• If you want drug coverage, you can add a separate Drug plan (Part D).
• You can also add a Medicare Supplement Insurance (Medigap) policy to help pay your out-of-pocket costs.

Medicare drug plan (Part D): A Medicare-approved plan from a private company that helps cover your prescription drug costs.

Medigap policy: Extra insurance from a private company that helps pay your share of costs in Original Medicare.

• Policies are standardized, and the basic benefits in each are the same. 
• Most policies don’t include prescription drug coverage.

Medicare Advantage Plan (Part C):

A Medicare-approved plan from a private company that offers an alternative to Original Medicare (Part A & Part B) for your hospital and medical insurance.

•  Most plans include prescription drug coverage. 
• These “bundled” plans include Part A, Part B, and usually Part D.
• Most plans offer extra benefits—like vision, hearing, dental, and more.

Pros and Cons of Medicare Coverage Types

Original Medicare

Original Medicare, consisting of Parts A and B, offers several advantages. 

• Provides the flexibility to access healthcare services in any state with providers accepting Medicare, 
• Allows you to see specialists without the need for primary care provider approval.
• Offers transparent coverage and predictable costs, ensuring financial peace of mind. 
• Unlocks additional savings: Part A which often has no premiums if your loved one or their spouse paid Medicare taxes for at least a decade while working. 

However, there are downsides:

• Part B requires income-based premium payments, an annual deductible, and cost-sharing for outpatient services. 
• Routine dental, hearing, and vision coverage are not included and require separate private insurance.
• There are deductibles and copays for hospital stays. 
• You are obligated o pay Medigap and Part D premiums, even if your loved one doesn’t utilize these benefits. 

Quick take: Opting for Original Medicare with Medigap and Part D can be an excellent strategy, especially for those with preexisting conditions or concerns about their health declining, as it offers more certainty about out-of-pocket costs and access to a broader network of healthcare providers.

Medicare Advantage

If you’re considering Medicare Advantage, there are both pros and cons to weigh. On the positive side: 

• Often come with lower monthly premiums compared to Option 1, which can benefit caregivers on a budget. 
• Provide peace of mind by capping annual out-of-pocket expenses 
• May include coverage for prescription drugs, dental, and vision care

However, there are limitations, including:

• Restricted healthcare access to a network of local providers,
• Potential need for primary care physician referrals to see specialists
• Higher likelihood of coverage denial compared to Original Medicare

Quick Take: Medicare Advantage plans bundle together Medicare Parts A, B, and often D, along with additional services. Premiums typically average around $18 per month, with some plans offering premiums as low as $0. However, most costs are incurred through coinsurance and copays when using the coverage. 

The choice between Medicare Advantage and Original Medicare should hinge on individual health needs and preferences. If your loved one is generally healthy and expects to remain so, Medicare Advantage may be a good fit, but it’s crucial to ensure your preferred providers are in-network. The unpredictability of future health emphasizes the importance of making an informed decision based on their current circumstances and requirements.

Tips for Getting the Most Out of Your Medicare Coverage

To make the most of your loved one’s Medicare coverage, it’s important to stay informed and proactive.

• Take advantage of preventive services like screenings and vaccinations to catch any potential health issues early. 
• Carefully review their plan’s coverage and network to ensure preferred providers are included. 
• Don’t hesitate to ask questions and clarify any uncertainties with the insurance provider. 
• Regularly review their medications and consider switching to generic or more cost-effective alternatives when possible. 
• Stay on top of any changes to their plan’s coverage and compare options during the annual open enrollment period to ensure they’re still getting the best coverage for their needs. 

Remember, their health is worth investing time and effort into understanding their Medicare coverage. Still have questions on Medicaid and MassHealth? Check our Mass Care Link’s MassHealth FAQs. Are you currently caring for someone at home? Mass Care Link can help caregivers access the financial assistance they need. Contact Mass Care Link today to learn more.