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Which Medicare insurance plan is the right one for me? Is it a Medicare Supplement or Medicare Advantage Plan? Our advisors will take the time to do the research to find a plan that meets your needs.
Medicare Advantage (Part C) adopts a different approach. Medicare approves these private insurance plans to provide all your Part A and Part B benefits. Most Medicare Advantage plans also include Part D prescription drug coverage built right in. They often bundle additional benefits that Original Medicare doesn’t cover – things like vision, dental, hearing aids, and wellness programs.
But here’s the trade-off: Medicare Advantage plans often restrict their networks of doctors and hospitals. Medicare Advantage plans often restrict their networks of doctors and hospitals. You might need prior authorizations for certain services or referrals to see specialists. The cost structure differs too – you might pay lower monthly premiums but incur higher copays when using services.
The key difference our clients need to understand: Medicare Advantage plans have out-of-pocket maximums that cap your yearly spending, while Original Medicare has no such limit (unless you add a Medigap plan).
We help our clients understand which option makes the most sense based on their health needs, budget, and preferred doctors.
Medigap policies help fill the gaps in Original Medicare, such as deductibles, coinsurance, and copayments that you would otherwise have to pay out of pocket. Private insurance companies offer these plans, but the government regulates them, so a Plan G from one company provides the same coverage as a Plan G from another company.
Here’s what’s important: You must have Original Medicare (Parts A & B) to buy a Medigap policy. You cannot use Medigap if you have a Medicare Advantage plan – it’s one or the other.
Timing is crucial with Medigap: A special 6-month period, known as your Medigap Open Enrollment Period, begins when you initially enroll in Medicare Part B (typically at age 65). During this time, insurance companies cannot deny you coverage or charge you more because of health issues. This is your best chance to get the coverage you want at the best price.
If you miss this window, things become complicated. Outside of this period, insurance companies can require you to answer health questions and may deny you coverage if you have certain medical conditions.
Our experienced advisors help clients navigate this timing to ensure they don’t miss their opportunity for guaranteed coverage.
HMO (Health Maintenance Organization) plans are the most restrictive but often the least expensive. You’ll typically need to choose a primary care doctor and get referrals to see specialists. You must use doctors and hospitals in the plan’s network, except for emergencies.
PPO (Preferred Provider Organization) plans give you more flexibility. You can see out-of-network providers, though you’ll pay more. You usually don’t need referrals to see specialists, making them popular with our clients who want more freedom in their healthcare choices.
Special Needs Plans (SNPs) cater to people with specific chronic conditions, such as diabetes or heart disease, or those eligible for both Medicare and Medicaid. These plans tailor their benefits, provider networks, and drug formularies to meet the specific needs of their members.
Private Fee-for-Service plans allow you to see any Medicare-approved provider who accepts the plan’s payment terms, but these are less common.
Each plan type has different rules for cost-sharing, provider networks, and accessing care. The key is matching the plan type to your health needs and preferences. Our advisors help you evaluate which type makes the most sense for your situation.
Every Medicare Advantage plan must have an annual limit on how much you’ll spend out-of-pocket for Part A and Part B services. Once you reach that limit, the plan pays 100% of covered services for the rest of the year.
Why this matters: Without this protection, a serious illness or injury could result in thousands of dollars in medical bills. Original Medicare by itself has no such limit – your costs could theoretically continue to climb all year.
But here’s what to watch for: These maximums can be quite high – sometimes $8,000 or more per year. Also, some plans only apply the maximum to in-network services, so out-of-network care might not count toward your limit.
Different plans have very different maximums. We’ve seen plans with limits as low as $3,000 and others as high as $8,850 (the maximum allowed by law). This is one of the key factors our advisors help clients compare when choosing between plans.
Remember: prescription drugs often have their own separate out-of-pocket maximum, so your total potential costs could be higher than just the medical maximum.
If you have employer or retiree coverage: The coordination depends on several factors, including the size of your employer. Sometimes your employer plan pays first, sometimes Medicare does. Enrolling in Medicare might affect your existing coverage, so it’s crucial to understand the rules before making changes.
If you qualify for both Medicare and Medicaid (dual eligible): You have special options, including Medicare-Medicaid Plans and Special Needs Plans designed specifically for people in your situation. These plans often provide additional benefits and lower costs.
Medicare Savings Programs: These state-run programs help people with limited income pay for Medicare premiums, deductibles, and coinsurance. Many people don’t realize they qualify for this help.
Important warning: Don’t assume you can just add Medicare to your existing coverage without consequences. Sometimes enrolling in Medicare can affect your spouse’s coverage or your access to Health Savings Accounts.
Our experienced advisors work with clients to understand how Medicare will coordinate with their existing coverage and help them make informed decisions that protect all their benefits.
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I had the pleasure of working with Kayla Cox as my benefits advisor, and I can't recommend her highly enough! She was incredibly patient and knowledgeable, guiding us through the entire process of enrolling in Medicare and selecting a supplemental plan that perfectly fit our needs. Kayla made a complex process feel seamless and manageable, and her support was invaluable. Thank you, Kayla, for your exceptional service!
Mike was very thorough and knowledgeable showing us choices and coverage of options for Medicare supplementals and part D drug plans. He made the process very easy. Highly recommended!
I think Kayla is absolutely fantastic. From the moment you walk in, you know you’re going to be taken care of. Medicare and supplemental plans can be very hard to understand, but Kayla explains everything clearly and patiently. She truly takes the time to make sure you feel comfortable, informed, and confident in your decisions. I highly recommend working with her.
I have worked with Kathy Shoemaker for over 15 years and she has always made my medicare choices easy. She is extremely knowledgable and proficient in her job. Always has my best interest in mind. I don't hesitate to commend my friends to her for help. She is a wonderful person and I consider her a friend.
Micheal was so helpful in getting the best benefits for me! He went over everything and answered all my questions. He’s very knowledgeable, kind and caring. I’ll refer everyone that needs help or has questions regarding their Medicare, coverage. He saved me money and got me better coverage. I’m so happy he spoke to our group and I was able to meet with him! He’s truth Blessings. Elizabeth
