Many gaps in original Medicare Part A and Part B can leave you with unexpected expenses. These include deductibles and co-pays, which may be new to you if you’ve moved from employer health insurance. Other gaps in original Medicare coverage include prescription drug costs and medical services, including dental, vision, and hearing. When you add premium costs to these out-of-pocket costs, Original Medicare alone can become quite costly for many people.
What Gaps Are There in Original Medicare?
Original Medicare, also known as Parts A and B, covers hospital stays and medical services. It does not cover prescription drugs, dental care, and vision care. Medicare Advantage is a health plan that works with Original Medicare to give you all the benefits of both programs in one place.
Medicare Part A (hospital insurance) covers most hospital stays but doesn’t cover everything. You’ll pay for your room and board directly through the hospital or facility you’re admitted to and potentially more.
Out-of-Pocket Costs for Part A
Your deductible for Part A is $1,556 per benefit period in 2022. There will be co-payments after meeting your deductible. These co-payments are due for long-term stays depending on what type of setting your stay is in. For hospital stays from 61 days to 90 days, there is a $389 per day copayment. If your stay is in a skilled nursing facility, the copay is $194.50 from days 21 through 100. For hospital stays longer than 90 days, the copay goes up to $778 per day until your lifetime reserve days are used up, at which point you’ll pay 100% of the cost. Additionally, after 100 days in a nursing care facility, you will be responsible for 100% of the cost.
Out-of-Pocket Costs for Part B
As Part A has a deductible, so does Part B – $233 for 2022. This amount only has to be met once per year, then Medicare Part B will pay 80% of eligible Part B services, including doctor appointments, physical therapy, outpatient surgeries, and more. You will then pay 20% – the portion not paid by Medicare. If your provider is allowed to charge a 15% excess charge, you will then be responsible for that also.
Gaps in Medicare Coverage
Medicare Advantage does not provide all the benefits that traditional Medicare does. It is meant to supplement traditional Medicare coverage — not replace it. If you have a gap in your Medicare coverage, you may have to pay for some services out of pocket. For example, if you go into the hospital and need surgery, traditional Medicare will cover 80% of the cost, while your Medicare Advantage plan will cover 20%. If your plan doesn’t cover 100%, you may have to pay the remaining 20% yourself.
What Is Medicare Advantage?
Medicare Advantage (Part C) is one of several types of Medicare health care coverage plans. In contrast to original Medicare (Part A and Part B), which is federally funded but administered by private insurers, the federal government administers Medicare Advantage plans directly through its own provider networks and benefits packages.
Medicare Advantage plans are sometimes referred to as Part C plans because they fall under section C of the Social Security Act — where Part A and Part B are also listed.
How Do Medicare Advantage Plans Work?
Medicare Advantage plans are a type of Medicare health plan, but they’re not the same as traditional Medicare. With a Medicare Advantage plan, you get medical coverage through a private insurer. Medicare Advantage plans are a type of Medicare health plan, but they’re not the same as traditional Medicare. With a Medicare Advantage plan, you get medical coverage through a private insurer.
Medicare Advantage HMO Plans
Medicare Advantage HMO plans include health maintenance organization (HMO) services and other benefits such as prescription drug coverage, vision, and dental care. These plans require you to choose a primary care physician (PCP) who coordinates your care with any specialists you need.
Medicare Advantage PPO Plans
Medicare Advantage PPO plans offer more flexibility than HMOs because they allow you to choose any doctor or provider who accepts Medicare. You’ll also have more freedom over where you receive treatment since there’s no network of doctors available through these plans.
When Can You Enroll in a Medicare Advantage Plan?
You can enroll or initiate a change in a Medicare Advantage plan between October 15 and December 7 each year — unless you qualify for an extension based on hardship or disability.
Initial coverage has a seven-month window for application – 3 months before and after the month you turn 65 years old, and the month you turn 65. There are exceptions to enrolling in Medicare early, but most people enter at 65.
How To Enroll in a Medicare Advantage Plan?
To enroll, you must:
Have Original Medicare Parts A and B with no late penalties or premium tax charges;
Be eligible for both Part A and Part B;
Be enrolled in a stand-alone prescription drug plan (Part D) if needed, or have an end-stage renal disease (ESRD) waiver or ESRD HRA that covers the cost of drugs; and
Not be in a hospital or skilled nursing facility (SNF).
