medicare or a map?

The first Medicare program was created and administered by the federal government in 1965. Original Medicare consists of hospital services (Part A) and doctor visits (Part B). This basic coverage has premiums and deductibles and does not cover prescriptions or medical services received outside of the U.S., except in very limited circumstances. Adding an optional Part D plan to cover prescription costs and a Medigap plan (also known as supplemental coverage) to cover the cost gaps in Original Medicare is strongly recommended. Without these additions, prescriptions and other out-of-pocket medical expenses can become costly.

For those turning 65, sign up for Medicare during your Initial Enrollment Period (IEP): the seven-month window surrounding your 65th birthday. If you miss your IEP, you can enroll between January 1 and March 31, but coverage will not begin until July 1. During Open Enrollment, from October 15 to December 7, you can change health plans or pick up (or change) a Part D plan or a Medigap plan. You can also change plans during Special Enrollment Periods (SEPs), resulting from special circumstances, such as losing coverage from a job or when a Medicare Advantage Plan (MAP) is no longer available in an area. To ensure you don’t have any gaps in coverage, do not discontinue a plan until receiving the paperwork guaranteeing your new coverage has started.

The best time to buy a Medigap plan is within six months of enrolling in Medicare. During that time, you can buy a plan in your state even if you have pre-existing conditions.

Dealing with multi-part Medicare plans can be tricky. A MAP is beneficial because the insured only has to contract with one insurance company to get the same coverage they would through Medicare Parts A, B and D. The cost is usually the same and negotiating denials and gaining approvals for care is direct and easy.

Private insurance companies sell MAPs that are approved by Medicare. Enrollees pay the Medicare premium and the MAP may charge an extra premium that is comparable to supplementing Medicare Parts A and B. Every month, Medicare pays the private insurance company a fixed amount, and that company covers your costs, governed by the same standards as Medicare. But, the enrollee is no longer covered by Original Medicare and must adhere to referral and pre-approval requirements set by the MAP.

Most MAPs offer extra coverage such as vision and hearing and dental.

Whether enrolling in Medicare or in a MAP, make sure that desired doctors accept your coverage if going to a particular doctor is important to you. Keep in mind that doctors do not have to make or renew contracts with insurance companies or Medicare, so having to change health providers is always a possibility when staying compliant with a plan’s coverage.

Any plan comes with pros and cons, depending on coverage needs. Knowing the right plan to enroll in requires self-assessment and researching which plan will provide the most comprehensive coverage.

Adria Goldman Gross

Adria Goldman Gross

Adria Goldman Gross, FIPC, is author of "Solved! Curing Your Medical Insurance Problems: Advice from MedWise Insurance Advocacy," and CEO of Medwise Insurance Advocacy. She helps people navigate the complexities of medical coverage contracts and helps those struggling to pay their medical bills.Call 845-238-2532 or visit
Adria Goldman Gross

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