Medicare plans for persons with chronic health issues
As original Medicare doesn’t cover all medical services, supplies and prescription drugs, seniors with chronic health issues or pre-existing conditions will need alternative insurance in order to avoid high medical bills. You have two choices: Medicare advantage plans or Medigap (Medicare supplemental insurance).
Medicare Advantage Plans
Medicare advantage plans are popular among seniors with chronic health problems, as they must by law offer guaranteed acceptance for all persons with Medicare Part B and living in the plan’s service area, regardless of past or current health issues. This means, even if you were diagnosed with a heart disease, cancer, diabetes, Alzheimer or any other serious or chronic illness or disease such as ESRD, a Medicare advantage plan in your local area must accept you. You won’t have to go through a health check, or have to pay a higher premium because of pre-existing conditions.
Many seniors decide to opt for a Medicare advantage plan since these kind of insurance plans typically offer better coverage, extra benefits, and lesser out of pocket obligations. One of the major advantages of Medicare Advantage plans is that many policies include for example prescription drug benefits, wellness or fitness programs, hearing, dental and vision therapy, which the traditional Medicare program fails to cover. All Medicare Advantage plans must be approved by the Federal Government and need to offer services that are comparable or superior to those offered by traditional Medicare Part A and B (hospital and out-patient insurance).
There is an overwhelming variety of Medicare advantage plans offered nationwide, but which plans are available to you depends on your geographic area.
If you want to enroll in a Medicare advantage plan, you can do so when you first become eligible for Medicare, typically 6 months before and after your 65th birthday. After the initial enrollment you are allowed to join or switch to a different advantage plan only during the annual ‘Open Enrollment’ period, from October 15th through December 7th, for ‘regular’ advantage plans, and at any time once per year for Medicare advantage plans with ‘5 star ratings’. In specific cases you may qualify for ‘special enrollment’, e.g. when moving outside of your current plan’s service area or your plan is discontinued by the insurer.
Your costs for a Medicare Advantage policy will be your monthly Part B premium, which you need to keep paying, plus the monthly premium for the plan (if any – there are also zero premium Medicare advantage plans), the annual deductible you have to met before the plan will cover your medical costs, and any co-payments or co-insurance the plan charges. It will also depend on the type and amount of medical services you use. If you are in a HMO plan you will have to select your PCP (primary care physician) from the plan’s network, and ask for referrals in case you need a specialist or admittance to a hospital (excluding emergencies).
If you don’t like to be limited by a network of health care providers, but rather select your own medical professional, you may instead of a HMO plan opt for a PPO or PFFS plan. With Medicare advantage PPO you may opt to use providers from outside the plan’s network for a higher co-payment. A PFFS (private fee for service) plan is the most expensive alternative, but you are completely free to select your provider.
Medigap Plans
While Medicare advantage plans typically are a good affordable choice for most seniors with health problems, you may alternatively give Medicare supplement insurance (Medigap plans) a thought. Currently there are 10 standardized Medigap policies offered, and each has a different set of benefits and costs. An all-inclusive, but quite expensive option is the Medigap policy Plan F. Plan F is perfect if you require extensive medical care, as it will pay 100% of the cost for all services approved by Medicare.
You must add Medicare supplemental insurance when you first become eligible for Medicare in order to have guaranteed acceptance. If you miss your initial enrollment, you will most likely have to go through medical underwriting to join a plan at a later time, which means the insurer will consider your health and may decide to deny coverage, or insure you with an increased monthly premium.
To find a plan in your area, you can use the Medicare plan finder at Medicare.gov. For detailed information about a specific Medicare plan, you may call the insurer directly and request a ‘Summary of Benefits’ to be mailed to you. You may also contact your State Health Insurance Assistance Program (SHIP) for help.
Conclusion:
Which alternative, Medicare HMO, PPO, PFFS or Medigap, is best for you if you have current or past chronic health problems depends on your individual case. All options cover only Medicare approved services. A Medigap policy is generally a more expensive but comprehensive alternative, and you cannot loose coverage, as long as you pay your premium. With a Medicare advantage plan, you will usually have additional benefits (such as prescription drug coverage, which is not included in Medigap), but you are limited in your provider choice. Also, as the government contracts with private insurance companies for Medicare advantage each year, a plan might be discontinued at the end of a year, which means you must switch to a different policy.
