13 Things You Might Not Know About Your Medicare Plan but Should

By Adam Bean |

Medicare Open Enrollment is your chance to get wise about the ins and outs of your health coverage. Start with these important facts.

medicare facts

How well do you really know your Medicare Plan? If your answer is along the lines of “I’ve got a basic idea of what’s what, but I’m a little fuzzy on the details,” you’re not alone.

For starters, there are different ways to get Medicare. You can get Original Medicare, which includes hospital coverage (Part A) and medical or doctor coverage (Part B). Or you can get a Medicare Advantage Plan (Part C), which is a “bundled” way to get your Part A and Part B coverage.

Plus, if you have a Medicare Advantage Plan or Medicare Prescription Drug Plan (Part D), your coverage or costs—such as your premiums, deductibles, and copayments—can change from year to year. If your current plan is changing, you’ll receive an Annual Notice of Change (ANOC) document in September.

No matter how well you understand your coverage, Medicare Open Enrollment gives you a chance from October 15 to December 7 to get a handle on your health needs and care for the coming year. If you want, it’s your chance to join a Medicare Advantage Plan or switch to Original Medicare.

To get you started, we’ve put together a handy guide of incredibly important facts about Medicare that often go overlooked. For expert help, we talked to Sherry Biggs, a Medicare counselor for Pennsylvania’s State Health Insurance Assistance Program (SHIP). Here’s what you should know.

Fact #1: You Can Get Free One-on-One Help for Your Medicare Questions

All you have to do is call your state’s SHIP. These programs offer trained, unbiased representatives like Biggs who can walk you through your options during Open Enrollment.

They’ll help you understand the ins and outs of your coverage, benefits, premiums, deductibles, and more. They can even weigh in on the perennial question: Should I go with Original Medicare or a Medicare Advantage Plan?

“Take advantage of this service,” Biggs says. “We can set you straight when you have questions or worries. The language around Medicare can be hard to understand. We’ll help with that.”

Go to shiptacenter.org to find your local SHIP contact number.

Fact #2: Original Medicare Covers You Anywhere in the United States, but It Doesn’t Cover Everything

With Original Medicare, you can go to any doctor or hospital that is enrolled in Medicare, but you don’t get vision, hearing, or dental care. Many Medicare Advantage Plans, on the other hand, include these additional benefits.

The drawback? Medicare Advantage Plans often include local doctor and hospital networks. So if you’re a snowbird, for example, and spend several months away from home each year, you may have to pay out-of-network costs during those times.

“If someone is deciding between the two main coverage options, I ask if they see doctors a lot or use a lot of medical care in general,” Biggs says. “If the answer is yes, I may advise them to go with Original Medicare. That way they can see anyone with no network restrictions.”

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Fact #3: Original Medicare Doesn’t Cover Long-Term Care

Long-term care services (a.k.a. custodial care) are for people who are unable to perform basic activities of daily living, such as dressing, bathing, or preparing meals.

Other things that Original Medicare doesn’t cover:

  • Eye exams for prescribing glasses
  • Hearing aids and exams for fitting them
  • Most dental care, including dentures
  • Routine foot care
  • Acupuncture

If there’s a specific test, treatment, or service you might need, you can check what Medicare covers at medicare.gov/coverage.

Fact #4: Original Medicare Doesn’t Cover Prescription Drugs

You have two main options:

  • Enroll in a Medicare Prescription Drug Plan.
  • Sign up for a Medicare Advantage Plan that includes drug coverage.

If you have either one of those, Open Enrollment is your chance to make sure any medications you take regularly will continue to be covered in the coming year. If not, you may face higher out-of-pocket costs.

“One thing that can really hurt is a prescription drug you depend on is no longer covered by your plan,” Biggs says. “If that happens and you don’t realize it because you haven’t checked what’s covered the following year, you could be paying a lot more for that prescription.”

Fact #5: You Pay for Medicare—It’s Not Free!

Most people don’t pay a monthly premium for Part A, or hospital coverage.

However, you will likely pay a monthly premium for Part B, or medical coverage. This includes coverage for doctor services, outpatient care, durable medical equipment like canes or walkers, and so on. In 2020, the standard monthly premium for Part B is $144.60. This goes up as your income goes up.

Fact #6: When You Have Original Medicare, You Will Likely Be Responsible for Deductibles for Parts A and B

A deductible is an amount you must pay for health care before Original Medicare or a Medicare Plan begins to pay.

If you have Original Medicare, the deductible for Part A, or hospital coverage, in 2020 is $1,408 per benefit period. And for Part B, or medical coverage, the deductible is $198 per year.

Fact #7: If You Have Original Medicare, Medicare Supplement Insurance (Medigap) Can Help with Costs

Original Medicare may come with higher out-of-pocket costs. For example, after you meet your Part B deductible, you typically pay a 20 percent coinsurance for Part B services.

“When people opt for Original Medicare, I always make a point of telling them about Medigap,” Biggs says. “It literally will fill in the gaps in your coverage, including things like doctor copayments, coinsurance, and deductibles.”

You’ll pay a monthly premium to a private insurance company for a Medigap policy. This premium will be in addition to the monthly premium for Part B.

Fact #8: You Don’t Need to Choose a Primary Care Doctor If You Have Original Medicare

That said, a primary care doctor is a good thing to have! A primary care doctor is typically the first doctor you see when you have a health issue. This person knows you, your medical history, and your health concerns—and is often the best person to direct your care.

If you have a Medicare Advantage Plan, you may need to select a primary care doctor.

Fact #9: You Usually Don’t Need a Referral for a Specialist If You Have Original Medicare

With Original Medicare, as long as a specialist is enrolled in Medicare, you typically don’t need a referral from your primary care doctor first.

If you have a Medicare Advantage Plan, you may need a referral before you can see a specialist.

Fact #10: You Can Get a Free, Yearly “Wellness Visit” with Original Medicare

You can make this appointment by asking specifically for a yearly “wellness visit” with any doctor who is enrolled in Medicare. It’s a way for you and your doctor to develop or update a disease prevention plan that’s unique to your needs. Some providers may also perform a cognitive impairment assessment to look for signs of dementia or Alzheimer’s disease.

During this “wellness visit,” your doctor will:

  • Ask you to fill out a questionnaire called a “Health Risk Assessment.”
  • Review your medical history, current health, and medications with you.
  • Measure your height, weight, and blood pressure.
  • Recommend preventive screenings or shots you may need.

Important: With Original Medicare, a “wellness visit” isn’t a physical exam. Also, if your doctor performs additional tests or services during this visit, you may have additional costs to pay.

If you have a Medicare Advantage Plan or are considering one, Medicare Open Enrollment is a great time to check what’s covered by preventive care.

Fact #11: You Won’t Have to File a Claim Except in Very Rare Circumstances

Hallelujah, right? If you have Original Medicare, doctors and other providers are required to submit claims on your behalf. If you have a Medicare Advantage Plan, these private plans don’t have to file claims because Medicare pays them a set amount each month.

Fact #12: Many Medicare Plans Includes SilverSneakers

SilverSneakers is a health and fitness program designed for adults 65+ that’s included with many Medicare Plans. SilverSneakers members can go to thousands of gyms and other fitness locations across the nation, plus take fun exercise classes led by trained instructors. Oh, and they can access an on-demand video library of classes and workouts.

Learn more with this handy guide to SilverSneakers.

Fact #13: It’s Easy to Find Medicare Plans That Are Available to You

If your health care needs or costs have changed significantly since last year or your plan is no longer participating in Medicare in the coming year, you can see what what’s available to you during Open Enrollment.

Just go to medicare.gov/plan-compare. You can do a quick search for Medicare Advantage Plans, Medicare Prescription Drugs Plans, and Medigap policies using your zip code.

Ready to Get Started with SilverSneakers?

SilverSneakers is a health and fitness program designed for adults 65+ that’s included with many Medicare Plans. Learn more about SilverSneakers here.

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