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Medicare Basics
By Mathew Kirshner

Enrolling in Medicare for the first time can be a confusing and intimidating process. Simply determining Medicare eligibility can sometimes be difficult, as hours of research and Google searches can often result in only more confusion. It is for these reasons that many individuals choose to work with an independent broker to help sort through the noise. An individual is entitled to certain benefits upon in enrollment in Medicare Parts A and B. Part A covers most medically necessary hospital services, and Part B covers most medically necessary doctor visits. Part A is provided for any individual who paid Social Security taxes for at least ten years while a premium is required for Part B. Additionally, individuals can purchase a Part D plan to help with prescription drug costs through a private insurer.
Although Parts A, B, and D provide a good baseline of coverage, most individuals choose to purchase additional coverage from a private insurance company. Typically, this additional coverage takes the form of either a Medicare Advantage Plan or a Medigap plan, also known as a Medicare Supplement.

Medicare Advantage Plans and Medigap plans are structured very differently, so there is not one solution for everybody. The primary difference involves who pays. A Medicare Advantage Plan, for instance, replaces your red, white, and blue Medicare card. In this case, the Medicare Advantage Plan provides primary coverage. The beneficiary continues to pay their Part B premium, but carries their Medicare Advantage Plan card to the doctor, the pharmacy, and the hospital. Medicare Advantage Plans tend to have lower premiums but beneficiaries must stay within a network of doctors and hospitals and must satisfy various co-pays and coinsurance. Medicare Advantage Plans provide worldwide emergency coverage and contain annual maximum out of pocket dollar figures for the protection of the beneficiary.

On the other side of the spectrum is a Medigap or Medicare Supplement plan. With these plans, Medicare remains the primary care provider. Beneficiaries keep their red, white, and blue Medicare card, and purchase an additional plan to cover what Medicare does not. Finally, unlike a Medicare Advantage plan, Medigap plans do not contain prescription drug coverage. To avoid paying a penalty, beneficiaries must purchase a standalone Part D plan or have creditable coverage through an organization like the VA.

What makes a Medigap plan attractive to some people is the simplicity of it. Because Medicare is the primary provider, the beneficiary does not need to be concerned with staying within a network of doctors and hospitals. Depending on the Medigap plan selected, beneficiaries may be faced with minimal co-pays or coinsurances. Unlike a Medicare Advantage Plan, however, there is no coverage outside of the United States, even in the event of an emergency.
Finally, Medigap plans are medically underwritten, whereas Medicare Advantage plans are not. For individuals first enrolling in Medicare, however, Medigap plans are "guaranteed issue," meaning that beneficiaries can skip the medical questions associated with Medigap enrollment and cannot be denied.

Deciding between a Medicare Advantage Plan or a Medigap plan is ultimately up to the individual. Every situation is different, so a plan that makes sense for one person may be a bad fit for another. Working with a licensed agent is a good idea for a lot of people because agents are required to remain up-to-date in their product knowledge and certifications. Enrolling in Medicare can be intimidating and confusing but with a little bit of knowledge it does not have to be.

Our agency, Insurance Services of Zelienople, has been in business since 1980 and our independence has allowed us to maintain a loyal client base. We are certified to work with many companies in Western Pennsylvania so we are able to present our clients with insurance options that best suit their needs. Although the process can be confusing, having a little bit of knowledge can take away a lot of the anxiety and uncertainty associated with initial enrollment.

Matt Kirshner is a Senior Insurance Specialists at Insurance Services.  For additional information, call 412-461-4538.



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