Question: I have a Medicare Advantage Plan (HMO). My friend has Medicare and a Medigap Plan. Who has the better insurance?

Answer: Like most questions related to Medicare coverage, my answer will have to be “That Depends!” You both have good Insurance! Most Medicare products are good, some better for some situations, while others are better for other situations. So, let me explain some of the differences.

Once you turn 65, and you have Medicare A & B, you can insure two different ways: one path is through Medicare Advantage Plans. This path usually includes prescription drug coverage. The other path is through a Medigap Plan. This plan usually requires purchasing an additional Prescription Drug Plan. For this discussion I am NOT going to talk about Part D (prescription Drugs).

The Medicare Advantage Plan path requires that you have Medicare A & B, and that your insurance will be handled by a private health insurance company. It also means that once you sign up for the Medicare Advantage Plan, your Medicare A & B go inactive – however the Medicare Advantage Plans MUST provide coverage for all the benefits that Original Medicare would cover but can set up its own cost structure for you to pay. You will always pay for your Part B premium, but your insurance coverage will fall under the Medicare Advantage Plan.

Most Medicare Advantage Plans fall into two categories: Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). These plans have had relatively low monthly premiums and usually require co-pays as you access healthcare. So you will have to pay for part of the cost for most of the care you receive. The Medicare Advantage Plans will pay for a hospital stay, but it can restrict which hospitals you are allowed to go to and how much you pay for that hospital stay.

These Medicare Advantage Plans also often provide benefits that Original Medicare may not provide. Some provide money towards paying for glasses, dental benefits, or even a fitness benefit. These are NOT Medicare Benefits, as these are benefits that are above and beyond what the companies are required to provide. These additional benefits are a big part of the appeal for these plans.

For the person who rarely goes to the doctor and would enjoy having some extra benefits like a Health Club membership, these could be perfect plans. Remember that these extra benefits like dental should NOT be the reason you chose the product. Consider, if your providers aren’t in the network and your medication isn’t covered, having a health club membership or dental benefits will not be as cost effective as a plan that covers your doctors and medications.

With Medicare Supplemental Plans (Medigaps), you have an entirely different insurance package, especially because you KEEP Medicare Part A & B (“Original Medicare.”) Original Medicare is national, so it will be accepted wherever you go for care with no restrictions and no referrals to access your health care. With this path, you add a Medigap Policy, purchased from a private health insurance company to your original Medicare. The policies come in many different types we call “lettered plans” – each are named A, B, C, D, F, G, K, L, M, or N. Each letter is a different variety of coverage. Medicare is the primary payer and the Medigap Plans are the secondary payer.

When Medicare approves a treatment, it usually only pays part of the medical claim, so there is some amount that is left. The balance may be a deductible, or a percentage. The Medigaps fill in those amounts. These Medigap Plans are universally accepted regardless of the insurance company. In New York State, the premiums are based on your county of residence. In other states there could be criteria like smoking, or age that impacts your premium cost. If there are two people with Medigap G, they insure with different companies, they have different premiums but the same overall coverage. One could pay $200 per month more than someone else in the same county, simply by going with a different company. Is there a reason to pay the higher amount? Do you get “better coverage”? NO: a Plan G is always a Plan G, and there is NO difference in the Plan Coverage with different companies. I usually suggest going with the lowest cost Medigap Plan carrier if possible. However, it is your money to spend how you want, you can choose where you get your insurance.

The Medicare + Medicare Supplement Plans allow you to go anywhere, anytime to access healthcare. You can see you will pay more in premiums, but your access to healthcare is anywhere, anytime, and the cost to you for that healthcare is usually very low. For an individual looking at lots of traveling in the coming year, this insurance package may offer them the flexibility they desire. For those individuals looking at serious medical concerns like cancer treatment, this insurance solution is very cost effective, because the higher premiums are outweighed by lower cost to receive treatment.

The insurance answer is not the same for everyone! That is the biggest point I try to make week after week with these articles. It isn’t right or wrong for everyone. It is what works for you now, knowing that in the coming months and years you can make a different choice based on what works for you then.

How you complete your Medicare picture needs to be based on what you need and the priorities you have. Your insurance will only be right for you.

Janell Sluga is a Geriatric Care Manager helping seniors in our community access services and insurance. To reach her, please email editorial@post-journal.com.