Your Medicare plan may affect the healthcare you get. What to know at enrollment deadline

The deadline to enroll in Medicare is almost here.

The public insurance is for people 65 and older although some younger people who have certain disabilities or conditions may also be eligible.

There’s two main ways to get coverage, either through original Medicare or Medicare Advantage. Open enrollment period ends Dec. 7.

We asked readers to share their questions about Medicare and Medicare Advantage. And then we asked the Centers for Medicare and Medicaid Services, a federal agency, to help answer them.

Here’s is a Q & A on what to know:

What’s the difference between original Medicare and Medicare Advantage plans?

Original Medicare:

Traditional Medicare, also known as original Medicare, covers inpatient care in hospitals, skilled nursing facilities care, hospice care and home health care, according to the Centers for Medicare and Medicaid Services. It also covers services from doctors, outpatient care, “durable medical equipment” such as wheelchairs and walkers and preventive services such as screenings, an annual wellness visit and certain vaccines, including the COVID-19 vaccine.

Medicare has four parts and traditional Medicare is what’s considered to be Part A (hospital insurance) and Part B (Medicare insurance), according to the agency. Part C is Medicare Advantage plans and Part D is drug coverage.

“People with Medicare can go to any doctor or hospital, anywhere in the United States that accepts Medicare. If they have traditional Medicare, they can also buy Medicare Supplement Insurance (Medigap) policy from a private insurance company,” the federal agency told the Miami Herald in an email. “Traditional Medicare pays for much, but not all, of the cost for covered healthcare services and supplies. A Medigap policy can help pay some of the remaining healthcare costs, such as copayments, coinsurance, and deductibles.”

The federal agency recommends people who get traditional Medicare should also enroll in Part D, which provides prescription drug coverage. This way you’ll get hospital, medical and prescription drug benefits.

Medicare Advantage:

Medicare Advantage plans typically “bundles” original Medicare — so hospital insurance and Medicare insurance — with Medicare prescription drug coverage into “one health insurance plan,” according to the agency.

“If someone selects Medicare Advantage coverage, they join a plan offered by Medicare-approved private companies. Each plan can have different rules for how someone gets services — like referrals to see a specialist,” the agency said. “All plans must cover emergency and urgent care, as well as all medically necessary services covered by traditional Medicare.

However, while most Medicare Advantage plans include hospital, medical and prescription drug coverage, you can’t go to any doctor you want. Medicare Advantage plans usually require you to use doctors and other providers who are in a plan’s network and service area. “Costs for monthly premiums and services vary depending on which plan you join. Some plans may offer some extra benefits that traditional Medicare doesn’t cover — like vision, hearing, and dental services,” the agency said.

-This question was inspired by Miami Herald reader Kaisraj Panchoo. The next question is also by Panchoo.

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What documents do you need to apply for Medicare?

If you want to enroll in Medicare Part A (hospital insurance) and Part B (Medicare insurance), you’ll need to contact the Social Security Administration. This is the information the Centers for Medicare and Medicaid Services says you should have available:

▪ Your Social Security number

▪ Where you were born (city, state and country)

▪ The start and end dates of any group health plans in which you’re enrolled. If you’ve enrolled for a 65+ group health plan ahead of time, make sure to have the start and end date.

▪ A valid email address and your existing Medicare number, though the federal agency notes this information is only needed for people who want to enroll in Part B (medical insurance.)

Should I stay in my spouse’s private insurance or enroll in Medicare?

This is a personal decision. You’ll have to review the benefits and costs of staying in your spouse’s health insurance versus enrolling in Medicare or a Medicare Advantage plan. You should also consider whether your wife or husband works for a small business or a large company, according to AARP.

The good news: “No matter what the size of the company, you won’t have to pay a late enrollment penalty if you have health coverage through your spouse’s current employer and you enroll in Medicare within eight months of losing that coverage,” AARP explained in a blog post. “But if you get your coverage through a small business, you may face gaps that you’ll have to pay for yourself if you don’t sign up for Medicare at age 65.”

Some people also opt to stay in the employer health insurance and enroll in Medicare Part A once they’re 65 because they don’t have to pay premiums if they or their spouse have paid Medicare taxes for at least 40 quarters, which is about 10 years of work, according to AARP. If you decide to do this, and the company has more than 20 employees, the employer’s insurance will pay medical bills first, with Medicare being the secondary payer. If the company has fewer then 20 employees, Medicare will pay the bills first and the employer insurance will be the secondary payer.

This question was inspired by Miami Herald reader Audley C Hamilton. The next question is also by Hamilton.

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Can I keep my doctors if I enroll in Medicare?

Most likely you can keep the doctors you see.

People with traditional Medicare can go to any doctor, hospital, facility or other healthcare provider that accepts Medicare. The good news is that many providers accept Medicare. You also don’t need to choose a primary care doctor, and in most cases, you also don’t need a referral to see a specialist, according to the Centers for Medicare and Medicaid Services.

For people with Medicare Advantage plans, take note: You can only use doctors and other providers who are in your plan’s network. Keep in mind that “costs for monthly premiums and services vary depending on which plan you join” and “some plans may offer some extra benefits that traditional Medicare doesn’t cover — like vision, hearing, and dental services,” according to the federal agency.

If you want to make sure your doctors accept Medicare and Medicare Advantage plans, call and ask. The federal government also has an online Medicare provider database you can use to find and compare providers near you. The website lets you filter by location, provider type (doctors, hospitals, nursing homes) and you can also search for your doctor by name.

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For people who have Medicare A and B, how much does it usually cost to add Plan D for drugs?

Medicare Part D (drug coverage) is an optional and recommended Medicare benefit people can enroll in to help cover the cost of prescription drugs.

“In Medicare Part D, prescription drug plans may charge a monthly premium. Premiums vary by plan. People enrolled in a Part D plan may pay this premium in addition to the Part B premium,” according to the Centers for Medicare and Medicaid Services. “If someone is in a Medicare Advantage plan with prescription drug coverage, the monthly premium may include an amount for drug coverage.”

It’s recommended that people with traditional Medicare enroll in Part D to get drug coverage. Most Medicare Advantage plans include prescription drug coverage, but it’s important to make sure your plan of choice has it.

What’s the cost difference?

Monthly premiums for stand-alone Part D plans range from less than $1 to nearly $200 per month in 2024, though those with higher incomes ($103,000 per individual, $206,000 per couple) will also have to pay an income-related premium surcharge, which can range from $12.90 to $81.00 per month depending on your income, according to KFF, a nonprofit that specializes in health policy research.

Medicare Advantage plans, on the other hand, usually only charge one monthly premium for hospital, medical and prescription drug coverage, according to AARP. The average monthly premium for people with Medicare Advantage is $18.50 in 2024, plus the standard Part B premium of $174.70, according to AARP.

This question was inspired by Miami Herald reader Maxine Kornitzer.

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If you already have Medicare, is it worth switching to a Medicare Advantage plan?

This depends on what you need. Here are some of the differences listed:

▪ Doctors and hospital choice:

Original Medicare lets you visit any doctor or hospital in the U.S. that accepts Medicare, and you usually don’t need a referral to see a specialist. Medicare Advantage requires you to use doctors and other providers who are in the plan’s network and service area. You may also need to get a referral to see a specialist.

▪ Coverage:

Original Medicare covers most medically necessary services and supplies though it doesn’t cover some benefits like eye exams, most dental care and routine exams. Medicare Advantage plans, on the other hand, are required to cover all medically necessary services, just like traditional Medicare, but depending on the plan, may also offer extra benefits including vision, hearing and dental services.

Similarly, people with original Medicare would need to enroll in Part D to get prescription drug coverage. Most Medicare Advantage plans already include drug coverage, and won’t let you join a separate Medicare drug plan. And while you don’t need approval for original Medicare to cover your services or supplies, you might need approval from your Medicare Advantage plan.

▪ Cost:

People with original Medicare usually pay 20% of the Medicare-approved amount for Part B (medical) services after meeting their deductible. Medicare Advantage out-of-pocket costs will vary for certain services depending on the plan.

Original Medicare doesn’t have a yearly limit on out-of-pocket costs, unless you have supplemental coverage. Medicare Advantage plans do have a limit for Part A (hospital) and Part B (medical) services. This means that once you hit the plan limits, you don’t have to worry about paying out-of-pocket anymore for hospital and medical services for the rest of the year. For reference, the out-of-pocket limits for Medicare Advantage plans were $8,300 for in-network services and $12,450 for in-network and out-of-network services combined, according to KFF.

Original Medicare also lets you buy Medigap, a supplemental insurance, to pay for remaining out-of-pocket costs; Medicare Advantage does not.

To learn more about the differences and to compare plans, visit https://www.medicare.gov/basics/get-started-with-medicare/get-more-coverage/your-coverage-options/compare-original-medicare-medicare-advantage

This question was inspired by Miami Herald reader Michael Martelli.

How to enroll in Medicare, Medicare Advantage? Who can I contact for help?

People who apply for retirement or disability benefits from Social Security or the Railroad Retirement Board and start getting benefits at least four months before turning 65 are automatically enrolled in Original Medicare (Part A and B) once you turn 65, according to the Centers for Medicare and Medicaid Services. (People who live in Puerto Rico or outside the U.S. would still need to sign up for Part B.)

Everyone else has to enroll in Medicare through Social Security, either at your local Social Security office, calling Social Security at 800-772-1213, or using the online portal, which is the easiest and fastest way to sign up.

If you have questions about Medicare, call 800-MEDICARE (800-633-4227). TTY users can call 877-486-2048.

You can also contact the Florida Department of Elder Affairs SHINE Program, which provides free Medicare and health insurance counseling and information to Medicare beneficiaries, their families and caregivers. Call 800-96-ELDER or email information@elderaffairs.org. For TTY, call 800-955-8770.

This question was inspired by Miami Herald reader Brian Mealey.