Original Medicare, Advantage plans differ in several ways

Dear Toni: Thank you for teaching my husband, Charley, and me the value of finding the right Medicare option for him since he retired at age 70 a few months ago.

Charley wanted to pick a Medicare Advantage PPO plan because it had a $0 monthly premium and he could keep his doctors even though many of the offices were out of network. He found no difference between original Medicare with a supplement and a PPO plan except that the supplement had a larger monthly premium.

Last week, Charley received a life-changing diagnosis of terminal lung cancer. Had we chosen the PPO Advantage route, Charley and his doctor’s medical team would not be in control of his health care. Please let your readers know of our situation, because health care needs can change in a flash. — Janet, Little Rock, Arkansas

Dear Janet: Americans need to understand that the premium isn’t the only difference between original Medicare with a supplement and a Medicare Advantage PPO plan.

With original Medicare, there is not a network; you have the freedom to use any health care provider or facility that will bill Medicare. The Medicare supplement will pay for out-of-pocket costs not covered by Medicare Parts A and B.

Medicare Advantage PPO plans have low or no premiums with lower costs for in-network providers or facilities but higher out-of-pocket costs for out-of-network benefits.

In these changing times, many providers or facilities nationwide are out of network with a Medicare Advantage PPO plan, and you will pay more. (Visit medicare.gov to explore current Advantage plan out-of-pocket costs.)

Here are important coverage differences to be aware of:

Medicare supplement

1. Medicare supplements work directly with original Medicare. Medicare pays its share of the approved amount for medically necessary, covered health care costs. The supplement will pay its share of the medical claim for the health care provider or facility.

2. Medicare Part D prescription drug plans are not included in a Medicare supplement. It is important to have your stand-alone Part D drug plan begin the same month the supplement does.

The downside to a Medicare supplement is the monthly premium can increase each year.

Medicare Advantage PPO

1. To qualify for any Medicare Advantage plan, you must be enrolled in Medicare Parts A and B and must live in the service area six months of the year.

2. Medicare pays the Advantage plan that you are enrolled in a specific dollar amount every month for your medical care.

3. When you go to the doctor, hospital or pharmacist, you must only use your Medicare Advantage plan insurance card, not your Medicare card.

4. A Medicare Advantage plan must provide all of your Parts A and B benefits, and some Medicare Advantage Plans include Part D prescription drug coverage.

5. Extra benefits such as gym membership, dental and vision may be offered.

Toni King is an author and columnist on Medicare and health insurance issues. If you have a Medicare question, email info@tonisays.com or call 832-519-8664.