Who knew deciding which Medicare plan to pick could be so challenging? To the unfamiliar, it may seem a bit like translating a foreign language! And, to make matters even more complicated, it’s not always clear which plans, particularly within Medicare Advantage, allow for home medical visits from physicians. Remember, paying a premium doesn’t necessarily guarantee more options or better care for you or your family. We recommend analyzing the various plans carefully with a trusted advisor before making a decision. 

With the enrollment deadline for Medicare Advantage just around the corner, we’re providing you with a general overview so you can better understand your options. In this post, we’ll break down the plans, comparing those of Medicare and Medicare Advantage so you can get a better understanding of which plan may be the best for you and know which ones cover home-based physician care. 

How Traditional Medicare Works in Brief

Medicare is health insurance created specifically for people 65 years-old and over as well as people with disabilities who otherwise wouldn’t be covered by other insurances or would otherwise receive inadequate coverage at a costly rate.

Medicare is split into two main groups: original Medicare, Part A and B, which is federally run and Medicare Advantage Plans, Part C, which are provided by private health insurance companies.  

Part A covers inpatient hospital bills, medical care in a nursing facility, home-based care, such as skilled nursing and hospice care. Part A does not cover in-home medical care

Part B covers doctor visits, preventative care, lab work, medical equipment, ambulance transportation, therapy, mental health services, outpatient care and home health services. Part B also covers home medical visits from physicians. Part B entails more costs on your end in comparison to Part A, but may be significantly lower than what you have to contribute to be covered by an employer sponsored plan. Your employer sponsored plan may also have more limitations such as required pre-authorizations and a narrower physician network than those who accept Medicare. You are able to opt out of Part B if your employer sponsored plan is more beneficial. However, if you enroll later, you may be subjected to paying  a higher monthly premium. 

Part C, which incorporates services otherwise covered by Parts A and B in Traditional Medicare  is the Medicare Advantage Plans offered by private insurance companies. Most Medicare Advantage Plans also cover additional services such as, vision, hearing, and dental. In the next section, we’ll dive deeper into Medicare Advantage Plans.

Part D, which is through a private insurer, covers the cost of some prescription drugs.The plan you pick under Part D should be chosen carefully. Make sure it covers your prescriptions and whether it covers the generic or brand names you use.

Most Utilized Types of Medicare Advantage Plans

The plans offered to you may vary depending on where you live. Here is a brief description of the more common plans that can be purchased .

Health Maintenance Organization (HMO) covers doctors, other health care providers, and hospitals in the plan’s network. Unless you have an emergency or need urgent care out of the area, you’re not covered for services from outside the network. Specialists also need to be referred by your primary doctor. Many plans of this type require prior authorizations for many treatments and procedures and various types of care. It’s important to know that if you use services or providers outside the network, you will not be covered for those costs .

Preferred Provider Organization (PPO) also has a network of doctors, other health care providers and hospitals, but you’re entitled to go outside the network in certain plans. Still, it should be noted that doing so may come at a high cost. 

Traditional Medicare vs Medical Advantage 

Comparing Doctor Visit Coverage 

With Traditional Medicare, you have the flexibility to choose your doctors and where you wish to receive care as long as they accept Medicare, and most providers do. You also don’t need referrals to see a specialized physician.

It’s important to understand that with Medicare Advantage, your doctor and facility options are generally limited to a network, which some find to be too small. Depending on which plan you select, you may be able to branch outside the network, but be aware that this may incur additional fees that can add up and become quite costly. 

Comparing Care

Traditional  Medicare covers a wide variety of services listed in Part A and B, such as hospital bills, doctor visits, preventive care and so on. Part A and B also include home-based care, but only Part B covers home-based physician care. However, Part and B don’t cover more specialized benefits like dental, vision, eye and hearing care.

For prescription drug coverage, you need to sign up with a private insurer under Medicare Part D. The drug plan will usually have premiums and may have required co-pays.

Medicare Advantage covers all services in Part A and B, and usually includes dental, vision, eye and hearing as well. It may also cover some other specialized services like prescription drugs and gym memberships. Medicare Advantage covers home-based care, but not necessarily in-home medical care so analyze the various Medicare Advantage plans carefully.

The main thing to note about Medicare Advantage plans is that you are often limited to a smaller network at a higher cost and often receive coverage for fewer services. This will vary by plan and each person will have to determine which makes the most sense for their individual needs, but make sure to do your research and make sure your plan covers access to home-based medical care from physicians. 

Comparing Costs

The costs will vary depending on where you live, your income, and the services covered. 

Without getting into too many specifics here, please be aware that the various plans within Traditional Medicare and Medicare Advantage are complex and there is often much more than meets the eye. Look them over with a trusted advisor and make sure to read the fine print of each plan to know what it entitles you to or doesn’t cover. 

Decide Carefully

Choosing a medical insurance plan is an important and personal decision that can greatly impact your health or that of a loved one. Choosing a plan is not something to take lightly. It’s not a decision to be made impulsively or under any pressure or duress. Be sure to read the fine print as not all plans are created equal, and not all will guarantee coverage for medical home visits from physicians.

Make sure you fully understand your options and the finer details of the plans you’re looking at so you can make an informed decision. While it may seem overwhelming, doing your due diligence will allow you to pick the plan that’s best for you or a family member without any unpleasant surprises down the road.

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