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4 Typical “New to Medicare” Scenarios. Which Situation is Yours?

If you choose to ask me for help, I promise to listen to you, answer your questions and advise you based on your unique situation.

However, you are likely to fit into one of these four scenarios. You’ll see the direction I’m likely to point you toward below. You’ll see how I look at Medicare Advantage vs Medigap plans in these different situations. But, I can’t recommend a specific policy until I know more about you.

1 If You’re Under Age 65

(Certain disabled persons qualify for Medicare before age 65.)

Only a few Connecticut Medicare Supplement Plans are available to individuals under 65. (These are also known as Medigap policies.) Unfortunately, only the most expensive plans are.

(Fortunately, most Medicare Advantage plans are available to all Medicare enrollees.)

All supplement carriers are required to offer Plan A to Medicare Enrollees. Some also offer Plan B and/or Plan C. Although these tend to be the most expensive options, they do not have the best benefits.

If you are under 65 your Connecticut Medicare Supplement choices are limited to the worst plans. Your Medicare Advantage choices include virtually all the plans.

What I’m Likely to Recommend:

A Medicare Advantage Plan will probably be the best choice for you. You’ll probably like one of the $0 premium plans.

However, if you need to see a doctor who is not in any Connecticut Medicare Advantage network you should enroll in a Medicare Supplement.

2 If You’re Turning 65 But Can Keep Your Employer Sponsored Coverage

  • Does your group plan cover you well?
  • Is the price reasonable?

Unless you want to contribute to a health savings account, you should probably enroll in Medicare Part A at 65. (You probably won’t have to pay for Medicare Part A.)

You can save money by waiting to enroll in any other coverage. You won’t need a Medicare Advantage Plan or Medicare Supplement Plan yet. You can enroll when you lose your group coverage without a penalty. (So long as you maintain coverage that meets the minimum standards, you won’t pay a penalty for late enrollment.)

A few employer-sponsored plans require you to have underlying coverage from Medicare. You’ll need both Medicare Part A and Part B, if this is the case.

This is not typical. Check with your human resources department before making a final decision.

For more information see should you delay enrolling in Medicare if you have group coverage.

What I’m Likely to Recommend:

If your current plan covers you well and is priced well, you should probably keep your group coverage. (Ask your human resources department for advice. There are exceptions.)

3 If You’re Turning 65 And Can’t Keep Your Current Coverage

(This is the most common scenario)

  • Are you likely to pay under $200 a month in out-of-pocket costs if you choose an Advantage Plan?
  • Are your doctors in the network of one of the $0 monthly premium (or other) Medicare Advantage Plans?
  • Are you likely to have a non-emergency medical expense when out-of-network?

How much will you pay in copays if you have Medicare Advantage Plan?

The most popular state of Connecticut Medicare Supplement and Prescription Drug Plan combinations cost $200 a month or more. If you expect to pay less than $200 a month in copays for doctors and other medical expenses, a Medicare Advantage plan is probably a better choice for you.

(Don’t include drug copays when making this comparison. Your drug copays are likely to be similar with either option.)

If your copays are likely to be over $200 per month (on average), a Medicare Supplement Plan (Medigap) will probably be a better choice for you.

You can expect to pay $10 to $50 in copays for each doctor appointment with most Medicare Advantage Plans. You won’t pay for annual preventive care checkups or for most screenings.

How likely are you to have a hospital stay? Here is what you can expect to pay if you have a Medicare Advantage plan. A covered hospital stay, even a long one, will cost you under $2,000. A one-day stay will cost you under $500. (This is based on the plans available in 2018.)

Are All Your Doctors in One Network?

If you want my help selecting a plan, I’ll search the Medicare Advantage networks for your doctors. If I can’t find one network that has all your doctors, I’ll probably recommend a Medicare Supplement Plan for you.

Will You need Non-Emergency Care Out-of-Network?

Routine and other non-emergency care will cost you more when you are out of network if you choose a Medicare Advantage Plan.

If you have an HMO, you will pay the full price for the service. If you have a PPO or POS, you may get some reimbursement. Any reimbursement will less than your plan would pay if you received care from an in-network provider.

Emergency care is treated differently by Medicare Advantage plans. If you seek care in the United States, you will have the same out-of-pocket expenses for emergency medical care whether you seek care from an in-network provider or an out of network provider. (Many plans include worldwide coverage for medical emergency.)

What I’m Likely to Recommend:

I recommend you go for a lower cost Medicare Advantage Plan if all the below are true:

  • Your out-of-pocket costs are likely to be under $200 with an advantage plan
  • We can find a plan that includes all your doctors in network
  • You are not likely to need non-emergency medical expense when out-of-network

However, if any of the above is not true, a Medicare Supplement Plan may be a better option for you.

If You’re Over 65 And Will Lose Your Employer Sponsored Coverage Soon

See the section above. Your situation is the same as a persion who will need Medicare at age 65..

The Devil is in the Details

The information above will help you decide which category to look in for the best plan. I can help you choose the specific plan likely to serve you best. I can also help you find dental insurance for seniors on Medicare

Let me know when you need help with any of the above. I can email you a recommendation along with prices and benefits for the plan I think you will be happiest with.

One Last Thing!

You can change plans during any Annual Enrollment Period. We should do the research each year together and make sure this year’s plan will be the right plan for next year. (I’ll do most of the work for you. Let’s just make sure we talk every October.)

About Post Author

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Alston J. Balkcom

“ Connecticut-licensed insurance agent since 1985.”

Medigap, Medicare Advantage or neither? See which type of plan is likely to cover you better if you fit into one of these 4 situations.