Medicare Open Enrollment is in full swing through December 7th. Most, if not all, Wesley residents are covered by Medicare insurance. Medicare is offered to individuals, not families, which allows couples to select different plans. Choices include Original Medicare or various Medicare Advantage plans. Medicare Advantage plans are offered by approved private insurance companies that follows the rules set by Medicare.
When one enrolls in Medicare for the first time, he or she is enrolling for Part A (Hospital Insurance) and Part B (Medical Insurance) and typically does not need to re-enroll each year. The open enrollment period between October 15 and December 7th each year allows participants to join, drop or switch plans.
Those choosing Original Medicare have the option to pay for drug coverage (Part D) to help lower costs for prescription drugs. They may also choose to purchase supplemental coverage, like Medigap, which lowers one’s portion of the costs for care under Parts A & B.
Medicare Advantage plans bundle Part A, Part B, and usually Part D. Some plans may offer coverage for vision, hearing and dental services; services not covered by Original Medicare. Since Medicare Advantage is offered by various private companies, each plan can have different rules for how you get services such as:
- Have a referral to see a specialist
- Use doctors/providers in the plan’s network
- Pay a premium for the plan in addition to the monthly Part B premium
- Not able to buy supplemental coverage like Medigap
Compare Plans
Medicare.gov offers a helpful side by side comparison of Original Medicare with Medicare Advantage on its website:
| Original Medicare | Medicare Advantage |
| You can go to any doctor or hospital that takes Medicare, anywhere in the U.S. | In most cases, you can only use doctors and other providers who are in the plan’s network and service area (for non-emergency care). |
| In most cases you don’t need a referral to see a specialist. | You may need to get a referral to see a specialist |
| For Part B-covered services, you usually pay 20% of the Medicare-approved amount after you meet your deductible. This amount is called your coinsurance. | Out-of-pocket costs vary – plans may have lower or higher out-of-pocket costs for certain services. |
| You pay a premium (monthly payment) for Part B. If you choose to join a Medicare drug plan, you’ll pay a separate premium for your Medicare drug coverage (Part D). | You pay the monthly Part B premium and may also have to pay the plan’s premium. Some plans may have a $0 premium and may help pay all or part of your Part B premium. Most plans include Medicare drug coverage (Part D). |
| There’s no yearly limit on what you pay out-of-pocket, unless you have supplemental coverage – like Medicare Supplement Insurance (Medigap). | Plans have a yearly limit on what you pay out of pocket for services Medicare Part A and Part B cover. Once you reach your plan’s limit, you’ll pay nothing for services Part A and Part B covers for the rest of the year. |
| You can get Medigap to help pay your remaining out-of-pocket costs (like your 20% coinsurance). Or, you can use coverage from a former employer or union, or Medicaid. | You can’t buy and don’t need Medigap. |
| Original Medicare covers most medically necessary services and supplies in hospitals, doctors’ offices, and other health care facilities. Original Medicare doesn’t cover some benefits like eye exams, most dental care, and routine exams. | Plans must cover all medically necessary services that Original Medicare covers. Plans may also offer some extra benefits that Original Medicare doesn’t cover – like vision, hearing, and dental services. |
| You can join a separate Medicare drug plan to get Medicare drug coverage (Part D). | Medicare drug coverage (Part D) is included in most plans. In most types of Medicare Advantage Plans, you can’t join a separate Medicare drug plan. |
| In most cases, you don’t have to get a service or supply approved ahead of time for Original Medicare to cover it. | In many cases, you have to get a service or supply approved ahead of time for the plan to cover it. |
| Original Medicare generally doesn’t cover medical care outside the U.S. You may be able to buy a Medicare Supplement Insurance (Medigap) policy that covers emergency care outside the U.S. | Plans generally don’t cover medical care outside the U.S. Some plans may offer a supplemental benefit that covers emergency and urgently needed services when traveling outside the U.S. |
Medicare Coverage at Wesley
Original Medicare is generally accepted at Wesley Des Moines Health Center, Wesley Lea Hill Rehabilitation & Care Center, Wesley Home Health, and Wesley Hospice & Palliative.
However, not all Medicare Advantage plans cover services at Wesley. When considering the purchase of a Medicare Advantage plan, we recommend that Wesley residents consult with the management or care teams on campus about which plans are accepted and the services that are covered.
Learn More at Our Zoom Webinar
Register for our Zoom webinar for a guided presentation from Lori Hutson on Medicare 101.
Wednesday, Nov 16 • 10:00 a.m.
Other Resources
Office of the Insurance Commissioner Washington State
Statewide Health Insurance Benefits Advisor (SHIBA)