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Tips For Making Smart 2024 Medicare AEP Choices (Part 2)

PCF Senior Benefits Practice Leader Keith Wallace continues his in-depth guide to the 2024 Medicare Annual Enrollment Period.

Following our recent exploration of the 2024 Medicare Annual Enrollment Period, it's clear that there are more concerns to address when it comes to the best way forward in Medicare. Let’s dive a bit deeper in this guide, where we’ll uncover the truths behind deceptive ads, discern the subtleties between Medicare Advantage and Original Medicare, and shed light on essential cost structures. Consider this a continuation of our journey into making well-informed Medicare decisions. Let's get started.

Dissecting Deceptive Health Care Ads

Over the years, I've seen a surge in deceptive healthcare advertisements aimed at seniors, making it challenging to decipher what's real. Fortunately, stricter rules and penalties have been implemented, prompting many companies to reevaluate their tactics.

Do you remember those ads urging people to call and discover unknown benefits they could receive with Medicare? As it turned out, these ads were predominantly intended for folks eligible for Medicaid, since they can sign up throughout the year, but the ads tried to target Medicare prospects. After facing significant fines, these companies had to straighten up and offer more transparent information. But the lesson remains: always be cautious and stay informed when you come across advertisements for Medicare.

Understanding the Differences Between Medicare Advantage & Original Medicare

For those new to Medicare or considering making changes to their plans, understanding the differences between Medicare Advantage (MA) and Original Medicare Only (OMO) is crucial. 

Let's break it down:

  • Original Medicare Only (OMO) is the federally provided coverage, which includes Parts A (hospital insurance) and B (medical services). If you're eligible for Medicare, you'll automatically receive this, and there's no need to shop around.
  • Medicare Advantage (MA) can be a combination of Part C (health plans) and Part D (drug plans) or either of them separately. They provide all the benefits of Parts A and B and often come with extra perks. For clarity:
    • Some MA plans come without drug coverage, meaning they're Part C only. These are designed for folks who might already have drug coverage from another source, like someone who has Veterans Affairs benefits or Tricare coverage.
    • You can also find MA plans that are solely Part D, catering to individuals who have Original Medicare and only want to add drug coverage.

When it comes to drug coverage specifics, if you decide to add a Part D plan—whether with MA or Original Medicare—the structure of this coverage remains consistent. We're talking about the four levels: deductible, copays, the "doughnut hole," and catastrophic coverage. One key thing to remember, though: while all plans must cover at least two drugs in every therapeutic category, they might not cover every specific drug available. So always double-check a plan's formulary (the list of covered drugs) to ensure your medications are included.

While many AEP shoppers might already be familiar with these details, as they often have an existing Medicare plan, newcomers approaching 65 or those considering a change should be aware of these nuances. This knowledge ensures that you select the plan that's just right for your healthcare needs.

Making Sense of Copays and Cost-Sharing

Healthcare is notorious for having an overabundance of unique terms and concepts. But there are two specific terms that directly affect what you might pay: copays and cost-sharing. Let’s focus on the key differences between these common terms. 

Copays are straightforward. It's a fixed amount you pay when you see a doctor or pick up medication. For example, if your medicine has a $35 copay, that’s the amount you'll pay at the pharmacy, every time.

Now, cost-sharing is a bit different. Here, you and your insurance share the costs of a service. Let's say you have an 80/20 cost-sharing for some Part B medications. This means you're responsible for 20 percent of the cost, and your insurance covers the other 80 percent. The good news is there's a limit to how much you'll have to pay in a year. Once you hit that amount, your plan covers the rest. It’s like having a safety net in place.

Copays and deductibles are not the same. I've heard them used interchangeably, but they serve different roles. A copay is a set fee you pay for services or medication, while a deductible is an amount you need to spend before your insurance starts chipping in. It's vital to know the difference so you can best understand and use your health plan.

Addressing Escalating Healthcare Costs

When it comes to the increasing costs of healthcare, I can't stress enough the importance of aligning your medications with your plan's list of covered drugs. It might sound a bit tedious but ensuring that your medications are well-matched with your plan can lead to notable savings.

I've often found that just when you think you've identified the best plan, there might be another one that fits your needs even better, potentially offering even greater savings. I understand it can feel overwhelming, but investing a little time now can help prevent unexpected bills down the road. It's all about finding the right fit for your needs and budget. This is when working with a licensed insurance agent could help you save time, stress and potentially money on your annual premiums.

Closing Thoughts: Empowering Your Medicare Journey

With the right knowledge, the ins and outs of Medicare become much more manageable and easier to understand. From spotting misleading advertisements to grasping the specifics of your plan options and costs, every piece of information serves as a tool to carve out the best healthcare journey for you. 

Throughout this guide, I've aimed to offer clarity on these pivotal areas, hoping to empower each one of you to make informed decisions. Because in the end, your health and financial well-being deserve the best care. Stay informed, stay proactive, and remember that the best healthcare decisions are the ones tailored to your unique needs.

Find out how PCF Senior Benefits can help you make the right Medicare decision for your needs at

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