Medicare Supplement Vs. Medicare Advantage

medicare supplement vs medicare advantage text overlaying image of a splitting arrow going two waysPart A (hospital insurance) and Part B (medical insurance) pay for a lot of your healthcare needs, but they are not able to cover everything. Before your insurance kicks in, you’ll have to pay a deductible. After that, you’ll have to pay other fees, like coinsurance, which is a percentage of certain costs. Also, Original Medicare doesn’t cover routine services like eye, dental, and hearing care, so you may be paying more out of pocket costs than you think. Some people buy Medicare Supplement Insurance or a Medicare Advantage plan (also called Part C) to help pay for these costs. The way each one works is a little bit different so you will need to compare them to help figure out which one might suit you best.

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Medicare Supplement Plans

Medicare Supplement Insurance works with your Original Medicare plan. It helps pay for services that Part A and Part B don’t cover, like traveling outside the country and extra costs, such as when a doctor doesn’t accept Medicare. It can also help pay for your Part A deductible, which was $1,556 in 2022 and the 20% coinsurance you’ll have to pay for your Part B coverage. Keep in mind that Medicare Supplement Insurance isn’t a standalone plan, so you’ll need to sign up for Original Medicare first. Prescription drugs are another thing that Medicare Supplement doesn’t pay for, and you will need a third plan, Medicare Part D, for that.


Plans A, B, C, D, F, G, K, L, M, and N are the 10 different Medicare Supplement insurance plans that exist as of right now. Unfortunately, people who sign up for Medicare after January 1, 2020, will no longer be able to choose Plans C and F. Medicare Supplement plans cover 100% of your Part A coinsurance costs, which is the percentage you pay for services after you reach your deductible. Most plans also cover 100% of your Part B coinsurance and copayment costs.


If you choose Medicare Supplement, keep in mind that it will also cost you money every month. The amount depends on the plan, but each month it could be hundreds of dollars and some plans also have co-pays and deductibles.

How Much Does Medicare Supplement Cost?

How much you pay for your Medicare Supplement premium can depend on your plan, your age, and where you live. In general, the cost of your plan can go up the more coverage you choose. Some Medicare Supplement plans limit how much you have to pay out of your own pocket. For a clear idea of how much you’ll pay, check out our state-by-state Medicare Supplement Plan guides.

Medicare Supplement Eligibility

You’re eligible to buy a Medicare Supplement plan if you’re:


  • 65 years old or older.
  • Have signed up for Parts A and B of Medicare.
  • Currently living in a state where the policy you want is offered.

In some states, even if you are younger than the age of 65, you can get Medicaid if you have a disability or end-stage renal disease (ESRD).

Medicare Advantage

The Medicare Advantage (MA) plans are an alternative to Original Medicare. Private insurance companies are able to give them out. Under an MA plan, you’ll still get Parts A and B, but you may also get Part D and other benefits, like regular hearing, vision, and dental care, all in one policy. By law, Medicare Advantage plans cover the same kinds of care as Original Medicare. For example, hospital stays, doctor visits, and lab tests are all covered by Medicare Advantage plans. However, before the plan will pay for the costs, you may have to stay in the network or get a referral. You can choose any doctor who takes Original Medicare.


If you sign up for Medicare Advantage, your benefits will be handled by that private plan and Original Medicare will no longer cover you. You also won’t be able to sign up for a Medicare Supplement plan or a Part D plan that stands on its own. Many Medicare Advantage plans don’t charge a premium on top of what you already pay for Part B. You may still have a deductible, copays, and coinsurance, but most MA plans limit how much you have to pay out of pocket each year, this is known as the out-of-pocket maximum.

How Much Does Medicare Advantage Cost?

Premiums, deductibles, and other costs for Medicare Advantage can vary by plan and change every year. To stay in your plan, you must pay the Part B premium, which was $164.90 in 2023 and keep paying it. The out-of-pocket limit can also vary by plan, but once you reach it, the plan pays for all of your covered health services for the rest of the year.

Medicare Advantage Eligibility

To sign up for a Medicare Advantage Plan, you must:


  • Sign up for Parts A and B of Medicare.
  • Live in the area where the plan is available.
  • Be a U.S. citizen or are in the U.S. legally.

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Comparing Medicare Supplement and Medicare Advantage

There are several ways in which Medicare Supplement and Medicare Advantage plans are different. A Medicare Advantage plan (Medicare Part C) is an all-in-one option with low monthly premiums. Medicare Supplement plans provide extra coverage on top of Original Medicare for little or no extra cost. Let’s take a look at all of the differences.


Medicare Advantage includes Original Medicare Parts A and B, plus extra benefits like routine dental, vision, hearing, and fitness services. While Medicare Supplement Plans help fill in Original Medicare’s “gaps” by paying for out-of-pocket expenses that Parts A and B won’t cover.


There are specific enrollment periods throughout the year during which you are able to sign up for a Medicare Advantage plan or switch to a different one. After turning 65 and enrolling in Medicare Part B, you are eligible to apply for a Medicare Supplement policy at any point after that age.


You may be required to use hospitals and doctors that are part of the Medicare Advantage network if you have Medicare Advantage. You are free to visit any doctor in the country who participates in Medicare if you have Medicare Supplement Plans.


Medicare Advantage plans are more likely to require referrals to see specialists, while Medicare Supplement Plans do not require referrals at all.


Medicare Advantage has lower premiums but includes copays. Medicare Supplement Plans have higher premiums, but little to no copays.

Prescription coverage

Medicare Advantage Plans may include a Part D prescription drug plan with your policy. With Medicare Supplement Plans you’ll have to enroll in Medicare Part D separately to get this coverage.


Medicare Advantage has no medical underwriting and includes coverage for any and all health conditions. Medicare Supplement plans also have no underwriting as long as you enroll during your IEP. If you don’t enroll during this time, there is a possibility you will face underwriting.

Switching From One to The Other

You can’t change from Medicare Supplement to Medicare Advantage whenever you want. You’ll have to wait until the Medicare Open Enrollment Period, which runs from October 15th to December 7th each year. Before you sign up for a Medicare Advantage plan, you should tell your Medicare Supplement insurance company that you are dropping it. 

On the other hand, if you want to switch to Original Medicare and buy a Medicare Supplement policy, you should check with your Medicare Advantage Plan to see if you can drop out. If you can leave a Medicare Advantage plan and go back to Original Medicare, you can only do so during two enrollment times:


  • The Medicare Advantage Open Enrollment Period (MA OEP) between January 1st and March 31st.
  • The Annual Enrollment Period (AEP) between October 15th and December 7th.

You can usually sign up for a Medicare Supplement plan once you’re enrolled in Original Medicare. When you switch from Medicare Advantage to Original Medicare, you usually lose your right to “guaranteed issue” Medicare Supplement coverage. When you are 65 or older and signed up for Medicare Part B, you usually have guaranteed-issue rights for 6 months. If you don’t have guaranteed-issue rights, insurance companies may check your health status before they sell you a plan.

How To Choose

If you want to know what your costs will be, be able to choose any doctor, avoid referrals, and feel safe when traveling, then you will need a Medicare Supplement plan. If you are willing to trade a lower monthly premium and more benefits for copayments that can change, as well as strict doctor networks, and referrals, then Medicare Advantage may be a good choice for you. The best thing about working with agents is that no matter which option you choose, we’ll make sure it’s the best one for you. 

Working With an EZ Agent

We don’t offer Medicare Advantage, but if you’re looking for a Medicare Supplement Plan, it’s important to compare the benefits and costs of each one. That means you’ll have to do an abundance of research, which can take a while since you’ll have to call a lot of insurance companies to get price quotes. 


If you decide to work with an agent from EZ, you can compare prices in half the time. Working with a licensed agent gives you access to many Medicare Supplement Plan carriers and plans in one place. 


In addition to giving, you price comparisons, your agent can tell you how each plan is different. Also, your agent can help you compare out-of-pocket costs with premium costs to figure out which plan will save you the most money over time. Call us today at 877-670-3602 to start looking for a Medicare Supplement Plan. 

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How To Maximize Your Medicare Budget

How To Maximize Your Medicare Budget text overlaying image of someone writing medicare on a white boardMedicare is an essential program for seniors over 65, however, many of its benefits are underutilized or misunderstood. Consider the annual “wellness” visit. During which a physician will assess your health risks, take your blood pressure and other routine measurements, test for cognitive impairment, and provide personalized health advice. It’s Free! Nonetheless, a surprising number of people do not take advantage of this benefit. This isn’t the only benefit that has gone under the radar. Many healthy seniors ignore a variety of free preventive services, ranging from bone density screening to cancer detection. Other benefits such as home health care, are also frequently unused due to their strict eligibility requirements. Below you’ll find all the ways to make sure you’re using all of your benefits and getting your money’s worth.

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Choose The Right Doctor

It is important to choose a doctor who accepts Medicare assignments in order to save money. If a doctor accepts a Medicare assignment, they accept Medicare-approved amounts as full payment, and you cannot be charged more. Most physicians who treat Medicare patients will accept Medicare assignments. Providers who don’t participate fall into two categories:


  • Non participating providers – These providers can charge up to 15% more than the Medicare approved amount for covered services and leave you responsible for the additional costs
  • Opt-out providers – These providers can charge whatever they want which is outlined in a private contract with the patient.

To locate physicians in your area who accept assignment, visit to find doctors and other health professionals section. The search tool displays which physicians accept Medicare payments.


If you have a Medicare Advantage plan, check your plan’s provider directory or website to ensure you’re choosing doctors in the network. Keeping in mind that doctors may be added or removed at any time. Generally, you will pay more to see non-network providers. Make sure that you research different doctors. Confirm that they accept Medicare and are willing to educate you on what is and is not covered so that you are not overcharged.

Understand Your Policy

Medicare provides coverage for skilled services such as nursing, speech therapy, and physical therapy, but there are eligibility requirements. To qualify for these services, you must be homebound. Meaning you are unable to leave your home without assistance or because of a medical condition. Many seniors mistakenly believe that they are covered for these services, only to receive a hefty bill in the end. Before assuming something is covered, carefully read your policy’s guidelines.

Look Into Medicare Advantage

Medicare Advantage plans are offered by private insurance companies and offer the convenience of having Part A, Part B, and Part D services all bundled into one plan. Whereas traditional Medicare has you sign up for each plan individually. Medicare advantage plans may also include coverage for routine dental, vision, and hearing exams. Which are not available under Original Medicare. However, the biggest benefit of Medicare Advantage is the annual out-of-pocket maximums for seniors excluding 

prescription drug plans. Which as of 2023 is $8,300. With Original Medicare, there are no annual out-of-pocket maximums. 


However, you should also be aware of the disadvantages of Medicare Advantage. Original Medicare is widely accepted by physicians and hospitals all over the country. Whereas a Medicare Advantage plan will have a smaller network of providers. So, it’s possible that your doctor isn’t in their network. Next, you may be required to get a referral before seeing a specialist. Which is not the case for Original Medicare enrollees. There are also certain covered services that Parts A and B that may have a high copayment under a Medicare Advantage plan. Meaning you would have higher out-of-pocket costs with Medicare Advantage than you would with Original Medicare.

Consider Medicare Supplement Plans

If you have a chronic or serious health condition and will likely visit the doctor frequently, you may want to consider a Medicare Supplement Plan. Medicare covers the majority of eligible medical expenses for seniors, but you are still responsible for 20%-25% of the total cost of care. Medicare Supplement Plans were designed to help cover a substantial portion of the medical expenses that come from having Medicare Part A and B, that you would otherwise be responsible for.


As with Part D, private insurers offer Medicare Supplement Plans and with Part D, there are a variety of plans to choose from. So you should shop around carefully to find the plan that fits you best. While yes, Medicare Supplement Plans do have premiums and can increase your monthly expenses, the additional coverage could give you peace of mind and eliminate some of the uncertainty that comes with your out-of-pocket Medicare costs.

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Save On Medications

Even if you have Medicare Part D prescription drug coverage, your out-of-pocket costs can be astronomical, in part because Part D does not have a limit for out-of-pocket expenses. After you reach the catastrophic coverage threshold of $7,400 (as of 2023), the majority of people will continue to have to pay 5% of the cost of covered drugs. In certain instances, you can reduce drug costs by forgoing your Part D plan and paying cash. Big-box stores such as Costco and Target offer a variety of generic prescriptions for much cheaper, whereas many Part D plans have a high standard copay to fill a prescription. The only problem with paying in cash and not using your coverage is that the expense won’t count towards your deductible. 


If you stick with your Medicare Part D plan’s list of “preferred” pharmacies you will typically pay less for your prescriptions. Also most Part D plans separate their drug formularies (list of covered drugs) into 5 tiers: preferred generic, generic, preferred brands, non preferred, and specialty. With preferred generics being the lowest cost-sharing tier and the most affordable for enrollees. If you find a drug that is approved for your condition on a lower tier than the one you currently take, ask your doctor if you can switch to the more affordable one.

Review Your Quarterly Summary

Your quarterly Medicare summary displays services and supplies for which Medicare was billed. This summary will also indicate whether or not any claims have been denied; if so it is important to contact the provider of the denied claim. If you believe the claim is unjust, you can appeal the claim denial by following the instructions on the summary’s final page. When admitted to the hospital, for instance, you will receive a notice outlining your Medicare rights. You may request an appeal of the decision and a review of your case if you believe you were discharged prematurely.

Use Your Preventative Care

Many Medicare recipients don’t realize that there is a long list of services that they can get for free. Medicare provides numerous screenings and annual wellness visits at no cost to you. These free preventative measures are important for detecting serious illnesses early. The screenings may include depression, cardiovascular disease, and other conditions. There are free counseling sessions for tobacco and alcohol abuse, as well as free vaccinations for flu and pneumonia. Additionally, you are eligible for a free “welcome to Medicare” preventive visit within the first 12 months of receiving Medicare Part B. During this initial appointment, you can also receive free assistance planning for end-of-life care. And your physician can help you draft an advance directive that outlines all of your wishes.


Utilizing these freebies can aid doctors in detecting major health problems before they worsen, thereby preserving your health. You might also have access to free wellness benefits if you have a Medicare Advantage plan. Some Advantage plans, for instance, include SilverSneakers membership at no extra charge. This program provides a basic gym membership and access to senior-specific group exercise classes.

Plan Yearly Expenses With The Out-Of-Pocket Maximum In Mind

Individuals’ Medicare costs can vary widely based on their circumstances and the type of coverage they have. Original Medicare typically covers 80% of a beneficiary’s Part A and Part B expenses. Such as doctor visits, hospital stays, and lab work. Individuals are responsible for remaining 20% of out-of-pocket costs, with no annual cap. Medicare Advantage plans offer predictable copayments and an annual limit on out-of-pocket costs. Once you reach your plan’s out-of-pocket maximum, all Medicare-covered services for the remainder of the year are covered in full. This cap can provide peace of mind if you have a sudden illness or are preparing for a major medical procedure.

Shop Around Every Year

Original Medicare, which includes Part A (hospital insurance) and Part B (medical insurance), is relatively simple. There is no need to shop around for Parts A or B because they come in a universal package. Where you should shop around is your Medicare Part D plan and your Medicare Supplement Plans. Medicare contracts with private insurance companies that offer Part D and Medicare Supplement Plans to provide seniors with a variety of coverage options. Moreover, these coverage options and their costs can change from year to year. This means that the plan you have this year might not be the best for you next year. The worst thing you can do is automatically enroll in your previous year’s plan without comparing options. This could result in higher out-of-pocket costs and for Part D could mean less coverage for prescription medications.

Get Help From EZ

If you’re looking for a Medicare Supplement Plan or Medicare Advantage Plan, you must compare the costs and benefits of each. This requires extensive research. Which can be time-consuming, as you will need to contact multiple insurance companies to obtain rate quotes. However, if you work with one of EZ’s agents, you can compare prices in half the time. Working with a licensed agent provides you with access to a variety of carriers and plans. 


In addition to providing price comparisons, your agent can explain the differences between each plan. And explain the differences between each plan. In addition, your agent can assist you in determining which plan will be the most cost-effective for you in the long run by comparing out-of-pocket costs and premium costs. Call us today at 877-670-3601 or enter your zip code in the bar below to begin comparing.

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Most Common Medicare Mistakes

Most Common Medicare Mistakes text overlaying image of a older man worried Medicare is the nation’s health insurance program for seniors 65 and older. It also provides coverage for younger people who meet specific eligibility criteria. Medicare Parts A, B, C, and D cover a large variety of your major medical expenses. It’s a great program but it can be difficult to read through all of the plans, options, and rules. This can make it difficult to choose the right plan on time. Below we’ve outlined some of the most common Medicare mistakes so you know what to avoid and not wind up with penalties, coverage delays or gaps.

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Signing Up Late

Medicare has specific deadlines to enroll. Your Initial Enrollment Period (IEP) happens when you first become eligible for Medicare. It starts 3 months before your 65th birthday, including your birth month, and then ends 3 months after you turn 65. This gives you 7 months to enroll. If you’re receiving Social Security benefits then you will be automatically enrolled and you don’t have to do anything or worry about the deadlines, Social Security handles enrollment for you. However, if you are not automatically enrolled you have to apply yourself during your IEP. If you miss the IEP you do have another opportunity between January 1st and March 31st called the General Enrollment Period (GEP).


Missing these enrollment periods is one of the most common and costly mistakes people make. If you miss both enrollment periods you can face late enrollment penalties for Medicare Parts A, B, and D. It’s important to note that there is a way to avoid these penalties. If you qualify for a Special Enrollment Period (SEP) then you will be able to enroll in Medicare penalty free with all the same benefits as when others enroll during the IEP. 

SEP Types

  • Qualifying life event – If you have a qualifying life event then you qualify for a 2-month SEP where you have 2 months to enroll in Medicare. The most common qualifying events are:
    • You moved out of your current plan’s service area
    • Your plan no longer serves the area you are in
    • If you decide to switch from Medicare Advantage to Original Medicare within 12 months of enrolling in the Medicare Advantage plan.
    • You move into or out of a facility such as a nursing home
    • If you’ve lost Medicaid eligibility 
  • Working past 65 – If you decide to continue working past 65 and have creditable coverage through your or your spouse’s employer’s health plan then once you leave your job you will open an 8-month SEP. This SEP does have a stipulation, if you want Part D you have to enroll in it within the first 2 months of your 8 month SEP, otherwise you still face penalties. Your 8 months begin the day you no longer have credible health coverage.

Medicare Part A Penalty

Some people qualify for Part A premium-free. If you’ve worked and paid into Social Security and Medicare taxes for at least 40 calendar quarters, then you are eligible for Railroad Retirement benefits (RRB), or have a spouse that qualifies for premium-free Part A then you will get Part A for free. However, if you don’t and have to pay for Part A, then you can face a 10% increase on your premium for missing the IEP. This penalty stays with you for twice the number of years that you were eligible and didn’t sign up. For instance, if you were eligible for Part A for 3 years and did not enroll, you’ll have the penalty for 6 years.

Medicare Part B Penalty

If you miss your enrollment period and don’t qualify for an SEP, you will face a Part B penalty. This penalty is a 10% increase for every year you did not sign up. For example, say you waited 2 years to enroll. You’re looking at a 20% increase in your premium, 10% for each of the 2 years you delayed. The standard Part B premium for 2023 is $164.90, plus adding the 20% will bring your premium up to $197.88 which will be rounded up to the nearest $.10, making it $197.90 for part B. That’s $32.98 extra every month that you could have saved by enrolling on time. Now that might not seem like a lot, but if you look at it on a yearly basis that is $395.76 a year!

Medicare Part D Penalty

The amount of the penalty depends on the length of time that you did not have Part D or a creditable prescription drug plan. Medicare determines the penalty amount by multiplying 1% of the national base beneficiary premium ($32.74 in 2023) by the number of full months you went without drug coverage. The penalty amount is then rounded to the nearest $.10 and added to your monthly premium. The national base beneficiary premium can vary from year to year, so your penalty will change with it.


For example, say you waited 14 months to enroll in Part D and didn’t have creditable drug coverage for any of that time. You’ll have to pay a 14% penalty. For 2023 that would be $4.58 rounded up is $4.60 extra on your premium.


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Assuming Spouse Coverage

Assuming your spouse is covered by Medicare because you have it or vice versa is a big mistake. It could leave you or your spouse without insurance. Medicare doesn’t work the same as an employer group plan. Meaning it won’t cover your family, it only applies to the individual who enrolls. If you worked and paid your Medicare taxes for the last ten years then at most your spouse who is 65 will be eligible for premium-free Part A. If your spouse is under 65, they need to find their own coverage elsewhere, such as a plan from the Health Insurance Marketplace, their own group plan, or COBRA. Additionally, if your spouse is under 65 they still may be eligible under certain conditions. Medicare is available to anyone who receives Social Security Benefits for at least 24 months, has End-Stage Renal Disease (ESRD), or Amyotrophic Lateral Sclerosis (ALS).

Not Weighing Your Options

There are many options to choose from with Medicare. There’s Original Medicare, Medicare Advantage, and Medicare Supplement Plans. It’s important that you know the differences and their benefits. If you make the mistake of not weighing your options you can leave yourself with large gaps in your coverage or end up paying far more than you need. Below we’ve outlined these plans to give you a starting point.

Original Medicare

Original Medicare, also known as traditional Medicare, consists of only Parts A and B. Medicare Part A is hospital insurance, and it covers hospital inpatient care and skilled nursing facility care. Part A coverage typically includes the following:


  • Semi-private hospital rooms
  • Hospital meals
  • Inpatient lab tests and X-rays
  • Operating room and recovery room services
  • Drugs and medical equipment used while in the hospital or skilled nursing facility
  • ICU care
  • Skilled nursing services
  • Hospice care

Part B of Medicare covers your general medical expenses. Such as doctor’s visits, urgent care, and specialists. Typically Part B covers:


  • Doctor visits and services
  • Some preventative screenings and services
  • Ambulance services
  • Outpatient surgery services
  • Mental health care
  • Some durable medical equipment
  • Some medically necessary tests such as X-rays, MRIs, CT scans, and EKGs

Medicare Advantage

Medicare Advantage, commonly known as Part C, is a type of Medicare plan that is offered by private insurance companies. These companies have a contract with the Medicare program that ensures the plans they offer comply with Medicare’s regulations. Medicare pays a set amount to the insurers for each participant enrolled in the plan. Additionally, you will pay your medical bills directly to your insurance company while your insurance provider must follow Medicare’s regulations. They are allowed to set their own rules for out-of-pocket expenses as well as decide if you need a referral to see specialists.

Medicare Supplement Plans

Medicare Supplement Plans are plans that you can buy to supplement your Original Medicare. These plans fill in any gaps in coverage, ensuring you get the most coverage for all the medical needs you specifically have. You do have to pay a monthly premium for these plans, and you must enroll in both Part A and Part B to be eligible for a Medicare Supplement Plan. However you may end up paying less than you would overall with your Original Medicare because Medicare Supplement Plans all have benefits that cover a lot of the out-of-pocket costs for Part A and B. One of the biggest advantages with Medicare Supplement is the variety. There are 10 plans to choose from and all of them cover different benefits at different amounts. It’s important you look through these plans and compare to tailor your coverage specifically to what you need.

Working With EZ

In order to save as much as possible during your Medicare journey, it’s important to keep all of these mistakes in mind. You can rely on EZ if you have any questions or need help choosing your plans. Whether you’re looking for help enrolling, or just need some information. Give us a call today at 877-670-3608 to speak to your own Medicare Agent or you can get free instant quotes by entering your zip code in the box below.

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Medicare Advantage Vs. Medicare

You’re probably already familiar with Original Medicare, especially if you’re nearing the age of 65 and getting ready to enroll. You may not be aware, though, that there are some gaps in Original Medicare’s coverage, which lead many people to either add a Medicare Supplement Plan or choose a Medicare Advantage Plan. Medicare Advantage Plans, also known as Medicare Part C, are very similar to Original Medicare. However, there is a slight difference between the two, mainly that Medicare Advantage Plans offer more coverage than Original Medicare.

caucasian hand over an older caucasian hand bringing it towards blocks
Medicare Part B covers physical therapy, doctor visits, and more. 

Original Medicare Overview

Medicare is a government health insurance program consisting of:

  • Part A– Hospital insurance that covers hospital stays, skilled nursing care facilities, hospice care, and limited home healthcare services.
  • Part B– Medical insurance that covers preventive services, doctors’ office visits, flu shots, physical therapy, durable medical equipment, diabetes screening and supplies, and mental health care.

In most cases, you will not pay a monthly premium for Medicare Part A; the Medicare taxes that you paid while you were working are what pay for Part A. However, Part A does have a deductible, coinsurance, and co-payments. 

Part B, on the other hand, does have a monthly premium: the Medicare Part B premium for 2020 is $144.60, but could be higher depending on your income. Like Part A, Part B also has a deductible, coinsurance, and co-payments for most services. Medicare Part B covers 80% of your costs, meaning you will need to pay the remaining 20% of any bills. 

Medicare Advantage Overview

Medicare Advantage is an “all-in-one” alternative to Original Medicare. Private insurance companies approved by Medicare can offer Medicare Advantage Plans. Unlike Original Medicare, most Medicare Advantage Plans include prescription drug coverage, and some plans offer more benefits, like routine dental or hearing care. In order to be eligible for Medicare Advantage, you have to be enrolled in Medicare Part A and Part B. You must also live in the plan’s service area, and you cannot have end-stage renal tag with the words low price on itMedicare Advantage Plan premiums differ from plan to plan. Many Medicare Advantage Plans have low-cost, or even $0, premiums. The average Medicare Advantage premium is only $30 a month. Remember, you will still have to pay your monthly Medicare Part B premiums in addition to any Medicare Advantage premium.

The Similarities

All Medicare Advantage Plans have to offer at least the same benefits as Medicare Parts A and B do. This means that if Original Medicare covers hospital care at a certain level, then so will a Medicare Advantage Plan.

The Differences

The benefit of Medicare Advantage Plans is that they offer more coverage than Original Medicare. The following chart breaks down the differences between the two:

Group Health Plans Accused of Medicare Fraud

If you live in the Seattle area, you might have seen that Group Health Cooperative (GHC) is under investigation. The nonprofit health insurance company allegedly took advantage of Medicare’s system, stealing millions of dollars to recover from earlier financial losses.

A former employee noticed the company was embellishing patient stories to claim more funds. This extended to even billing Medicare for conditions that were not real. 

This all started in 2012 but has remained under lock and key in court until this year. While several employees came forward, the investigation is still in the “ongoing” phase.

Situations like these aren’t isolated.

Almost 20 major cases under Kaiser Health News saw companies skimming off the top of government funds. Medicare Advantage is the easiest tool to do so. All the companies have to do is lie about their patient’s cases, and the money pours in.

face of an insurance building with people walking alongside of it
Make sure to double-check your information when you give it to your insurance company.

How It Happened

One employee, Teresa Ross, worked at GHC and noticed the company’s management making some bad choices. Because of these, Group Health saw a drop in operating income by $60 million.

To recover from this, the insurer allegedly took advantage of Medicare’s billing formula. Under Medicare, they give a patient a “risk score.” The higher the risk score, the sicker the patient, and higher-risk patients receive more funds. 

GHC hired another company, DxID, to assist with medical charts. With their help, GHC gained $12 million in new claims, and DxID received $1.5 million that year for their assistance.

Ross, with a doctor’s help, reviewed cases GHC oversaw. In the medical coding, she found errors that directly contradicted each other. One case stated the patient had a great disposition, but on further searching, this patient was also billed with having major depression. Clinical depression easily raises a patient’s risk score under Medicare, and this is only one of $35 million in new claims that GHC inflated.

Overestimating these scores, the company received enough funds from Medicare to climb out of their financial hole, but at the cost of government funds allocated to help a sick country–and directly from taxpayers’ pockets. The estimated gross damages climbed up into billions of dollars in just the past few years.

What Happens Next

The Justice Department is investigating this whistleblower case. Like other insurance cases, these last for years in order to provide the most accurate evidence to support such allegations. If Ross succeeds in her case, she will share in reparations the company must make for their actions.

meeting room to discuss medicare fraud
Investigations take a while for a reason. People just like to make sure justice will be served without any doubt.

However, the company’s official stance is: “We believe the doing policies being challenged here were lawful and proper and all parties paid appropriately.” GHC’s defense is that Ross found an “honest mistake” and made a bigger conflict out of it than was necessary.

Two conflicting defenses for one stance? For now, we wait for the Justice Department.


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