Medicare, Medicaid, Medigap and Advantage Plans; A Simple Breakdown

Medicare, Medicaid, Medigap and Advantage Plans - A simple guide cover image

Across the board, Medicare has been at the top of the list for inducing PTSD at the mere mention of the word; it’s complicated and disrespectful to our alphabet that it has taken hostage, those poor letters never saw it coming! We can even throw in dual coverage and Medigap terms to seal its intent to make our coverage quiver in confusion on what in the healthcare is going on, amongst other terms and words ruining our day.

It’s okay, though, because today we are going to uncomplicate it and hopefully, arm you with a formula to navigate between those terms.

I think the issue is too much data, it becomes similar to common core math where there’s all these formulas and words overcomplicating the root; 1+1 becomes distorted, a simple thing you could have deducted but instead became buried in ridiculousness.

Let’s start with basics in a formula and save those letters with our sanity!

The Basics: Medicare, Medicaid/Dual Coverage, Supplemental and Advantage Plans

Medicaid is health insurance through the state for low-income qualifying individuals and families; children with diagnosis can continue to qualify until eighteen despite income levels, so there is some variation here.

Medicare is federal health insurance for those sixty-five years of age and older, those under this age receiving SSI or SSDI, and exceptions with end-stage renal disease.

Base is Part A (Hospital Insurance), Part B (Medical Insurance), and Part D (Prescription Coverage).

Dual coverage is those who have both Medicaid and Medicare; an individual will become dual covered if they qualify financially for Medicaid and become active with Medicare due to age or being on SSI/SSDI after two years.

Advantage Plans are Part C, or a plan that takes A, B and D and roll them into the new C. Your Medicare coverage becomes a C plan.

Because there are diverse needs, there are Supplemental plans/Medigap that allow you to have A, B, and D, as well as a letter like G, etc. These are specific separate plans; there is reason for the madness!

It’s that simple at base; just know those terms and what they affix.

What is right for me?

Here’s where issues arise because it’s skipped; you don’t need to follow suite, rather you need to understand what makes sense for you.

In mental health, more often locations will take straight Medicare but not the advantage plans.

This creates an issue as those with mental health needs on Medicare are already limited due to any provider they see having to be Medicare certified; most coming into the field are not certified and don’t choose to be, leaving generally one or two staff certified at a location. In turn, they have no openings and those advantage plans, not as diverse with mental health locations as they are medical health, leave participants nowhere to go.

I have a client who would have loved to participate in an advantage plan, given the perks, but they didn’t want to leave their therapist; in this field, people come and go a lot and between all services, one tires of starting their life story over and over again. Absolutely understandable, yea? We attempted to review with potential plans that allow out of network providers, but some of those conflicted then on their physical health side and caused major conflicts.

Now, luckily for her, she is dual covered with Medicaid and Medicare (Medicare starting after two years due to SSDI); the most sensible solution for her was to stay with straight Medicare and Medicaid, being able to keep all of her mental and physical health providers in place and Medicaid paying what for Medicare doesn’t.

Another client with high mental health needs chose to stay with straight Medicare and Medicaid for the same reasons, using a supplemental plan elsewhere. This person, too, drew the line with leaving their psychiatrist and attempting to find a plan that kept their long-term providers for physical health, with mental health needs, was an extreme battle.

My stepfather, however, was over the income limit with his social security payments from retirement so he didn’t qualify for Medicaid, therefore being left with straight Medicare. We absolutely onboarded him to an Advantage plan, especially feasible given he didn’t have mental health needs.

The formula has to start with your own needs and what that means overall.

If you have dual coverage and needs in both the physical and mental health side, it may be more beneficial for you to stay dual covered with straight Medicare, using the Medicaid to pay where Medicare stops.

If you have dual coverage and can get on an advantage plan that covers all your needs with no issues, there are a lot of perks you could get by onboarding and is well worth it, generally. My father has an Advantage plan and is dual covered, which works out well for him.

Let’s make this actionable!

Make a Data Set:

If you’re currently debating for yourself or a loved one on how to manage health insurance needs, get a paper out and write out current care and care needs; start with basics and branch out.

  • PCP (Main doctor’s office); general health needs, main source of care.
  • Vision and associated vision specialists, if any.
  • Dental and associated specialists, if any.
  • Physical health specialists, if any; neurologist, pain management, etc.
  • Mental health specialists, if any; therapists, psychiatrists, etc.
  • Additional services; case management, I/DD services, social support, etc.
  • Write current medication with each location, if any.

Keep this list with the location’s name, number, and general information. It helps organize the information and will be useful for review. You will want to leave a space for the specific person being seen at each location – if you don’t know for sure, spend time calling and requesting who you are under the care of.

Medicare Advantage plan agents will review by the staff’s name, not general provider, you are seeing to confirm if they accept the plan/are certified or not and it causes a lot of hold up; I’ve spent entire days on and off the phone between providers and the Medicare Advantage plan staff, it’s insane.

You’ll want medication information on hand to review for Part D.

Now, you have your base needs written out – let’s look at straight Medicare.

Straight Medicare

Let’s start with what exactly A, B, and D mean.

Part A – Hospital Insurance:

Part A covers inpatient care at the hospital, skilled nursing facilities, long-term care hospital services, nursing home care that’s not custodial or long-term care (Medicare doesn’t cover custodial care if it’s the only care you need), hospice care and home health care.

Social Security will pay this premium.

Part B – Medical Insurance

Part B covered Medically necessary services and preventative services, which break down and have different caveats between. Follow the link below for more precise information, but think of Part B as more of your doctor visits and associated tasks – x-rays, assessments, etc.

You will pay a monthly premium; low-income programs may cover this cost if you qualify.

Part D – Prescription Coverage

Part D is purely prescriptions, think of D for Drugs. Don’t overthink by grouping; no matter who prescribes them, it falls to D.

For Part D, you can choose the company that will manage this plan. Each provider will have different coverages and benefits, allowing you to review which makes sense for your current prescription needs.

Bob’s Drugs might not cover something, but Nancy’s Drugs does so I’ll run with Nancy.

For the most part, it breaks down into five tiers from preferred generics to specialty medications – if your current medication is not covered, they can often find a preferred generic that is covered, and you can review with your provider on changing the medication to avoid costs of the other.

You can find a short blurb about formulary lists and tiers here:

There are incentives to who you choose to manage Part D, as each period you are with the plan, percentages decrease and change what you pay out of pocket in tiers; I’ve seen this, at least. Never feel rushed to select any plan; ask about incentives or for the handbook and review.

You will also hear the term open enrollment period, which varies by how you qualify (age or disability), which I won’t delve into here, but I am going to provide a link with what enrollment periods are and general time frames.

What is important is to know how you qualified and what your time frames are to avoid barriers with onboarding or changing your providers. Calling Medicare directly and requesting your specific information is a good place to start if you are unsure.

The national number is 1-800-633-4227 (1-800-MEDICARE)

What about my vision and dental needs?

I don’t know how to rationally state this, but your eyes and teeth weren’t determined to be medically necessary.

Yes, I know how ridiculous that sounds.

For Dental, Medicare may cover some cases such as being inpatient in the hospital with required dental services or other inpatient/outpatient services required for other surgeries.

With Vision, there are exceptions, as well. I found a good breakdown I will link to covering vision, dental and hearing needs with Medicare.

Medigap is your supplemental plans; in most states, there are ten plans offered:

A-D, F, G, and K-N.

You know A through D already, F is no longer available unless you qualify (qualifying for Medicare on or before January 1, 2020) nor is E, H, I or J available (2010 cutoffs/grandfathered in) and generally the difference between the rest is the price you will pay for the specific plan and what they cover.

Plan G is a supplemental plan that you pay for, aimed at covering expenses with co-pays and other out of pocket expenses left over after Medicare pays. Apparently, it is an answer to the loss of the F Plan and is supposed to work similarly. Again, there are deductibles and specifics; I am linking to a good write up on Plan G.

Plan N is similar to Plan G, but Plan N covers less than G and has lower premiums for it; if you don’t have a lot of doctor visits, then N may be more beneficial with a lower premium.

Plan K and L, also similar, have different breakdowns with costs and premiums.

More on K, L, M and N:

There are also four different savings programs within Medicare that work with the state to assist with payments:

These are different income and background qualifiers, but it can help save between all these costs.

You can review different data with state-by-state information and other low income assists here:

Going back to dental and vision – guess what? They still aren’t covered!

You’ll have to pay for a standalone plan for dental and vision through a provider, each having different rates and benefits. They can range from $23 a month to over $80 and what is covered varies.

The Advantage (C) plans usually incorporate vision and dental with different costs associated.

This has been a lot of data to swallow, but what I want you to do is assess it outside that emotionally overwhelming context because it doesn’t have to be.

Organizing Medicare

What we have is a base, simplifying it:

A (Hospital), B (Doctors) and D (Drugs)

This is your Medicare straight. It’s the apple you have to work with.

The Medigap supplemental plans are additives in the garden that will keep your apple healthy, and you want the optimal values your apple needs; if one needs higher nutrients in the soil, you utilize Plan G but if it needs less soil nutrients, then N provides a soil with nutrients at a lower cost and fit the needs adequately.

That is a basic idea to utilize and think with to assist with the mess that is privatized healthcare because everyone wants to service you and they all have different gives and takes. This doesn’t make it necessarily negative or positive, there are just so many options and details, making it an intense mental activity, especially given the population’s ages and/or disabilities.

This is where the Advantage Plans (C) come into play and make sense, a lot having no monthly premium and adding vision and dental into the mix.

If you have straight Medicare, the Advantage Plan is your advantage because it’ll cover way more than straight Medicare and has lower deductibles, especially if you need vision and dental care.

Advantage plans have been adding perks, as well, with food cards and other financial assists with utility bill coverage or sending care packages with different items. You can even use some to cover rental costs or transportation needs!

Straight Medicare is paying for each facet separately; you need those high soil nutrients on top of a monthly sprinkle of magic apple dust and an irrigation service every four months, etc. Now you are paying for each service separately, on top of high deductibles with out-of-pocket costs and have a fixed income that’s crying in a corner at this point.

For those dual covered, it is less problematic as Medicaid picks up where Medicare doesn’t – you can get your dental and vision needs without needing to buy x, y, or z, and you likely qualify within a saving plans, the state paying often for your monthly B premium, unless you are working and going above an income limit.

You can see where there are benefits to being dual covered and your state may have a program that can qualify you for Medicaid that is often overlooked. Let’s pause a moment and look at a potential save to the mess!

MAWD – MA for Workers with Disabilities.

In Pennsylvania, you have to be at least 16 years old but less than 65 years old, have a disability by Social Security Administration standards (you don’t need have SSI/SSDI, just a valid diagnosis), have a countable income less than 250% of the federal poverty income limit, and have less than $10,000 in countable resources (this doesn’t include property residence, or the first vehicle owned).

You also have to be employed but settle down a moment – a note from a friend or family member stating you wash their dishes once a month for $10 literally counts as employed.

What happens is if your income is over the general Medicaid limit, you can earn up to $10,000 over it and potentially qualify for Medicaid under MAWD.

You will pay a monthly premium of 7.5 percent or more of your monthly net income after allowable deductions.

Now, if you have Medicare and can qualify for MAWD, you may pay less overall by onboarding dental and vision through MA and having other costs covered by MA where Medicare stops. Also, at least in PA, MAWD swaps Prescriptions to MA paying and they will cover the Medicare premium and assist with deductibles.

You can call your local assistance office to inquire on information or other programs similar; I am posting a link that reviews for states and MAWD programs.

And here is a state list covering Medicaid data and how to Apply, generally:

If your state doesn’t have an explicit MAWD program, know there are a lot of other programs likely available and please, please, please – do not assume staff there know their own programs.

For instance, life changing events can even lower amounts you pay through IRMAA:

I have had to download manuals and read everything myself through waiver programs to qualifiers and exceptions to obtain the data in my head; I could literally walk into these locations and start working there, highly likely to know more than people currently working there. I can’t tell you how often I am directing and telling people about their own programs and coaching staff on where to pull the data up.

I’m not magical; I just reviewed the handbook and investigated data.

You have to understand this; the ideal that you’re reaching out to a service and requesting information you assume is known is a fallacy! Your luck literally depends on who answers your call and how much they actually know or are willing to look for you. I swear to you, feeling something was irrational, I have gotten off a call with someone and called back to speak to a new staff and obtained a whole different set of information.

Enrollment brokers for home aid services was the worst, literally six different staff stating absolutely different information…in a day. It’s real and blows your mind when you see what really is happening.

To find the loopholes and data on lines you can tip, google for their handbook and read it yourself. It’s the most powerful thing you can do for yourself or anyone you’re trying to help navigate the system – you’ll be amazed at how much there is out there that you or they can qualify for and utilize.

We can’t correct service workers being overburdened, undertrained, and thrown high caseloads (we can by reporting services to pressure the real issue, the corporation/business) but we can empower ourselves by taking ten minutes to review.

What do I do with this information?

For those who can qualify Dual, it becomes more what makes sense and is available to your needs between advantage plans or keeping both straight. In this area, I have experienced mostly barriers with mental health and choices more aligned to provider desires.

If you don’t qualify for MA or a potential program like MAWD, being outside of certain income/age limits, your best resource is remembering you have an apple and your goal is reviewing between supplemental plans, or the advantage plans, available in your area that make sense for its needs.

Take your current care and needs list and spend time itemizing costs and what makes sense between different providers – you have a lot of options.

What you’re aiming for is how much you pay out of pocket before coverage picks up and what is covered in yearly screenings, etc. Straight Medicare has percentages after you meet your deductible, for instance, but if a supplemental plan can assist then you want that supplemental plan, or the advantage plan that can even everything out.

Just the same, Medicare has no yearly limit on what you pay out of pocket – supplemental and advantage plans offer this.

You want to follow your core needs and potential arising long term needs and let that dictate what works for you.

Realistically, my stepfather could not manage all the data; programming his alarm clock is something I help him with – this isn’t something he could jump on a computer and navigate, the man doesn’t even have Wi-Fi.

I feel that those similar to him are more like prey thrust into things with no real understanding of what they are doing and had he not me, he’d have assumed it just and as something that just was. Luckily for him, he doesn’t have a lot of health needs so those details would go unnoticed, overall. For those with higher needs, it could hit like a brick wall.

The thing is, we should be aware to some degree on how our healthcare system works before we enter into that blackhole and the system heavily needs to update, even looking at Medicare alone with the mental health field is a stark reminder of current changes in the system and how, now, Medicare recipients with mental health needs are left with fewer options.

Maybe if it were something incorporated into our basic learning profiles, we’d have more minds collaborating to find solutions and update the system.

I don’t like or keep many ideals, but I have one I absolutely believe in and that is we, as a people, have the power to change the world and it’s these seeds we plant in others that grow and bloom to create something new, something powerful in change.

I am giving you a seed right now, and since I am unable to harness the power alone to change the system, I am hoping for the latter; it blooms into tomorrow.

Today, though, this is our medium and what we’re working with; hopefully, this information has given some ease to the anxiety and can assist in organizing the chaos that is so you can help others or yourself with your current healthcare needs and changes Medicare presents.

As always, I wish you the best of luck and welcome any questions or information I may be able to add here to help others! This is how we empower another – please share what you can!

Additional Resources:

SHIP – State Health Insurance assistance Programs

Medicare Support

SSA Part D Assistance and Information

USA.Gov Medicare Information

Center for Medicare Advocacy

There are webinars, as well, on site.

Administration for Community Living

Many areas for support and agencies you can find in your area that help with Medicare and other age-related needs.

Eldercare Locator

Find local agencies for age related programs, Medicare support related.

Medicare Rights/Advocacy

Free or Low-Cost Dental Programs State Searches

Free or Low-Cost Vision Programs

Trust and Grant Programs

You can google for outside assists to help with payments not covered for items/needs; there are a lot of resources here for specific diagnoses needs and assists. You can think outside the box here, even programs with home needs/adaptations Medicare may not cover!

Guides for Finding Medicare Agents

There are differences between brokers and agents – your goal is finding someone unbiased, which means don’t work or provide information for only specific insurance agencies.

You’ll likely talk to a lot of different agents, be sure to request who they represent so you can verify what options they are giving you overall between providers.

You generally know because they hard sell x or give you fewer options when they call; just know, there are more options than just their options.


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