Supplement, Advantage Plan or Employer Coverage
How would you feel if your insurance agent told you he has a medical insurance plan for you that is an 80 / 20 plan (meaning, you just pay 20% of the medical costs) and has a monthly premium of only $164.90? In today’s market, you would consider that a good deal, right? And you might feel that having to pay only 20% of your future medical costs is a good risk for that premium.

Medical Coverage that Risks You $60,000?!!!

But suppose you buy that plan and then discover that, in a worst case scenario, your risk could be as much as $60,000 in a calendar year! How would you then feel about that plan?!

That “plan” describes Original Medicare. (For more specifics on Original Medicare, see my blog post, How Does Medicare Work?) Because of that enormous risk, most people decide to “cover” Medicare’s coverage “gaps”. In other words, they significantly lessen their risk by adding another plan to work with, or in place of, Original Medicare.

Coverage through a Job

Some people are able to keep their medical insurance through work when they turn 65. If so, this may be a viable alternative to Medicare. However, if you are under 65 and are currently covered through your work, there are a few things to keep in mind about this option.

First, it may not actually be an option for you when you turn 65. More and more employers are terminating medical coverage for employees at age 65 and beyond. The obvious reason for this is to save money for the company. With a record number of people turning 65 this year, many employers believe they can no longer afford covering people from 65 till death.

Second, even if your employer does offer coverage for you at age 65 and beyond, you could incur significant out-of-pocket costs (such as a high deductible and coinsurance) for events such as MRIs, CT scans, and hospitalization—costs that could be provide you with a much greater cost risk than, say, a Medicare supplement may offer you. In addition, the monthly premium you pay for this plan may be greater than either a supplement or an Advantage Plan premium.

Coverage at age 65, for some selected employee insurance, continues unchanged. This means that the employee on this kind of plan does not need to purchase Medicare Part B insurance, because this kind of coverage does not work with Medicare. That would provide you with a monthly premium savings of $164.90 (as of 2023).

However, more and more employers are changing the coverage at age 65 to work with Medicare (again, for cost savings to the employer). So, if your coverage works with Medicare, you will need to purchase Part B (as you will need both Parts A and B in that case). If so, either a Medicare supplement or a Medicare Advantage Plan may be a better option for you.

Medicare Supplement

Another alternative to consider for covering the Medicare coverage gaps is a Medicare supplement, also known as a Medigap policy. Supplements, which work with Medicare, have been designed by Medicare, but have been handed over to private insurance companies to administrate and to sell. (To get a supplement, one must have Medicare Parts A and B. A future blog post will provide more specifics on Medicare supplements.)

A benefit of having a >Medicare supplement plan (verses a Medicare Advantage Plan) is that there is no network. (Although there are some “select” supplement plans, where one must use hospitals within the network, this article is referring to a true supplement with no network. By the way, this writer has encountered people who have unwittingly purchased a select supplement because the premium was lower than a true supplement; it is important to understand the difference and why it makes a difference to purchase a true supplement.) When you have a supplement, you can see any doctor throughout the U.S. who works with Medicare, providing you with greater freedom of choice—particularly among specialists—than is generally afforded by employer insurance or an Advantage Plan.

(Though there is a fear among some that it will be difficult to find a doctor who will accept their Medicare coverage, only 2 percent of seniors on Medicare nationwide have reported trouble finding a doctor when needing one. Furthermore, according to a national survey of physicians, 91% of doctors accept new Medicare patients, the same rate accepting new patients on non-Medicare private insurance. In fact, a 2013 Forbes article declares that the number of doctors accepting Medicare is on the rise, a statistic also cited by the New York Times.)

Another advantage of the most popular supplements, the G Plan and the F Plan, is the low out-of-pocket potential faced by supplement holders. On medical events covered by Medicare (see the blog post, How Does Medicare Work?), your annual maximum out-of-pocket cost should only be $166 with a G Plan and $0 with an F Plan. Not too bad.

A downside with a Medicare supplement is that prescription medications are not covered. Thus, one would need to purchase a prescription drug plan separately. (Note: It is important that your agent “shop” your medications among all Medicare Part D [prescription drug] plans in your service area to make sure you do not overspend on your plan or on your medications.)

Overall, a Medicare supplement is popular with seniors who are looking for great medical coverage with low out-of-pocket costs and who want to preserve their freedom of choice when needing a doctor (particularly a specialist).

Medicare Advantage Plan

A third option for dealing with the Medicare coverage gaps is a Medicare Advantage Plan. Advantage Plans, too, are administrated by private insurance companies, but they are highly regulated by Medicare (more so than are supplements). To acquire an Advantage Plan, one must have Medicare Parts A and B, be in the service area for the plan being purchased, and not have End-Stage Renal Disease.

In general, advantages of an Advantage Plan include a low monthly premium. Depending on the plan and service area, the premium on an Advantage Plan may be as low as $20. (There are still some $0 premium monthly plans available, but remember the old adage: “You get what you pay for.”)

Another advantage with many Advantage Plans is prescription drug coverage. Not all Advantage Plans come with prescription coverage, but most do. However, it is important for your agent to look up each of your medications to see how the Advantage Plan covers them—BEFORE you enroll on a plan; for some of your medications may not be covered by the plan, or you may consider the plan’s deductibles and copays to be too high for your medications.

Finally, an Advantage Plan can cover benefits not covered by Original Medicare or a supplement, such as dental, vision, hearing, etc. Some plans may even provide free over-the-counter items.

So, what are the downsides of an Advantage Plan? First, you will find that Advantage Plans have a network. PPO plans generally have a larger network, and you can use out-of-network providers by paying a greater cost; but you will need to stay within the network for all providers with HMO plans, or else pay the entire cost of the out-of-network provider. (There are also other kinds of Advantage Plans that will be covered in a future blog post.)

Another potential downside to the Advantage Plan is that each time you use it you will need to pay a copay. Some copays are not bad, such as a $5 copay for primary care physician visits on some plans; however, you may have to pay up to $400 per day for a hospital stay on some plans. While the Advantage Plan lowers your max risk (meaning, it puts a ceiling on your annual out-of-pocket costs) from the worst-case-scenario of Original Medicare at $60,000, still, a $6700 annual cap (as some plans have) does not compare with the $166 or $0 of a G Plan or F Plan supplement.

What Are Your Options?

All of this means you will have options for your medical coverage at age 65 and beyond. If you have an employer plan which does not work with Medicare, and both your premium and your potential out-of-pocket costs are low enough, you may want to stay with it. If your employer plan will work with Medicare, keep in mind you will have to purchase Medicare Part B for $164.90 monthly premium (as of 2023); and, as a result, you may want to compare the coverage being offered to you with a supplement and / or an Advantage Plan. If you will not be offered employer coverage, your basic choices are: Original Medicare only (with a significant out-of-pocket risk), an Advantage Plan, or a Medicare supplement.

While it’s nice to have options, it is wise to do comparisons on your situation. To make sure you make a wise choice, sit down with an experienced, independent agent (one who represents many insurance companies and plans) who will put you first. For it is only an advantage to have choices if you can make the wisest choice among those options. Happy shopping!


KevinKevin
14:47 24 Jan 24
John is a very knowledgeable subject matter expert and is thorough in his approach. He takes time breaking down and explaining what can be a somewhat complex subject and helps makes it easier to understand! John always has the best interests of his clients guiding his recommendations. We have found John's advice to be extremely helpful and would recommend him to anyone seeking health insurance.
Laura BogenschutzLaura Bogenschutz
18:06 21 Jan 24
John Claeys is the best! He has helped my husband and I tremendously with our Medicare and supplement coverage! He breaks it down to where you can understand it! We would be so confused without John!! Thank you John for being there for us!!
Thompson FamilyThompson Family
15:46 18 Jan 24
John Claeys is one of the most knowledgeable individuals on Medicare and supplemental insurance plans you can ever find. Not only is he very personable he also stays involved from year to year to ensure you have the best policies for your current needs.
Ingrid FauskeeIngrid Fauskee
23:21 17 Jan 24
I just got a Medicare plan through John Claeys. I was getting a lot of mail about Medicare and was so confused. Some friends told me about John so I emailed him and he contacted me right away.. He was amazing! He went through everything with me, he explained every detail and was so patient with all my questions . So grateful to him for all he did. Thank you John.😁
John Claeys helped me understand the in's and out's of Medicare. He found the best insurance and prescription plan to best suit my needs at an affordable price.Thank you John!Laurie Boriskie
Marsha AllenMarsha Allen
16:55 24 Oct 23
My experience with John was definitely 5 Star! He explained everything thoroughly, and simply. He answered all my questions regarding Medicare completely. I would absolutely recommend John, without reservation.
Linda WilliamsLinda Williams
10:08 12 Jul 23
I had a 5 star experience and would recommend him. Always returning my calls promptly, very helpful and informative, listened to what my needs was regarding my Medicare. I truly felt comfortable with John's help to navigate through the maze of Medicare
Cindy KulakCindy Kulak
14:51 18 Jun 23
John is very knowledgable, honest and ethical in helping clients evaluate Medicare options and get enrolled. He made the process extremely easy for myself and my husband.
Dale SimsDale Sims
16:28 11 May 23
John did a great job of explaining Medicare and supplemental insurance. He was thorough and patient. He answered all of my questions. I greatly appreciated his help.
Leeann MoosLeeann Moos
17:26 06 Apr 23
When I became eligible for Medicare, my phone was constantly under attack from Medicare options sales folk. Since I needed help understanding my options and life is too short to do business with annoying people a little research was in order. Thats how I found John. His other customers seem very pleased with his service and I decided to give him a try. I was NOT disappointed! He did an excellent job for me, is extremely personable and I could not be happier. Thank you John
Rose WrightRose Wright
16:07 05 Apr 23
I am so thankful for the help that Mr. John was able to assist me with medicare information. After being bombarded with letters and phone calls you just need someone who can walk you through the confusion. And after getting all the info and the best plan and benefits for what i needed. I am glad that He was there for me.Thank you so very much,Rose Wright
Steve HenselSteve Hensel
21:08 04 Apr 23
Claeys Group is great to work with. John is truly professional, knowledgeable and makes the entire process flow so much more smoothly than I expected. I would highly recommend him.
Deborah RounsavallDeborah Rounsavall
14:25 07 Mar 23
I changed from my person finance planning group to John for help. Others led me astray. John is very responsive and follows up promptly. Even helped me on the weekend at the end of year to get all my documents in on time so I didn't lose insurance coverage. Explains all the options in a manner that us rookies can understand it. I highly recommend John.
Setella ParksSetella Parks
13:12 07 Mar 23
John's knowledge is invaluable when it comes to navigating the murky water of Medicare plans. He answered all our questions in a manner we could understand and helped us compare benefits between plans, services, and providers readily available in our area. I am so happy we called on him to assist us! He handled EVERYTHING professionally and patiently and has followed up to make sure we are good. Highly recommend his 5 star service!
Sherry JonesSherry Jones
21:01 23 Feb 23
John was recommended by my sister-in-law, who spoke very highly of him. He wrote out the differences between policies and explained it step by step to me so I could understand which policy would be best for my needs. He was professional but also down to earth so I could be at ease. He did this at my bed side which was such a blessing for me. I highly recommend John for your Insurance needs.
T/D HT/D H
19:40 20 Feb 23
We were recommended by friends to call John Claeys for our insurance. He came twice to gather information on what we were looking for and returned with information and details. We are delighted to have John Claeys as our agent and would recommend to our friends and anyone else to call John Claeys today.Tom and Debbie
Joyce SandvikJoyce Sandvik
20:32 30 Aug 22
John Claeys came to our house to talk about all aspects of Medicare. He wrote out some information on a notepad as he talked and answered our questions. He gave us the handwritten notes along with printouts of more information specific to my needs. My husband and I took o a few days to discuss the options. John took a list of my medications and researched all the available prescription insurance policies for me. He narrowed it down to the best policy (best prescription prices) for me. It was so easy and I felt confident I was getting exactly what I need when I turn 65. Every September, he will research prescription policies from my updated list of medications to find the best policy for my needs. Thanks to John Claeys for making this transition extremely easy and effortless.
Marilyn ScottMarilyn Scott
09:35 23 Jul 22
John enrolled my husband into Medicare 4 years ago. I knew then I wanted him to help me with my Medicare when it was my time to enroll. John helped me recently. He is very knowledgeable, humble and so patient. He made sure I had the best plan for me. He genuinely cares about his clients. He is the best insurance consultant! I highly recommend John for your Medicare needs!!
James MartinJames Martin
20:31 20 Jun 22
John did a great job of providing many options for my insurance. He is very thorough.
Judy MarkmanJudy Markman
17:02 20 Jun 22
John goes above and beyond to find the best insurance to fit your needs at an affordable price. I definitely recommend!
Dave LemingDave Leming
16:56 20 Jun 22
John was referred to my wife and I as we began to transition to use Medicare as our insurance options. He was very knowlegeable about all things related to government programs and supplemental options as well. I would strongly recommend his services to anyone requiring such support.
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