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How’s Your Health?

Your medical condition should be top of mind as you evaluate your Medicare coverage

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Your health care needs are a key factor in any Medicare decision, from your daily pill regimen to your preexisting conditions to your desire to keep a favorite doctor.

Many Americans have trusted doctors who have taken care of them for years, and they’d like to keep going to them once they are covered by Medicare. If that sounds like you, the first thing you might want to do before making any coverage decision is to ask your doctors if they accept Original Medicare and if they participate in any Medicare Advantage plans in your area.

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According to the Kaiser Family Foundation, 93 percent of primary care physicians accept Original Medicare, so the odds are good that your current physician does. Under Original Medicare, you don’t need a referral to see a specialist, as long as the specialist accepts Medicare.

On the other hand, Medicare Advantage plans have specific networks of medical providers. Some plans let you go to a doctor outside the network, but generally you’ll pay more out of pocket to see those providers. Many Medicare Advantage plans require a referral from a primary doctor to see a specialist. The government’s Medicare Plan Finder can help you find Medicare Advantage plans in your area, and it also lists the doctors within each plan.

Your preexisting conditions

One of the great things about Medicare is that it covers existing medical conditions, regardless of whether you chose Original Medicare or Medicare Advantage.

But that’s not always the case with Medicare supplemental insurance, commonly known as Medigap policies. These private plans help you pay for out-of-pocket costs not covered by Original Medicare. For example, they would pay the 20 percent of your doctor bill and lab tests, screenings and other outpatient services that Original Medicare doesn’t cover. They also pay for the Part A deductible you are charged each time you’re admitted to the hospital. Some Medigap policies also have an out-of-pocket limit so once you’ve spent a certain amount on your health care in any year, the policy picks up 100 percent of any subsequent charges.

In order to make sure these policies cover your preexisting condition, you have to sign up at the right time. The window to purchase them is within six months of enrolling in Part B. If you don’t, the insurance companies offering Medigap policies can refuse to sell you one, charge you a higher premium because of your medical problems, or refuse to cover any medical problems you had before you bought their insurance.

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Keep this in mind as you enroll in Plan B, but also if you decide later to switch from Original Medicare to a Medicare Advantage plan. While the government has created a specific program allowing Medicare beneficiaries to try out a Medicare Advantage plan on a short trial basis — between Jan. 1 and March 31 of each year — if you opt to return to Original Medicare you may have difficulty getting a Medigap policy.

“Generally, people may not be able to switch Medigap plans, depending on where they live, or will have to pay more, depending on their age, medical requirements and/or other factors,” says Fred Riccardi, vice president of client services at the Medicare Rights Center. “For instance, companies can refuse to sell you a Medigap policy or impose certain medical requirements.”

There are some circumstances when beneficiaries who want to switch from Medicare Advantage to Original Medicare can purchase a Medigap plan without worrying about their preexisting conditions:

  • If you leave Original Medicare and buy a Medicare Advantage plan for the first time and revert back in less than a year.
  • If you select a Medicare Advantage plan when you first enroll in Medicare but decide within the first year that you want to switch to Original Medicare.

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