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How to Get the Most Out of Your Medicare Plan in Texas

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A comprehensive understanding of the available options and careful decision-making can help ensure you have Medicare coverage that meets your needs and saves you money. Below are some strategies to help you get the most out of your plan.

Understand the Basics

Medicare is a federal health insurance program for people aged 65 and older, certain younger people with disabilities, and those with end-stage renal disease. Being familiar with its structure and options will help you make choices to maximize your benefits.

Part A includes inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. 

Part B covers medical expenses, like certain doctors’ services, outpatient care, medical supplies, and preventive services. 

Part C, or Medicare Advantage, is an alternative to Original Medicare, which offers Part A and B coverage through private insurers approved by Medicare and includes some additional benefits. 

Part D includes prescription drug coverage.

Supplemental plans, or Medigap, can also be selected to provide the coverage for gaps in Medicare that you may need.

Because the opportunity to change plans is limited, review your options carefully to ensure your plan meets your needs, so you aren’t stuck with an unsuitable plan. If changes are necessary, use the Medicare Open Enrollment Period from October 15 to December 7. During this time, review your current coverage, consider any upcoming changes, and compare your plan to other available options to ensure it still meets your needs.

Assess Your Health Care Needs:

When choosing a Medicare plan, consider the frequency of doctor visits, as frequent visits might warrant a plan with lower co-pays and co-insurance. For chronic conditions, opt for a plan with comprehensive coverage and a wide provider network. Evaluate your prescription drug needs and compare Part D plans or Medicare Advantage plans with drug coverage. Original Medicare offers more flexibility in healthcare providers but may have higher out-of-pocket costs and requires separate Part D coverage. Medicare Advantage often includes additional benefits like dental, vision, hearing, and prescription drugs, with generally lower out-of-pocket costs but has limited provider networks.

Take Advantage of All Extra Services

To maximize your Medicare benefits, take full advantage of available services. Preventive services such as screenings, vaccinations, and annual wellness visits help maintain your health and catch potential issues early. Engage in wellness programs offered by many Medicare Advantage plans, including weight loss programs, smoking cessation support, and others. Telehealth services offer convenient access to healthcare providers without the need for travel, which is particularly helpful if you are in a rural area to give you access to the care you need.

Maximizing Your Medicare Advantage Plan

Medicare Advantage (Part C) plans offer an alternative to Original Medicare, often including additional benefits such as dental, vision, and wellness programs. 

To maximize your Medicare Advantage plan, familiarize yourself with the provider network of doctors, hospitals, and specialists. Visiting in-network providers will minimize your out-of-pocket costs. Be aware of any referral requirements for seeing specialists to avoid unexpected expenses.

Take advantage of any additional benefits your plan offers, including preventive services, vision, dental, or hearing coverage. Schedule regular check-ups, and participate in wellness programs and health education programs.

For prescription drug coverage, be aware of your plan’s formulary to ensure your medications are included and understand the cost-sharing structure for each drug tier. Use preferred pharmacies within your network to reduce costs, and consider mail-order services for long-term medications for added convenience and savings.

Optimizing Your Medicare Supplement (Medigap) Plan

A Medicare Supplement (Medigap) plan is purchased on top of Part A and B to cover the additional costs you would pay that Medicare doesn’t cover.  

Review plans carefully before deciding, and afterwards to be sure of what your plan covers and your out-of-pocket responsibilities. Some plans cover Part B excess charges, eliminating additional payments beyond the Medicare-approved amount.

Medigap plans have no network restrictions, allowing you to see any doctor or specialist who accepts Medicare. This flexibility is especially beneficial if you travel throughout the US or require multiple specialists. 

Track your medical expenses, including co-pays, coinsurance, and deductibles, to manage your budget. Understand your Medicare Advantage plan’s out-of-pocket maximum, where applicable, to plan for 100% coverage after reaching the limit. Regularly review your prescription drug plan’s formulary and compare medication costs at different pharmacies. If medication costs are high, consider applying for Extra Help, a program assisting with prescription drug payments for those with limited income and resources.

Annually review the Annual Notice of Change for updates on coverage, costs, and service areas. Keep the Evidence of Coverage handy for detailed information on your plan’s coverage and your member rights and responsibilities. Staying informed ensures you understand your benefits and any plan changes.

Maximize Drug Coverage

Ensure your medications are included in your plan’s formulary, or the list of drugs covered. Discuss cheaper generic alternatives with your doctor or pharmacist, and confirm that any necessary brand-name drugs are covered by your provider. Since formularies can change, stay proactive in monitoring your coverage.

Monitor your medication expenses throughout the year. Try to stay in the initial coverage phase as long as possible, by timing and managing costs. This is the phase after your deductible, where you pay all costs, and before the donut hole, and have the best coverage. Use in-network pharmacies to lower costs; some plans offer even lower prices at preferred pharmacies. While getting a 90-day supply might seem like it would push you into the coverage gap faster due to higher upfront costs, it can actually provide savings through lower copayments per dose, so consider using mail-order pharmacies for a three-month supply of medications. Furthermore, coordinate any other insurance benefits to minimize out-of-pocket expenses.

If your plan denies a service or medication, you have the right to appeal, but be sure you know the process and can support your case.

The best way to maximize your Medicare plan benefits is to have a plan that fully matches your needs; Wise Insurance is here to help you, putting your best interests first.

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