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Is Basic Medicare Coverage Enough for You?


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Summary: Original Medicare coverage generally has no out-of-pocket maximum and doesn’t cover important things like prescription drugs. Additional coverage from private insurance companies can help meet your healthcare needs.

At age 65, most people in America qualify for Medicare Part A and B (Original Medicare), which is basic Medicare coverage. Basic Medicare coverage provides hospital and medical insurance but leaves out coverage for many things, including most prescription drugs you take at home.

Basic Medicare coverage still leaves Medicare recipients vulnerable to many out-of-pocket expenses and has no out-of-pocket maximum. That’s why most people wonder if basic Medicare coverage will provide enough protection during their retirement years.

Is Original Medicare coverage enough?

Most people get Part A for free and pay a premium each month for Part B. To understand why basic Medicare coverage from Part A and Part B may not provide you with enough health insurance, you can consider basic Medicare coverage costs:

  • Medicare Part A: Medicare Part A charges patients an inpatient deductible of $1,364 per benefit period in 2019. After day 60 in the hospital, you’ll have a coinsurance of $341 a day, and after day 91, the coinsurance goes up to $682 each day per “lifetime reserve day.” After your lifetime reserve days are used up, you pay all costs.
  • Medicare Part B: Besides the yearly deductible, you pay 20 percent of allowable charges for most covered healthcare. You may be responsible for a percent of an unknown number and not know the number until you get the bill. So it could be 20% of $300, or 20% of 5,600.

Prescriptions covered by basic Medicare

As an inpatient or outpatient, you get very limited Medicare coverage for prescriptions with Medicare Part A and B. For example:

  • Medicare Part B usually only helps pay for the types of outpatient prescriptions that must be administered by a healthcare professional. This limited drug coverage might extend to prescriptions that you have injected or infused. It may pay for some drugs you can administer yourself, like injectable blood-clotting medicine. Medicare Part B also won’t cover insulin and insulin supplies unless you have an insulin pump that is medically necessary.
  • Part A generally covers prescription drugs that you get as an inpatient in a hospital or other facility.

Basic Medicare Part A and B will generally not cover the prescriptions you might pick up at your corner pharmacy. For Medicare coverage of typical prescriptions, you have two choices:

  • A stand-alone Medicare Part D prescription drug plan
  • A Medicare Advantage plan that includes prescription coverage

If you don’t join a Part D plan or have other prescription drug coverage, you risk having expensive pharmacy bills. Also, you can get penalized by having to pay more for Part D if you delay enrollment.

Enhance Medicare coverage with Medicare supplements or Medicare Advantage

You might already have a complementary health insurance plan like TRICARE that will reduce out-of-pocket costs. If not, you can consider either a Medicare Supplement Insurance Plan or a Medicare Advantage plan. You need to qualify for both Part A and B to take either of these plans. They may both perform similar roles in helping you control medical expenses with Medicare coverage, but they work differently:

  •  Medicare Supplement Insurance Plans: After Medicare Part A and Part B pay their share, Medicare supplements will pay their share. Some Medicare Supplement Insurance Plans even provide coverage that’s not included in Part A and B. For example, some Medicare Supplement Insurance Plans may pay a portion of the cost for emergency health needs outside of the USA.
  • Medicare Advantage: Medicare Advantage plans will provide you with Medicare coverage in a different kind of plan. Instead of having Medicare pay your benefits, the government will help fund the plan, but the insurer will pay their share of your costs. You can get your hospital, medical, and prescription drug coverage bundled into one convenient Medicare Advantage plan.

Note that many Medicare Advantage plans come packaged with Part D. On the other hand, Medicare Supplement Insurance plans typically do not.

As a Medicare beneficiary, you have many coverage choices. Enter your ZIP code on this page to begin searching for additional Medicare coverage like:

  • Medicare Advantage all-in-one plans
  • Medicare Supplement plans to cover out-of-pocket costs
  • Stand-alone Medicare Part D Prescription Drug Plans

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