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Originally published Saturday, February 15, 2014 at 8:02 PM

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The basics of Medicare-related insurance decisions

Take some time to study up on health-care plans. To begin with, seniors have three fundamental choices when they turn 65: They must sign up for Medicare and enroll in Medicare Part B and Medicare Part D for medical and prescription coverage, respectively.

Syndicated columnist

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Good information but one correction, PFFS plans do not have a network you can go to any... MORE
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Q: Please give us some information about Medicare Advantage plans. We were switched last year by our insurance company to one and are not sure that it is the best option for us.

A: Medicare Advantage plans function as a substitute for Medigap insurance.

Seniors have three fundamental choices when they turn 65: They must sign up for Medicare and enroll in Medicare Part B and Medicare Part D for medical and prescription coverage, respectively.

Medicare, however, doesn’t cover all costs and, more important, does not have a limit on our maximum out-of-pocket expenses.

Medigap policies are standardized insurance policies from private insurers that cover many of the expenses not covered by Medicare and also have an out-of-pocket expense limit, typically $5,000 to $6,700.

These policies become more expensive as you age, which means their premiums can become intimidating.

Medicare Advantage plans are private health-insurance plans that wrap around Medicare and provide additional benefits and an out-of-pocket limit, much like the Medigap policies.

The additional premium for these plans varies from $0 to about $100 a month — in addition to the basic Medicare Part B premium. Some also include prescription-drug coverage.

The big decision with these plans is whether you join one that is an HMO (Health Maintenance Organization), PPO (Preferred Provider Organization) or PFFS (Private Fee For Service).

In an HMO or PPO, your choice of doctor will be limited to participating doctors, and you may also have to go through a “gatekeeper” doctor who makes referrals to specialists when needed.

In a PFFS, you can go to any doctor you choose, provided he or she has contracted with the insurance company. (Note that this is not the same as going to any doctor you choose.)

The next step would be to see if the doctors you visit participate in the plan you are considering.

You will find that many doctors participate in multiple plans, so a PPO may not be as limiting as you’d expect it to be. On the other hand, it may also turn out that the specialist suggested by your internist may not be a participant.

The best way to learn more is to visit the Medicare website ( and start exploring. Then check the list of doctors (or ask your doctor) to see if he or she has contracted with the insurance company you are considering.

You should be patient and devote some real time to learning how the site works. I think all of us suffer from what might be called Acquired Impatience Syndrome these days. This is a good place to take a relax pill.

The website has a calculator that will consider your location and your list of medications, and sort through the available plans in your area. It will provide a list of plans with an estimate of total annual costs for each. Good luck.


Copyright 2014, Universal Press Syndicate

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