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The Crucial Decision of Choosing Between Original Medicare and Medicare Advantage The Crucial Decision of Choosing Between Original Medicare and Medicare Advantage

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The Crucial Decision of Choosing Between Original Medicare and Medicare Advantage

As you near retirement, certain key ages become paramount. At 67, born in 1960 or later, you reach full retirement age, making you eligible for the full benefits based on your work history. Make no mistake: ponder the age at which to claim Social Security carefully, as you can start collecting smaller checks at 62, or even bump up the sum if you wait till 70.

Another milestone is your 65th birthday, the age at which you can sign up for Medicare. In a nation where healthcare costs are exorbitant, this choice carries significant weight. Missing the enrollment deadline can prove costly, haunting you for the remainder of your life.

A person is grimacing.

Image source: Getty Images.

Understanding the Medicare Maze

Enrolling in Medicare is no walk in the park. With different Medicare options available, careful consideration is crucial. You’ve got “original” Medicare with its Parts A and B for hospital and medical coverage respectively, along with Medicare Advantage plans, also known as Part C. The latter boasts more enrollees than the former.

Considering “original” Medicare? You should likely add Part D for prescription drugs and possibly a Medigap plan to supplement your coverage. See? It’s complicated.

Here’s a snapshot of the pros and cons of both original Medicare and Medicare Advantage.

Original Medicare

Pros

Cons

You typically cover just 20% of expenses.

No out-of-pocket spending cap could translate to spending a fortune.

Accepted widely by providers across the U.S.

Partial coverage might necessitate a supplemental Medigap plan to lower costs.

No specialist referral typically required.

Lacks coverage for hearing, vision, and dental care.

Data source: author research.

Medicare Advantage

Pros

Cons

Part B coverage is universal, with premiums potentially as low as $0.

Out-of-network providers can be an issue when traveling, although emergency treatment is covered.

Augmented coverage over original Medicare, including hearing, vision, dental, and drugs.

Tethered to a network, unless additional payments are made.

Out-of-pocket spending caps are imposed on expenses. For 2024, the ceiling is $8,850 for in-network services (excluding drugs) or $13,300 if some out-of-network providers are permitted. Certain plans feature lower caps.

Copayments are common during appointments.

Periodic switching to original Medicare is an option.

Transitioning back to original Medicare later might cost more for a Medigap plan, or coverage could be denied altogether.

Quality ratings on Medicare Advantage plans allow for optimization.

Specialist referrals are often a prerequisite.

Opting for Medicare Advantage can streamline the process compared to original Medicare, Part D, and a supplemental plan.

Some treatments denied by your plan that would’ve been covered by original Medicare. About 6% of authorization appeals were dismissed in 2021, though many were later overturned, as per a Kaiser Family Foundation report.

Data source: author research.

It’s wise to delve deeper into each option before making a decision. Original Medicare or Medicare Advantage could prove more favorable, depending on myriad factors like your health, preferences, and specific needs.

Timely Enrollment in Medicare

When’s the right time to enroll in Medicare? You can commence the process three months before turning 65, through your birth month, or within three months post your birthday — constituting the “Initial Enrollment Period” of seven months.

Enrolling before your 65th birthday month will trigger coverage starting that month. Joining during your birthday month or the subsequent three months will kickstart coverage the following month.

Failing to enroll promptly carries a hefty 10% penalty for each year beyond the deadline. This surcharge gets added to your Part B premium, a cost you’ll bear for your Medicare duration. There could also be a penalty for late Part A registration, stretching double the time you delayed signup. If three years late, prepare for six years of penalties.

Consider an illustration: Skipping Medicare enrollment for three years would levy a 40% charge on your standard $174.70 monthly premium (for most individuals in 2024), totaling $69.88, elevating your monthly payment to $244.58. Over a year, instead of $2,096.40, anticipate shelling out $2,934.96 — a whopping $838.56 extra. The 40% markup stays and compounds annually, likely for the duration of your Medicare tenure.

However, certain exceptions offer solace:

  • If you’re receiving Social Security benefits pre-turning 65, you’re typically auto-enrolled in Medicare, likely sparing you a penalty. Verify the enrollment nonetheless to avoid complications.
  • If covered by an employers’ group health plan at 65 due to your or your spouse’s ongoing employment, Medicare signup can wait. Be ready to enroll upon leaving your job.
  • Enrollment delays due to natural disasters or qualifying crises might permit penalty-free late registration.
  • Various extenuating circumstances, like volunteering abroad during your Initial Enrollment Period, offer flexibility.

Each of us must ponder Medicare decisions as retirement nears, selecting the appropriate plan and signing up punctually.

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The views and opinions expressed herein are solely those of the author and do not reflect Nasdaq, Inc.’s viewpoints.