If you turn 65 soon, Medicare is probably on your mind. You know you need to enroll. You know there are choices to make. And if you feel confused about what those choices are, you’re not alone.

Traditional Medicare and Medicare Advantage sound similar, but they work in different ways. Understanding those differences can help you choose the best fit for you.

How Traditional Medicare Works

Traditional Medicare is the federal health insurance program that’s been around since 1965. It’s run by the government, which means the rules are the same no matter where you live.

You get two parts:

Part A covers hospital stays, skilled nursing facilities, hospice care and some home health services. You don’t usually pay a premium for Part A if you or your spouse paid Medicare taxes while working.

Part B covers doctor visits, outpatient care, lab tests, medical equipment and preventive care. You pay a monthly premium for Part B, which is usually deducted from your Social Security check.

What That Means in Practice

• You can see any doctor or go to any hospital that accepts Medicare. No network. No referrals. If you need a specialist, you make an appointment. If you want a second opinion, you get one.
• You know the cost structure. For many covered services, Medicare pays 80% after you meet your deductible. You typically pay the other 20%.
• You can add coverage where you need it. Take medications? Add a Part D prescription plan. Want help with that 20% coinsurance? Add a Medigap policy. You build what works for you.

What Traditional Medicare Doesn’t Cover

• Prescription drugs. You need a separate Part D plan for that.
• Dental, vision and hearing. Routine cleanings, eye exams, glasses and hearing aids are out-of-pocket expenses.
• Out-of-pocket costs are unlimited. You’re responsible for 20% of covered services with no annual cap. If you have a serious health issue that requires ongoing care, that 20% can add up. Medigap helps cover it, but that’s another monthly premium.

How Medicare Advantage Works

Medicare Advantage (also called Part C) is run by private insurance companies that contract with the federal government. These plans cover everything Traditional Medicare does, and most include prescription drug coverage. You can also add extras like dental, vision and hearing coverage.

Here’s How it’s Different

• You’re tied to a network. You have to use doctors and hospitals that participate in your plan. If your doctor doesn’t take your plan or drops it, you’ll need to find a new one or pay to stay.
• You may need permission to see specialists. Some plans require referrals and prior authorizations, which means extra steps and possible delays.
• Your costs are capped. Unlike Traditional Medicare, Medicare Advantage plans limit your total out-of-pocket expenses each year. That provides some protection if you need a lot of care.
• Premiums vary widely. Some plans advertise $0 premiums, but they usually come with higher copays, deductibles, drug costs and tighter network restrictions.

What You Give Up with Medicare Advantage

• You can’t just switch doctors or see any specialist you want. You’re working within a network, and if you go outside it, you pay.
• The ability to add Medigap. If you pick Medicare Advantage, you can’t use a Medigap policy. If you decide to switch back to Traditional Medicare and want Medigap, you might face medical underwriting and higher premiums.

Which One Makes Sense for You

This decision comes down to what you value and what you’re willing to trade off.

Traditional Medicare makes sense if you want to choose your own doctors, see specialists without referrals or travel frequently. It also makes sense if you want the flexibility to change providers as your health needs change.

Medicare Advantage makes sense if you’re comfortable staying in a network, don’t mind getting referrals for specialists and want lower monthly premiums. The out-of-pocket cap can also provide peace of mind if you’re worried about high costs.

Neither plan is inherently better. They’re different. And what works for you now might not work for you in five years. That’s okay. You can switch during Open Enrollment (October 15 to December 7 each year) if your needs change.

How This Affects Home Health and Hospice Care

If you’re considering in-home care, both Traditional Medicare and Medicare Advantage cover home health and hospice services when they’re medically necessary.

The difference is in how you access that care. Traditional Medicare lets you choose any Medicare-certified agency. Medicare Advantage plans may require you to use providers within your network.

Ohioans Home Health & Hospice works with both. We’re Medicare-certified and accept Traditional Medicare and many Medicare Advantage plans. If you have questions about what your plan covers or how our services work with your coverage, call us at 855-600-0806 or contact us.

Trying to figure out Medicare and Medicaid can leave your head swimming with questions. What do I qualify for, and what are my coverage options? Ohioans Home Health & Hospice will help you compare coverage programs and determine which option is best for you.

Medicare vs Medicaid

What is Medicare?

Medicare is an age-based healthcare program funded by the federal government for people 65 and older. People under 65 with particular diseases and disabilities may also qualify. Medicare is paid for by the public, like an income tax. You’re automatically enrolled in Medicare once you turn 65.

What is Medicaid?

Medicaid is also a publicly funded healthcare program run by both federal and state governments. Medicaid is based on an individual’s income status. Coverage options vary because it is partially regulated by state governments.

Qualifications for Medicare

Medicare is split into Parts A, B, C, and D. To qualify for Parts A and B, you must be 65 or older, or disabled and collecting Social Security for at least two years. Part B is optional, and you must sign up during enrollment periods.
Part C, or Advantage Plans, requires the same criteria as Parts A and B but excludes individuals with renal diseases and those in hospice care.

Medicare Coverage Options

• Part A: Hospital services, part-time skilled nursing care and home health aide services, physical/occupational/speech therapies, and home medical supplies. Does not cover dental or vision.
• Part B: Medical services, like preventative and screening tests, and comes with additional costs. Similar home health care coverage as Part A. Does not cover dental but may cover basic vision tests.
• Part C/Advantage Plans: Similar coverage to Parts A and B and may cover prescription drug expenses. Advantage Plans offer coverage through Medicare-approved insurers and may include dental and vision.
• Part D: Prescription drugs.

Qualifications for Medicaid

The qualifications for Medicaid vary depending on your income, disability, the size of your household, and family status. Applying for Medicaid can take weeks to months and may require medical screening and documentation of past and present financial hardship. Qualified Medicaid applicants include:

• Low-income families and individuals
• Pregnant women
• Teenagers living alone
• Elderly, blind, or disabled
• Parents of sick children
• Those with high medical costs

Medicaid Coverage Options

Medicaid offers mandatory coverage of some services, but states decide which auxiliary services are covered. Coverage includes:

• Dental: Preventative, medical, and surgical dental services for adults, and all dental care for children.
• Vision: Eye exams, glasses, and optometry services
• Medical: Hospitalization/clinic services, labs and X-rays, family planning and midwife services, home healthcare for those eligible for nursing facilities, and doctor and nursing services
• Home health services: Part-time professional medical care, custodial home care, housekeeping services, medical equipment, and transport assistance

Can You Qualify for both Medicare & Medicaid?

You can qualify for both Medicare and Medicaid. Most healthcare costs are covered if you have dual eligibility, including costs incurred from Medicare Parts A and B. If you qualify for Medicare but cannot afford your monthly premiums and deductibles, Medicaid can typically bridge the coverage gap.

Call 855.600.0806 or contact Ohioans Home Health & Hospice online to learn more about our skilled nursing services.