Q: Is the coverage provided by Medicare as good as the coverage I’ve always had from my employer?
A: If you enrolled only in Original Medicare, you would almost certainly notice gaps in coverage that you didn’t have under your employer-sponsored insurance (ESI) plan. But here’s the thing: most Medicare enrollees don’t go with the barebones coverage. 81 percent of Original Medicare enrollees have some sort of supplemental coverage (generally Medigap, employer-sponsored insurance, or Medicaid), according to a Kaiser Family Foundation analysis.
The good news is that Medicare beneficiaries who have supplemental Medicare coverage will generally find that their resulting coverage is quite comprehensive. And depending on the cost of the employer-sponsored plan (including premiums and out-of-pocket costs), some people also end up with lower overall healthcare costs once they switch to Medicare.
Original Medicare + Part D + Medigap
If you opt for Original Medicare plus a Part D Prescription Drug Plan and a Medigap supplement, the coverage is likely to be just as good as what you had previously from your employer. Depending on which Medigap supplement and Part D Prescription drug plan you choose, your out-of-pocket expenses could end up being very minimal.
There are Medigap supplements that cover all or nearly all of Original Medicare’s out-of-pocket charges, with the exception of prescriptions, which are covered by Part D plans. Part D prescription drug plans currently still have a donut hole, but that is slowly being closed as a result of the ACA, and will be gone by 2020 (it closed a year early, in 2019, for brand-name drugs, and will close for generics as of 2020; once the donut hole is closed, enrollees in standard Part D plans pay 25 percent of the cost of their drugs until they reach the catastrophic coverage threshold).
Original Medicare paired with a Medicare Part D Prescription Drug Plan and a Medigap supplement provides very solid coverage, and it also gives you access to most doctors and hospitals across the nation. When compared with the more limited provider networks that commercial health insurance plans typically have, the access to doctors and hospitals under Medicare is likely to be a welcome change for many new Medicare beneficiaries.
But that’s not your only coverage option. You can choose a Medicare Advantage plan instead of Original Medicare plus supplemental coverage.
Medicare Advantage plans are often relatively inexpensive—some have no premium at all other than the cost of Medicare Part B. And Medicare Advantage plans come with built-in caps on out-of-pocket exposure, limited to $6,700 in 2019, although that does not include the cost of prescription drugs. (Although Medicare Advantage plans have caps on out-of-pocket costs, Original Medicare does not. This is why Medigap supplements are so important if you enroll in Original Medicare.)
Medicare Advantage plans can also include dental and vision coverage, which isn’t covered under Original Medicare. But Medicare Advantage plans have the same sort of provider network restrictions as other commercial health plans.
If you enroll in just Original Medicare—without a prescription plan or a Medigap supplement—you may find that your Medicare coverage is not as good as the coverage you had with your employer. But if you add the available supplemental coverage, or if you shop for a solid Medicare Advantage plan, you’ll likely find that the coverage you get with Medicare is just as good as—or maybe even better than—the coverage you had with your employer.
What about costs compared to ESI?
In 2018, the average employee premium cost for employer-sponsored health insurance was $1,186, or about $99 per month (this is far lower than the actual cost of coverage, but employers pay an average of more than 80 percent of their employees’ premiums.) In addition to the premiums, the average employer-sponsored plan had an annual deductible of $1,350 in 2018.
When you switch to Medicare, Part A is usually free. Part B costs $135.50 per month for most enrollees in 2019 (higher-income enrollees pay more.) Original Medicare is comprised of Part A and Part B together, although if you continue to work after age 65, you may want to consider delaying your enrollment in Part B and using your employer-sponsored coverage instead.
If you want to add supplemental coverage, the average Part D Prescription Drug Plan costs about $41 per month in 2019 (higher-income enrollees pay more.) And the average Medigap premium for Plan F (the most comprehensive Medigap coverage, which is very popular with enrollees) in 2018 was $143 per month.
The average Medicare Advantage premium in 2019 is about $40 per month (for Medicare Advantage plans that include Part D prescription coverage), in addition to the cost of Part B. Most Medicare Advantage plans include deductibles, and their out-of-pocket maximum can be as high as $6,700 in 2019.
So if we look only at the averages, Original Medicare plus a Medigap Plan F and a Part D Prescription Drug plan would cost roughly $320 per month ($135.50 plus $41 plus $143), while Medicare Advantage would cost roughly $176 per month (about $40 plus $135.50). Of course, the actual numbers vary considerably depending on where you live and which plans you select once you enroll in Medicare. And again, keep in mind that Original Medicare plus a comprehensive Medigap plan and a Part D plan could leave you with very little in the way of out-of-pocket costs, whereas a Medicare Advantage plan can have out-of-pocket costs as high as $6,700, in addition to out-of-pocket costs for prescriptions.
To see how your costs under Medicare will compare with what you pay now for your employer-sponsored plan, you’ll want to consider the premiums as well as the out-of-pocket costs for the various coverage options available to you, and see how they stack up against your employer-sponsored coverage.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.