Medicare: What's Covered and What's Not

• Premium: Varies. For a 65+ in excellent health, insurers in my county are charging from $60 to $250 a month per person.
• Out of Pocket: Varies
• Providers: Anyone who takes Medicare Hospital & Medical

Part C: Medicare Advantage from a private insurer 

When managed care was introduced for Medicare recipients, many insurers entered the market only to withdraw after a few years, leaving their policyholders unable to get coverage at the same rates. While this market has settled down, there is still a slight risk that this might happen again. Medicare Advantage Policies cover parts of A (hospitalization), B (medical), and D (prescription) and may cover other things, such as vision or dental. These are purchased from a private insurer and feature a "network" of authorized medical providers, much like an HMO or PPO, that restrict which providers you may see in order to be covered.

• Premium: Varies, perhaps slightly more than A+B+D together
• Out of pocket: Varies
• Providers: Restricted to a network of providers. Utilization outside of network may result in higher costs or denial of coverage.

Part D: Prescription

View an Instructive Diagram of Medicare Part D

Anyone who is taking significant prescriptions or who may take significant prescriptions may want this coverage. While the premium may exceed the cost of prescriptions while healthy, you may find that it works well if you need medication due to an illness. This is a particularly tricky one to figure out the point at which you break-even on the premiums due to the complex nature of the way it pays for medication.

• Premium: Varies, less than $100 a month
• Out of Pocket: Varies. An example, after a deductible near $250 a year, you pay 25% until you've paid over $500, and then you pay about another $1500 before you get benefits again: where you pay 5% of prescriptions. Confusing? Yes!
• Providers: Most pharmacies

Your Medicare Mileage will vary...

It may take some work to figure out the best Medicare options for you and your spouse. There are a few other things to keep in mind before jumping in:

• Get a good insurer - if you're selecting Medigap or Medicare Advantage, you'll be working with a private insurer - and there is variance in satisfaction.
• Make sure you play by the rules - ask first, don't assume, make sure it is necessary or covered when possible.
• Know when to appeal - to the insurer, to the government.
• Never miss a payment - if you do, you may not be able to get back into the plan, and if you can you may have to wait or pay a higher rate.

What is and is not payable under the plan is always changing - new items are added regularly, and things that you might have had last year may no longer be covered. You should check with your provider to determine what they believe is covered - and hold them to it. If in doubt about coverage of specific items, check with the Medicare Coverage website.

Jonathan Pletzke is a consumer expert on health insurance and author of the health insurance book Get a Good Deal on Your Health Insurance Without Getting Ripped-Off, available online and at bookstores nationally. Additional details can be found at the consumers health insurance book and resources website.