Toni Says: Which Medicare option is right for you

Reader Alert: Medicare Advantage and standalone Medicare Part D plans with specific 2025 plan changes and new prescription drug formulary updates were scheduled to be released on the Medicare.gov website Oct. 1. This column was written before changes were announced.

Hello Toni: Thank you for teaching us the value of finding the right Medicare option for my husband, Clint, and me. When he retired at age 70 a few months ago, Clint was determined to go with Medicare Advantage PPO plan because it had a $0 monthly premium and thought there was no difference between a Medicare Supplement and a PPO plan except cost.

Last week Clint received a life-changing diagnosis of terminal lung cancer. Had we chosen the PPO Advantage route, then Clint and his medical team would not be in control of his health care. Please let your readers know of our situation because health care needs can change in a flash, like Clint's did! Thanks, Toni. — Raquel, from Springfield, Mo.

Hi Raquel: Americans need to understand that there are differences between Original Medicare and a Medicare Supplement and Medicare Advantage PPO Plans other than the premium.

With Original Medicare, there is not a network of any kind; you have the freedom to use any health care provider/facility that will bill Medicare. The Medicare Supplement that you enroll in will pay for the out-of-pocket costs not covered by Medicare Parts A and B.

With a Medicare Advantage PPO (MA PPO) plan with low premiums, there are lower costs for in-network providers/facilities but higher out-of-pocket costs for out-of-network benefits. To review 2025 Medicare Advantage (MA) PPO plan out-of-pocket costs, check your new 2025 Medicare & You handbook or search www.medicare.gov.

Most people on a MA PPO plan never consider they may pay an out-of-network health care provider/facility for their medical claim. In these changing medical times, many providers or facilities are out of network.

Below are differences between a Medicare Supplement and Medicare Advantage PPO plan:

Medicare Supplement

1. Medicare Supplements work directly with "Original" Medicare. Medicare pays its share of the Medicare-approved amount for "medically necessary" covered health care costs.

2. The Supplement you pick will pay its share of the medical claim for the health care provider/facility providing the medical care.

3. Medicare Part D prescription drugs plans are not included in a Medicare Supplement. It is important to have your "stand alone" Medicare (Part D) prescription drug plan to begin the same month the Supplement does.

4. The downside to a Medicare Supplement is the monthly premium can increase each year.

Medicare Advantage PPO Plan

1. To qualify for any Medicare Advantage plan, you must be enrolled in both Medicare Parts A & B and must live in the service area 6 months out of the year.

2. Medicare pays the insurance company a specific dollar amount every month for your medical care to the Medicare Advantage Prescription Drug (MAPD) plan you are enrolled in.

3. When you go to the doctor, hospital or visit your pharmacist, you must only use your Medicare Advantage Plan insurance card, not your Medicare (red, white, and blue) card.

4. A Medicare Advantage Plan must provide all your Part A and Part B benefits, and some Medicare Advantage Plans have Part D prescription drug plans included.

5. "Extra" benefits such as gym membership, dental and vision may be offered.

Readers, as Raquel and Clint discovered, your health care needs can change overnight. Be sure to review your options carefully, because with Medicare, what you don't know will hurt you!

Toni King is an author and columnist on Medicare and health insurance issues. She has spent nearly 30 years as a top sales leader in the field. You can attend Toni's Confused about Medicare AEP Zoom Workshop on Wed. Oct. 23 at 4 p.m. CST. To register, visit tonisays.com or call 832/519-8664 for more information.