After working 40+ years in health care reimbursement, the issue of traditional Medicare versus Medicare Advantage (also referred as Part C, Managed Medicare) can be confusing, even to me. Medicare Advantage is not Medicare supplemental insurance. It is sold by private insurance companies, not the Center for Medicare and Medicaid Services (CMS). CMS oversees all rules that relate to the Medicare Advantage approval to sell insurance with their individual list of services, including a yearly renewal period.
A big piece to understand is that what you see on TV with advertisements for Medicare Advantage plans — such as zero monthly premiums or a scrolling list of additional services that traditional Medicare does not offer — is not available in every part of the country. The county-community specific benefits must include the basic traditional Medicare Part A and Part B services, but can offer more.
Getting ready to do an assessment of your Medicare options:
a) Preparing to turn 65. Initial enrollment period starts the first day of your birthday month.
b) Yearly open enrollment periods where movement from traditional Medicare to a Medicare Advantage plan or movement to a different plan or movement back to traditional Medicare from a Medicare Advantage plan is between Oct. 15-Dec. 7 yearly.
There are key areas to assess as each Medicare Advantage plan is different. Each plan has different monthly premiums, different drug coverage and different out-of-pocket expenses for all inpatient, outpatient hospital, physician visits, outpatient procedures, supporting services and skilled post-acute care.
Each Medicare Advantage plan has a list of in-network health care providers — hospitals, DME, physicians, outpatient treatment centers, skilled nursing centers and home health. Carefully assess your personal list of providers against the in-network list as there will be a significant cost to access an out-of-network provider.
Once the initial review of providers is done, look at the list of prescription drugs you are taking. Each plan has a list of drugs they cover with the out-of-pocket amount for each. When using a trusted insurance broker to guide you, review the drug list as this will likely be the most challenging to ensure you have a) your drugs included in the plan’s list, b) the tier they fall into and c) the amount you are paying for each. Each plan will have a different list so due diligence with this one is important.
Lastly, out-of-network costs can sneak up on you if you aren’t aware of the limited coverage area of the plan you select. If you are going to travel, traditional Medicare may be the better option since it has no network issues. Emergent care should always be covered by any Medicare Advantage plan.
Conduct a thorough assessment of Medicare Advantage plans, scope of coverage, in-network providers, prescription drugs and cost. Explore creating a spreadsheet of a) traditional Medicare costs and coverage, b) Medicare Advantage plans being sold in your county and c) which plan best fits your individual needs.
There are plenty of great online reference materials on MyMedicare.gov. Plus the Office on Aging at the College of Southern Idaho is a wealth of information. Don’t forget the “Medicare & You” official U.S. Government Medicare Handbook. Baby steps to enhanced understanding is possible.
UPDATE: The Nov. 7 “Medicare 101, Social Security Benefits and Assistance for Senior Boot Camp” has been delayed until the first quarter of 2021. Our community outreach education will resume when it is safe for all of us. See you in 2021.
Day Egusquiza is the president and founder of the Patient Financial Navigator Foundation Inc. — an Idaho-based family foundation. For more information, call 208-423-9036 or go to pfnfinc.com. Do you have a topic for Health Care Buzz? Please share at email@example.com.
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