As Medicare premiums rise, a Medicare Advantage plan can seem like an attractive option. But if you are considering switching from Original Medicare to a Medicare Advantage plan, you need to know what to look for.
Medicare Advantage plans are run by private insurers. Original Medicare is operated by the federal government, although the medical providers are private. The government pays Medicare Advantage plans a fixed monthly fee to provide services to each Medicare beneficiary under their care. The plans often look attractive on the surface because they offer the same basic coverage as original Medicare plus some additional benefits and services that Original Medicare doesn’t offer. As with any insurance, however, you have to look at the total cost of care, not just the premium.
To compare Advantage plans, go to the Medicare Plan Finder at Medicare.gov. When deciding whether a Medicare Advantage plan is right for you, the following are the main factors to consider:
- Cost. Since Medicare Advantage plans are offered by private insurers, the cost of the plan varies depending on where you live. While Medicare Advantage plans usually have lower premiums than paying for Original Medicare plus a Medigap plan, they can have higher deductibles and co-pays in certain circumstances, so you need to take those into account when calculating the cost of each plan. Medicare Advantage plans do have a cap on out-of-pocket costs, while Original Medicare does not. Check the annual maximum out-of-pocket costs for the plan. If you have a high level of health costs, a low out-of-pocket maximum may be the best option.
- Coverage. What coverage does the plan offer? Medicare Advantage plans must cover everything that Original Medicare covers, but some plans offer additional benefits, such as dental, hearing, and vision. Under Medicare Advantage, plans are allowed to require your doctor to get approval for certain procedures. If the plan administrators disagree with your physician that a procedure is medically necessary, the Medicare Advantage plan may legally refuse to pay for it. You will want to find out how the Medicare Advantage plan is “in the real world” on issues such as approving treatments, referring patients to specialists, or allowing patients to remain in the hospital if they are not ready to leave. You may want to check with your doctor to find out their experience with the Medicare Advantage plan and whether the plan frequently overrules the doctor.
- Doctors. Original Medicare does not have any restrictions on which doctor you use, but Medicare Advantage plans are HMOs and PPOs, meaning that not every doctor accepts the insurance. With an HMO, if you visit a doctor outside of the network, you will likely have to pay out of pocket (except in an emergency). With a PPO, you can usually see any doctor you want, but you will pay less for an in-network doctor. You will want to check if your doctor and hospital are part of the Medicare Advantage plan’s network. The best way to do this is to call your doctor’s office to confirm. If your doctor and hospital are out of network, you need to clearly understand the limits on the coverage that will be approved.
- Prescription drugs. Most Medicare Advantage plans include prescription drug coverage, so you should check to make sure the plan covers all the medications you take. You should also check if you need any special authorizations for any of your medications or if there any limits on the amount you can get. Other questions include whether your pharmacy is a preferred provider and whether you can get prescriptions by mail.
- Quality of care. The Medicare Plan Finder includes a rating system that measures how well the plan manages health screenings and chronic conditions, as well as how many customer complaints it receives, among other things. The ratings aren’t perfect, but they can give you an idea of plan’s quality.
*This article is provided for persons interested in elder law issues in Virginia and across the United States. This article has been written by a practitioner in the field of elder law, but unless otherwise noted, the writer is not affiliated with ThompsonMcMullan, P.C. Nothing in the newsletter or the articles is, or is intended to be, legal advice or a substitute for legal advice. If you need legal advice of any kind, please consult an attorney with experience in that area of the law, whether in our firm, or otherwise.