Here are the questions you need to ask when considering a Medicare Advantage plan

Marcella McCarthy
·6 min read

COVID-19 has most U.S. residents on high alert when it comes to healthcare, but for seniors, Medicare open enrollment season is the next big thing to be aware of this fall.

It kicks off Oct. 15 and goes through Dec. 7. During this period, U.S. citizens (and green-card holders who have lived in the U.S. for at least five years) from the age of 65, can choose between Original Medicare or Medicare Advantage Plans for their health coverage.

In Miami-Dade and Broward counties, 67% and 53% of eligible seniors, respectively, were enrolled in an Advantage plan as of September 2020, according to the Centers for Medicare and Medicaid Services (CMS). But before following the crowd, here’s what you should know when making a decision.

Original Medicare

The original Medicare plans (Part A and Part B) are run by CMS, and Part D (drug coverage) and Medigap (also known as supplemental insurance) are administered by private health insurance companies.

With Original Medicare, Part A is free, but you have to pay for Part B, Part D (optional), and Medigap (optional).

Lifestyle perks with Medicare Advantage plans

The Medicare Advantage plans are all-inclusive, but restrict which doctors and hospitals and nursing homes you can go to. Many include some lifestyle perks such as exercise classes a.k.a. “Silver Sneakers,” nutritionists and transportation to healthcare appointments.

“There are opportunities and tradeoffs with Original Medicare,” said Meredith Freed, a policy analyst for the Program on Medicare Policy at the Kaiser Family Foundation.

While original Medicare may have more out-of-pocket costs and fewer lifestyle perks, the central difference from the Advantage plans is that Original Medicare operates like a PPO, meaning you can see any doctor or hospital that accepts Medicare — which virtually all do.

You can also see a specialist without a referral, which isn’t the case with the Advantage plans.

The Advantage plans operate like an HMO, meaning you can only see doctors within the plan’s specified network. If you’re a person who sees lots of specialists — having to get a referral from your primary care physician every time, may be a hassle.

Advantage plans may not cover you if out of state

If you’re a snowbird or travel a lot within the U.S., the Advantage plans only work in the state in which you registered for them.

So, if you’re heading back North in the summer or taking a trip to a different state to visit the grandkids, and you registered for an Advantage plan in Miami, you’ll be uninsured.

Original Medicare is accepted nearly everywhere in the United States.

“If you’re in a Medicare Advantage plan and want to switch to [Original] Medicare, then you might not be able to get any Medigap plan because of a pre-existing condition.”

Like this “detail,” there are others, and we’ve outlined some of the main pitfalls below.

When your health is just in prevention or maintenance mode, being restricted to a network of providers in the Advantage plans may not seem like a big deal — especially since on the surface, the Advantage plans may seem more cost-effective, i.e. all-inclusive.

But when your life or that of a loved one is at risk — and you realize you can’t see the doctor of your choice or go to the nursing facility you like because they are out of network — you may find yourself reconsidering your decision.

If you signed up for an Advantage plan during the enrollment period and later rethink your choice, there is a dissenrollment period from Jan. 1 — March 31 each year.

“The intent of the Advantage plans is to cover out-of-pocket costs for people on Medicare,” said Kathleen Sarmiento, the SHINE Liason at the Alliance for Aging.

SHINE offers free and unbiased information about Medicare.

Hospital bill can cost you more under Advantage plans

Depending on your situation, the intent can be different from reality.

“Something that surprises people is that some of the Advantage plans have a co-payment when you’re in the hospital — and if you’re on your fifth day and it’s costing you more than $100/day, that can add up,” said Sarmiento.

With Original Medicare, your entire hospital stay should be covered.

Freed agrees with this assessment.

“The impression is that Medicare Advantage is cheaper overall, but we found that for hospital stays, for five days or more, it costs more [for the patient] than with Original Medicare, so it’s important to look beyond the premiums,” she said.

In South Florida, and in Florida in general, many people are enrolled in Medicare Advantage programs.

Part of the reason is that the insurance companies heavily advertise during the open enrollment period, blanketing people’s mailboxes with fliers in addition to running ads. For the insurance companies, the Medicare Advantage plans are very profitable.

Florida Blue, the state’s largest insurer, said 43% of its customers are enrolled in Medicare Advantage Plans. Through a contract with Medicare, “these insurance companies are getting paid behind the scenes for each person [per month],” Sarmiento added.

What’s new in 2021?

According to CMS and John McDonough, professor of Public Health Practice in the Department of Health Policy & Management at the Harvard T.H. Chan School of Public Health, these are some of the new things to expect in the coming year:

Medicare Part B will cover COVID-19 vaccine

Because of COVID-19, some prior authorization requirements have been lifted. Enrollees are now allowed 90-day drug supplies, and mail and home delivery are encouraged

Telehealth & other virtual services: Real-time interactive audio and video “visits and consultations” are now covered.

Lower out-of-pocket costs for insulin: If you join a Medicare drug plan that participates in the “Part D Senior Savings Model,” your monthly payment for insulin will only be $35.50, on average.

Acupuncture for back pain: Medicare now covers up to 12 acupuncture visits in 90 days for chronic low back pain.

Medicare Advantage plans now have to accept people who have End-Stage Renal Disease (ESRD). Coverage will start on Jan. 1, 2021.

Questions to ask when shopping for Medicare Advantage

According to Medicare.gov and Sarmiento (of SHINE), here are some questions you should ask — if they pertain to you — when looking at Medicare Advantage plans:

Do I have a co-payment for A) hospitals, B) supplies (including diabetes supplies), C) If I have to go to a skilled nursing facility, if they are not part of the plan?

Does the plan offer benefits that Original Medicare doesn’t cover, like vision, hearing, dental, or prescription drug coverage? (You may have to pay more for these extra benefits.)

If I need hearing aids, are there several brands I can pick from, or only one?

Are meals and home health offered following a hospital stay?

For wheelchairs or walkers, what’s my copayment?

Does the plan offer workout classes a.k.a “Silver Sneakers?”