Fall is in full swing accompanied by the constant infomercials about Medicare options. It's open enrollment for Medicare Advantage plan enrollment and changing between Original Medicare to Advantage plan or back to Original Medicare. It is also time to review your Part D coverage to evaluate which plan is best for you given the ever-changing medication coverage offered by various plans.
First it is important to understand the terminology of Medicare. Part A is hospitalization insurance. Part B is medical insurance, which covers a portion of physician visits, outpatient services (including hospital observation). Medicare A and B are referred to as "Original Medicare." Eligibility to sign up for Medicare begins at age 65. You may sign up three months prior to your birthday month, your birthday month and three months after your birthday month. Medicare Part A must be taken although B may be deferred if your employer insurance plan continues to cover you. There will be a penalty if you do not sign up for Part B when eligible and are not covered by an employer plan and you sign up at a later date.
Part C or a Medicare Advantage Plan is another option instead of taking A and B and usually includes Part D (medication plan). These plans are private insurance plans, which actually cost the government more ( and often offer you less). The catch is these plans are managed care HMO or PPO plans which often do not cover current physicians unless in the case of PPOs which have an increased cost if you use your own physicians.
Advantage Plans — Part C are marketing hard this time of year. I cannot stress enough that you should read, read and re-read the specifics of the plan. The packaging looks great in many cases. Promises of lower or no premiums are enticing, however the out of pocket costs are generally high. These plans are said to be for the healthy, not the ill.
Here's the other catch, freedom of choice. If you select a plan that does not cover you out of state or at various hospitals you have a big problem. You could be stuck if you need services at, say, Johns Hopkins and they only accept their Advantage plan not yours. Many hospitals do not participate with Advantage Plans, which means you will be transferred to another hospital unless it is an emergent life-threatening situation. I have had people sit in an emergency department for hours to find that they cannot be admitted because their plan is either not accepted or will not pay at a particular hospital only to be sent off to another facility. I have also had clients who have been given very limited choices for rehabilitation care after a hospitalization. Frankly, the options are usually, in my opinion, cost-cutting options, i.e., not top of the line. I have had clients from Anne Arundel County sent to Harford County because that's the only option that was available to them as dictated by their Part C Advantage Plan.
With Original Medicare you have a choice. You are not limited by where your Advantage Plan will allow you to go. Honestly I cringe when my client has an Advantage Plan. My experience is that many of us in health care are not fans. Another consideration: you can only switch out of an Advantage Plan during open enrollment October 15- December 7th.
The Medicare website describes the options of Medicare A and B versus Advantage Plans. Below, from the website Medicare.gov, the HMO and PPO Advantage Plans are explained:
In HMO Plans, you can't get your health care from any doctor, other health care provider, or hospital. You generally must get your care and services from doctors, other health care providers, or hospitals in the plan's network (except emergency care, out-of-area urgent care, or out-of-area dialysis). In some plans, you may be able to go out-of-network for certain services, usually for a higher cost. This is called an HMO with a point-of-service (POS) option.
In most cases, you can get your health care from any doctor, other health care provider, or hospital in PPO Plans. PPO Plans have network doctors, other health care providers, and hospitals.
Each plan gives you flexibility to go to doctors, specialists, or hospitals that aren't on the plan's list, but it will usually cost more.
Generally coverage is most comprehensive and gives the most freedom of choice when Part A and B is selected with a Supplemental or Gap Insurance which covers the copays of associated with services. Take the time to compare the premiums of Part B plus the premiums of Gap insurance versus the out of pocket maximum of Part C plans.
Supplemental insurance is really essential to pay the 20 percent copays. It is worthwhile and can be purchased when signing up for Original Medicare. It does not require underwriting at this time, however, if deferred when signing up for A and B then obtaining later can cost much more if medical conditions exist. In some cases it may not be available if not taken when signing up for Original Medicare.
In two weeks I will address Part D and more about supplemental plans. Please refer to the Medicare.gov website or call the Bureau of Aging at 410-386-3800 to schedule a review of your Part D plan or discuss Medicare options.
Jill Rosner is a registered nurse, certified geriatric care manager and owner of Rosner Healthcare Navigation. She provides patient advocacy and care management services to clients with health and aging issues. Contact her at JillRosnerRN@aol.com.