Is Medicare or Medicare Advantage Right for Me?

It’s that time of year once again. The open enrollment period for Medicare is October 15-December 7. When enrolling in Medicare or making a change to your plan, there are several options available, which can often feel overwhelming. Steve Pantaleo, RN, a certified application counselor for Phelps Health EnrollU, breaks down the differences between Original Medicare and Medicare Advantage.

What is Medicare Advantage, and how does it compare to – or supplement – Medicare?

Medicare Advantage Plans are another way to get your Medicare Part A and Part B coverage. Medicare Advantage Plans, sometimes called Part C or MA Plans, are offered by Medicare-approved private companies that must follow rules set by Medicare. If you join a Medicare Advantage Plan, you'll still have Medicare, but you'll get most of your Part A and Part B coverage from your Medicare Advantage Plan, not Original Medicare. 

With Original Medicare, patients can go to any doctor or hospital in the US that accepts Medicare. With Medicare Advantage, however, you can only use doctors and providers who are in the plan’s network and service area (in most instances, for non-emergency care).

Does Phelps Health accept Medicare Advantage?

Yes. Phelps Health is in-network with the following Medicare Advantage Plans: Anthem Blue Cross Blue Shield, Humana, UnitedHealthcare and Wellcare. If a person has a PPO (Preferred Provider Organizations)-type Medicare Advantage plan with another carrier, they can be seen at Phelps Health, but in most cases, they would have to pay an out-of-network rate. Some plans, like HMOs (Health Maintenance Organizations), are even more restrictive; in general, patients would not be covered if they went out of network.

Does Medicare Advantage help with prescription drug costs?

Medicare drug coverage (Part D) is included in most plans. With most types of Medicare Advantage Plans, you can't join a separate Medicare drug plan (unless your Medicare Advantage Plan doesn’t already provide drug coverage).

If I enroll in Medicare Advantage, should I keep my Original Medicare coverage?

Technically, you will still have Original Medicare. Services are not provided through it, however, and except for a few situations like hospice, you will not need your red, white and blue Medicare card. You should still keep this card in a secure location.

If I have Medigap, do I need Medicare Advantage?

You cannot have both. (Medigap is health insurance sold by private insurance companies to fill the “gaps” in Original Medicare.)

Who is a good candidate for Medicare Advantage?

According to Consumer Reports: “[Medicare Advantage is ideal for] healthy adults who prefer low premiums and are comfortable with managed care. But if you have chronic conditions or severe health needs, you may want to think twice about Medicare Advantage because of the requirements for pre-authorization and staying in-network,” says Melinda Caughill, co-founder of 65 Incorporated, a firm that provides Medicare enrollment guidance to financial advisers and individuals. “If you need to see multiple specialists, and you have to get referrals for each appointment or fight to overturn denials, it can be really challenging.”

Will Medicare Advantage cap my out-of-pocket costs?

Yes. In 2022, the out-of-pocket limit may not exceed $7,550 for in-network services and $11,300 for in-network and out-of-network services combined. These limits will increase to $8,300 for in-network services and $12,450 for in-network and out-of-network services combined in 2023. 

In contrast, there is no limit on out-of-pocket expenses with Original Medicare, if you do not have a Medigap Plan or Medicare Advantage (or retiree plan).

Does Medicare Advantage require prior authorization to see a specialist?

Prior authorization, sometimes called preauthorization or prior approval, is a health insurer or plan’s decision that a healthcare service, treatment, prescription drug or durable medical equipment is medically necessary. Today, 99% of Medicare Advantage members are in plans that require prior approval for services including inpatient admissions, skilled nursing facility stays, mental health services, home healthcare, chiropractic services, outpatient surgery and services, ambulance transport, medical equipment, diagnostic tests, and laboratory and radiology services. (Plans cannot require authorization in emergency situations.) If the test is not authorized, the Medicare Advantage Plan may not pay. In a plan’s Evidence of Coverage (EOC), which is the legal contract between the plan and the member, there is language stating, “If prior authorization is required and not obtained, no benefits will be payable under the plan.”

What are the main benefits and drawbacks of Medicare Advantage?

Benefits of Medicare Advantage Plans

With a Medicare Advantage Plan, you may have coverage for things Original Medicare doesn't cover, like fitness programs (gym memberships or discounts) and some vision, hearing and dental services (like routine checkups or cleanings). Plans can also choose to cover even more benefits.

Drawbacks of Medicare Advantage Plans

• In general, Medicare Advantage Plans don’t offer the same level of choice as a Medicare plus Medigap combination. Most plans require you to go to their network of doctors and health providers.
• Since Medicare Advantage Plans can’t select their customers (they must accept any Medicare-eligible participant), they discourage people who are sick by the way they structure their copays and deductibles. Many enrollees have been hit with unexpected costs and denial of benefits for various types of care deemed not medically necessary.
• Out-of-pocket costs can quickly build up over the year if you get sick. The Medicare Advantage Plan may offer a $0 premium, but the out-of\-pocket surprises may not be worth those initial savings if you get sick. “The best candidate for Medicare Advantage is someone who's healthy," says Mary Ashkar, senior attorney for the Center for Medicare Advocacy. "We see trouble when someone gets sick."

I am retired and travel frequently. Would Medicare Advantage be a good fit for me?

Most in-network doctors, hospitals and clinics are limited to the state where the plan is offered or in nearby states. So, if you are thinking of traveling out of state, here are a couple of things to keep in mind:

• With Medicare Advantage Plans, you’ll have emergency and urgent care coverage when traveling outside of your network, within the United States. That means you don’t have to worry about coverage if you get a sudden illness or break a bone while traveling.
• If you need non-emergency or non-urgent care while traveling, it may not be covered, and you’ll likely have to pay more out of pocket.

Can I join Medicare Advantage if I have a pre-existing condition?

Yes. Because Medicare Advantage plans have no medical underwriting, the insurer must accept you.

When can I enroll in Medicare Advantage?

You can join, switch or drop a Medicare health plan or a Medicare Advantage Plan (Part C) with or without drug coverage during these times:

• Initial Enrollment Period: When you first become eligible for Medicare, you can join a plan.
• Open Enrollment Period: From October 15 – December 7 each year, you can join, switch or drop a plan. Your coverage will begin on January 1, as long as the plan has your request by December 7.
• Medicare Advantage Open Enrollment Period: From January 1 – March 31 each year. If you’re enrolled in a Medicare Advantage Plan, you can switch to a different Medicare Advantage Plan or switch to Original Medicare (and join a separate Medicare drug plan) once during this time. Note: You can only switch plans once during this period.

Which factors should be taken into consideration when enrolling in a Medicare Advantage Plan?

• The cost of the plan; does it fit within my budget?
• A list of in-network providers, including any doctor(s) that you would like to keep
• Coverage for services and medications that you know you'll need
• The Centers for Medicare and Medicaid Services (CMS) star rating

What resources are available at Phelps Health? Who can I speak with to determine if Medicare Advantage is right for me? Is there a cost for these services?

The Phelps Health EnrollU team is here to help with any questions you may have about Medicare and Medicare Advantage. Our certified and licensed navigators and counselors are ready to assist you. In addition, staff can provide information on Medigap plans, Original Medicare and healthcare insurance through the Marketplace.

You don’t have to be a Phelps Health patient to receive assistance with EnrollU. We provide this service free to the community.