Medicare Advantage

Lately, some have wondered if Medicare Advantage Plans are bad. If you have been reading the news lately you have likely seen articles that are talking about how many seniors feel ‘trapped’ in a Medicare Advantage plan.  We all know that bad news sells while people often overlook good news.  

The reality is that the truth usually lies somewhere in between.  This article decodes the pros and cons of Medicare Advantage plans, aiding your decision-making process.   As you approach your golden years, the many decisions surrounding your healthcare can be both complex and crucial.

Among the myriad of choices, selecting the right Medicare plan is one of the most significant. Lately, Medicare Advantage (MA) plans have stirred up quite the debate, with opinions ranging from godsend to the scourge of elders’ healthcare.

But let’s dive deeper into the sea of healthcare options—do Medicare Advantage plans deserve their mixed reputation?

The Beginning of Medicare Part C: The BalancedBudget Act

If we start from the beginning, the Balanced Budget Act of 1997 (BBA) introduced Medicare Part C (now known as Medicare Advantage) and to put it mildly became a bit of a disaster.  Seniors flocked to these plans for primarily one reason, the prescription drug coverage benefit.  Of course, the low cost of many of these plans didn’t hurt either.  Over the months, it was a bit of the wild West and insurance companies were offering crab and even steak dinners to seniors just to come hear about the plans.  Many folks signed up right at the dinners and jumped head first into these new plans. 

Suddenly many of these Medicare beneficiaries were smacked in the face with why these plans were so low costing.  Unlike original Medicare, these Part C plans required seniors to use a doctors who participated in the plan’s network.  Since many of these carriers rushed their plans to market, the networks were very small.  Many seniors were having to pick a new doctor and give up the ones they felt comfortable with.  In addition to network issues, folks were also now dealing with pre-authorization requirements to continue to see a specialist for their more complicated health issues. The one thing that kept them in the plan was the prescription drug benefit, which at that time was one of the only ways that seniors could get help with the high costs of their prescriptions.  Sadly these plans quickly started to exit the market and seniors went back onto original Medicare and paying for all of their prescriptions out of pocket.

In 2003 Medicare Advantage and stand-alone Part D prescription drug plans were introduced back into the market.  If you are thinking that Medicare Advantage was basically a rebranding of Medicare Part C then you are on the right track.  The problem once again was the lack of robust networks and many doctors pushing back against joining them.  Many seniors remembered the fiasco of Medicare Part C back in the 1990s and were hesitant to enroll in the newer Medicare Advantage plans even though these plans had low daily hospital co-pays and reasonable maximum annual out of pocket limits for the plans.  By the end of 2004 out of the 41 million Americans on Medicare only about 5 million were enrolled in a Medicare Advantage plan.

Fast forward to 2023 and out of the 65 million Americans enrolled in Medicare just under 32 million were enrolled in a Medicare Advantage plan.  In less than 20 years there has been an increase in Medicare Advantage plan members of 540%.  That is quite a remarkable number.

How they differ from Original Medicare

The primary distinction lies in how they manage and pay for your healthcare benefits. While Original Medicare allows direct payment for healthcare goods and services, Medicare Advantage (MA) contracts with a network of providers, which dictates your access to care.

This basically means that instead of original Medicare paying benefits to your doctor, they are paying all your Medicare annual allowance to the Medicare Advantage plan you have enrolled in.  It is then up to the MA plan to manage your healthcare costs. 

If you have more expenses than what was paid by Medicare to the MA plan, then the plan loses money on you.  If you have a healthy year then the MA plan makes money. 

Additionally, MA plans receive federal subsidies from the Centers for Medicare and Medicaid Services (CMS) which helps with their profitability.

Pros of Medicare Advantage Plans

Despite their critics, Medicare Advantage plans have numerous advantages that make them a worthy competitor against Original Medicare. Let’s unpack these benefits to show a balanced side of the story.

Lower out-of-pocket costs

The financial burden of healthcare can be significant for seniors. Medicare Advantage plans cap out-of-pocket spending for Part A and B services, providing predictability in healthcare costs. We know these caps as the plan’s Maximum Out of Pocket (MOoP).

This can be especially beneficial for those who face chronic health conditions that necessitate frequent doctor visits or hospital care.  When an individual is covered only by Medicare Part A and Part B (without a Medicare Supplement) they do not have an annual cap.

Care Coordination

Another plus of Medicare Advantage is the focus on care coordination. Some plans offer nurse hotlines, wellness programs, and other resources to help beneficiaries manage their health more effectively. The attention to coordination can reduce medical errors and can make the patient experience smoother.

Cons of Medicare Advantage Plans

While the benefits paint a rosy picture, it’s crucial to address the drawbacks. Medicare Advantage plans have their shortcomings and may not suit everyone perfectly.

Limited provider network

Enrolling in a Medicare Advantage plan often means adhering to a specific network of doctors and hospitals. This can be restrictive, particularly for those who have established relationships with healthcare providers.

While the networks have become more robust over the last 20 years, they still pale in comparison to the number of providers who accept original Medicare.  It’s essential to ensure that your preferred healthcare professionals are part of the plan’s provider network. 

If the MA plan you are looking at uses an HMO network, then you need to understand that if you see a provider not in the plan’s network, then you are responsible for 100% of the medical bills. 

Since CMS directly pays all your benefits to the MA plan, you can’t ask Medicare to cover the costs.

Potential for higher costs in certain situations

While MA plans offer a ceiling for out-of-pocket costs, they can also lead to higher expenses if care is sought outside the network.

Emergency care and urgent care services can potentially not be as covered as well as with the traditional Medicare program, which doesn’t have the same provider restrictions.  As we mentioned earlier, an HMO network is the most restrictive and requires you to use a provider that participates in the plan’s network. 

If your MA plan uses a PPO network, then you would have coverage when using a provider not in-network.  There are serious pitfalls that you need to be aware of when using a non-participating provider. 

Most plans have a separate maximum out of pocket cap for in-network vs out-of-network.  The MA plan may have a MOop of $7,000 for in-network, but a separate MOop of $10,000 for out-of-network. 

In addition, seeing an out-of-network provider can be billed differently.  Instead of paying a $50 co-pay for the specialist, you might be required to pay 20% of the cost.  These situations can lead to much higher amounts of expenses being paid out of pocket.

Annual changes in plan coverage

Medicare Advantage plans can alter their coverage on a yearly basis, including prescription drug formularies and benefits. This means they may not cover next year what they coveredd this year.

A Medicare Advantage plan does an annual contract with CMS, which means that they can choose not to continue to offer the plan in a certain county or even state.  This means all those enrolled in that plan would have to find a new plan or return to original Medicare. 

Beneficiaries need to review their plans and potentially switch annually, causing potential inconvenience and confusion.

Considerations for Seniors

You may wonder what all this means for you. How do you know if Medicare Advantage is the right choice? The answer to this question, as we often find in healthcare, is that it depends. Here are some factors to consider when navigating the maze of Medicare Advantage options.

Factors to consider when deciding on a Medicare Advantage plan

1. Your health status – If you’re relatively healthy, you may find that the additional benefits of an MA plan are more advantageous. However, those with more complex or severe health needs might prefer the flexibility and broader coverage of Original Medicare. 
   
   A key point to remember is that your focus should be the core benefits of the plan and not the add-ons.  Many times, the add-ons are the ‘sizzle’, but you need to be more concerned with the ‘steak’. 
   
   Don’t get us wrong, having dental benefits is great, but if your plan makes you responsible for a daily co-pay of $350 for up to 5 days in the hospital, those extra benefits quickly dry up. 
   
   An example of this would be having $1,500 of dental benefits but ending up in the hospital for 5 days with a $350 per day co-pay.  This hospital stay would mean you having to come up with $1,750 out of your own pocket.
   
2. Location – Provider networks can vary widely by geographic area, so where you live can significantly affect your choice of MA plan.
   
   Rural areas, for example, may have more limited options than urban centers.  In fact, we have found that in many rural areas, doctors are less likely to join a plan’s network.
   
3. Your lifestyle and health care preferences – If you have specific needs or prefer a particular style of care, such as integrative or alternative medicine, you’ll want to ensure that the MA plan you choose aligns with those preferences.

How to evaluate plan options

Diving into the details is essential. Look beyond the surface benefits and consider the cost-sharing arrangements, such as premiums, deductibles, co-payments, and coinsurance.

• Does the plan cover the specific services and treatments you anticipate needing?
  
• How easy is it to access care if you’re out of town or need a specialist?  
  
• Does the plan cover all your prescriptions in their formulary? 
  
• Does the plan require you to do step-therapy? (trying other lower costing prescriptions before the plan will pay for the higher priced one you want). 

These are just a few of the aspects that require thorough examination.

Comparing Medicare Supplement to Medicare Advantage

Everything we discussed above is comparing original Medicare Parts A and B to Medicare Advantage.  The reality is that most folks on original Medicare also have a Medicare Supplement plan.  When you do a comparison between a Medicare Supplement and a Medicare Advantage plan, things change dramatically.

Read our article Medicare Supplements vs Medicare Advantage Plans

Frequently Asked Questions (FAQs)

• Why are people against Medicare Advantage plans?
  • One of the biggest issues folks have with Medicare Advantage plans after they enroll in one is the use of networks.  Under original Medicare there are no networks, so you can see any provider who accepts Medicare. 
    
• What is the downside of a Medicare Advantage plan?
  • Besides network restrictions, needing a referral or prior authorization to see a specialist is a major downside.  A Medicare Advantage plan typically requires these, but original Medicare does not.
    
• Why are people leaving Medicare Advantage plans?
  • There are several reasons why people leave Medicare Advantage plans and return back to original Medicare include such things as:
    • Prior-authorization requirements
    • Procedure denied by the plan
    • Doctors complaining to their patients about the plan (such as slow payment from the insurance carrier)
      
• Is Medicare Advantage under investigation?
  • In 2023 several Medicare Advantage plans came under scrutiny by the Senate for several issues:
    • Use of an algorithm to deny care that patients need.
    • Overbilling Medicare by saying that members were sicker or had illnesses that they really didn’t have which allowed the plans to be paid a higher rate.  This abuse was documented in a report from MedPac that was sent to Congress.
• Can I drop my Medicare Advantage plan and go back to original Medicare?
  • Yes, but there are certain restrictions that you must adhere to.
    • During the Annual Enrollment Period (AEP) which runs from October 15^th – December 7^th of each year, you can drop an existing Medicare Advantage plan and return back to original Medicare and enroll in a stand-alone Part D prescription drug plan.
    • If you enrolled for the first time in a Medicare Advantage plan you can disenroll within the first 11 months and return back to original Medicare and enroll in a stand-alone Part D prescription drug plan.
      
• Is Medicare Advantage draining Medicare?
  • In a report written by the Center for Economic and Policy Research it was reported that an individual on a Medicare Advantage plan costs Medicare more each year than an individual still on original Medicare. 
    
    The study cites that in 2020 CMS spent $1,538 more per Medicare beneficiary enrolled in a Medicare Advantage plan than it would for that same person to be enrolled in original Medicare.

So What Can We Conclude Regarding Medicare Advantage Plans?

Are Medicare Advantage plans really that bad? The truth, as always, is somewhere in the middle. They offer a host of advantages, including cost containment, supplemental benefits, and improved care coordination.

However, they also come with their share of inconveniences, such as provider network restrictions and the potential for increased costs under certain circumstances. It’s not about good or bad; it’s about what aligns best with your individual needs and preferences.

Contact Senior Benefit Services today at (800)924-4727 to see what type of plan is best for your personal needs.

For millions of Americans, Medicare is a critical safety net, helping to shoulder the burden of healthcare costs as they move into their senior years.

But despite its comprehensive reputation, there’s a surprising array of medical services and treatments that original Medicare doesn’t cover.

These gaps in coverage can lead to unforeseen expenses, leaving beneficiaries vulnerable and in need of additional insurance solutions.

In this guide, we’ll take a deep dive into what’s not included in that iconic Medicare coverage, and what you can do to bridge the coverage gap.

Here’s a comprehensive look at the services and treatments that you may not know are excluded from your Medicare plan—but perhaps should.

1.) Long Term Care

A common misconception is that Medicare provides for long-term care, but it does not. Medicare coverage is limited to short-term skilled nursing facility care following a hospital stay. Long-term care options typically must be financed through other means, such as long-term care insurance, Medicaid (for those who qualify), or out-of-pocket payments.

2.) Foreign Travel

When venturing beyond the borders of the United States, you will find that Medicare coverage is limited. With a few exceptions for emergency situations close to the US border or on a cruise ship, health care received abroad is not covered by traditional Medicare plans.

3.) Routine Foot Care Coverage

Services such as foot exams or treatment for conditions like flat feet, corns or calluses, are generally not covered under original Medicare. Only foot care that’s considered medically necessary, such as diabetic-related issues, may be included.

4.) Routine Vision Coverage

Medicare generally does not cover routine eye exams or eyeglasses/contact lenses. However, it may cover a yearly eye exam if you’re at high risk for glaucoma or diabetic retinopathy.

For those who desire vision coverage, additional vision plans or Medicare Advantage Plans with vision benefits are available.

In addition, there are many combo plans that cover vision, dental, and hearing benefits that can be purchased in addition to any other health insurance coverage that you might have.

5.) Routine Dental Coverage

Don’t expect Medicare to pick up the tab for routine dental visits, cleanings, fillings, or dentures.

These are out of pocket costs unless you have a separate dental insurance policy or a Medicare Advantage Plan that offers dental benefits.

6.) Hearing Aids Coverage

The cost of hearing aids can be substantial, but Medicare does not cover hearing aids or the exams needed for fitting them.

Some Medicare Advantage Plans may provide supplemental hearing coverage.

Just like Medicare not covering routine dental coverage, you can also purchase a separate combo policy that will provide coverage for hearing benefits.

7.) Prescription Drug Coverage

Original Medicare, made up of Part A and Part B, does not include coverage for most prescription drugs

. To get this coverage, you can enroll in a separate Medicare Prescription Drug Plan, known as Part D, or choose a Medicare Advantage Plan that includes drug coverage.

Some key points to always consider when shopping for Prescription Drug Coverage (Part D) are:

• The lowest monthly premium doesn’t necessarily mean the lowest total out-of-pocket costs for the year. Some low-priced plans have higher co-pays than others.
• Keep an eye on what tiers your prescriptions fall into. One plan may have your drug listed as a Tier 1 (lowest co-pay), but another might have it listed as Tier 2 (higher co-pay).
• Make sure all your drugs are covered on the plan’s formulary.

Beyond What Medicare Does Not Cover

Knowing what Medicare doesn’t cover allows you to explore supplementary insurance options and make necessary financial plans. For additional coverage, consider Medicare Advantage Plans or separate policies that fill these gaps.

It’s essential to perform due diligence and determine the best choice for your health and budget. Always consult with a knowledgeable Medicare advisor or insurance professional before making decisions about your health care coverage.

Stay informed and plan for what Medicare doesn’t provide, ensuring you have comprehensive healthcare coverage that meets your needs throughout your golden years. Call Senior Benefit Services, Inc. today at (800)924-4727 to make sure you have the coverage you need.

Many retirees want to know if Medicare will cover the cost of dentures. Medicare provides comprehensive healthcare but offers notably limited dental care benefits. This article delves into the extent of dental coverage under Medicare, shedding light on the options available for individuals seeking dental care.

The Scope of Medicare Dental Coverage

Medicare, established in 1965, was not designed to cover routine dental care, including dentures. At that time, authorities did not consider dental care routine medical care.

A 1980 Congress statute highly restricts Medicare’s dental coverage due to a dental exclusion. As a result, Medicare seldom covers dental procedures like extractions and fillings, which are essential for maintaining oral health.

Medicare does not cover denture costs, deeming them not medically necessary under Parts A and B.

Will Dental Ever Be Covered Under Medicare?

Factors prevent the inclusion of dental benefits under Medicare, despite widespread desire. It is important to keep in mind that there are almost 66,000,000 people on Medicare.1  Yes, you read that correctly….66 million! 

To cover one dental visit of $120.00 for each Medicare beneficiary, taxpayers would have to fund an additional $7,920,000,000.00 into Medicare.  Taxpayer dollars fund programs like Medicare and Social Security, as we all know.

So where do we come up with another $8 billion dollars to cover $120 per person in dental bills?  If you answered raising taxes, then you are on the right page.

So how much are dentures.  Roughly a complete set of ‘mid-priced’ dentures costs between $1,000 – $3,000.  A single denture plate can run between $500 – $1,500.2

Just using these costs for a complete set of ‘mid-priced’ dentures and not for a ‘premium’ set, here is how it would look for providing this to just 10% of the Medicare beneficiaries.

65,748,297 Medicare beneficiaries x 10% = 6,574,829 sets of dentures

6,574,829 sets of dentures x $2,000 (average of ‘mid-priced’ dentures) = $13,149,658,000.00 in additional costs for 1 year.

Offering dental coverage through Medicare, including routine visits and dentures for 10%, will require taxpayers to fund an additional $21 billion.

Last, but not least, the American Dental Association is against this proposal since it would likely result in pay cuts to dentists.

Options for Dental Coverage Under Medicare

Given Medicare’s limited dental coverage, individuals have a few options to consider for their dental care needs:

Self-Pay

Many Medicare recipients choose to pay out-of-pocket for dental services, especially those with generally healthy teeth who may only require routine cleanings.

Some may opt for dentists’ internal plans, which can offer a number of cleanings per year and discounts on other services.

Private Insurance

Dental insurance plans provided by insurance companies typically run between $25 – $75 per month depending on the level of benefits you are wanting. 

Most plans provide 100% coverage for preventive services such as routine exams, cleanings, and bitewing x-rays.  For items that fall under basic care, such as fillings and simple extractions, many carriers will cover these benefits at 80%. 

It is important to keep in mind that some plans do have a 6-month waiting period before they will cover these services.

Most plans cover major care at 50% with a possible 12-month waiting period for these services. Major services can include crowns, bridges, dentures, implants and more. You read that correctly, while Medicare does not cover dentures, a private dental plan can.

Final Thoughts

While we can always hope that one day we will be able to find a way for Medicare beneficiaries to have complete dental coverage, it is important to act and not wait until you are possibly burdened with thousands of dollars in out-of-pocket expenses.

Now you know that Medicare will not cover dentures, so it might be time to look at other options.

Give us a call today at (800)924-4727 to discuss your options.

Sources

1. Center for Medicare Advocacy: https://medicareadvocacy.org/medicare-enrollment-numbers/#:~:text=The%20Centers%20for%20Medicare%20%26%20Medicaid,are%20enrolled%20in%20Original%20Medicare.
2. Dentureliving.com: https://www.dentureliving.com/en-us/advice-tips/preparing-for-dentures/costs/how-much-do-dentures-cost

Are you a senior citizen wondering how much Medicare Part C will cost you? You’re not alone! Many seniors have questions about the costs and plan options associated with this important part of their healthcare. In our 2024 guide to Medicare Part C, we’ll explain the sample premiums as well as other fees that go into determining your exact out-of-pocket expenses for these plans. We’ll reveal the services Medicare Part C covers and guide you to choose the plan best fitting your needs. Don’t worry; understanding the costs associated with your healthcare can be simple!

Examples of Monthly Premiums for Medicare Advantage Plans

Expect an average premium range with Medicare Advantage (Part C), though costs can vary based on location and specific plan. In many cases, beneficiaries can still find plans with $0 premiums. Although the average Medicare Advantage premium in 2024 is around $30 to $40 per month. For instance, Carrier 1 Medicare Advantage Plan using an HMO network offers a $0 per month premium, but it’s limited to certain counties within each state. A different plan, Carrier 2 using a PPO network has monthly premiums that start around $35. It’s essential to remember that a lower premium often means higher out-of-pocket costs when you need care and/or a more restrictive network. Therefore, it’s crucial to balance the monthly premium with other expenses such as deductibles, copayments, and coinsurance when choosing the right Medicare Advantage plan for you.

Overview of Medicare Part C – what it is and who can get it

Getting older comes with various challenges, including healthcare needs. That is where Medicare Part C comes into play. Also known as Medicare Advantage, Part C is an alternative to Original Medicare (Part A and Part B). It is a health insurance plan offered by private insurance companies approved by Medicare, which covers all of the benefits offered in Part A and B. On top of that, it can offer additional benefits, such as dental, vision, or hearing, at an affordable cost. Remember, only those enrolled in both Medicare Parts A and B qualify for Part C.

It’s essential to understand the fundamental difference between a Medicare Advantage plan (Part C) and a Medicare Supplement (Medigap) plan. While both are intended to help cover out-of-pocket costs of Original Medicare (Part A and Part B), they function in entirely different ways. A Medicare Advantage plan is an alternative way to receive your Medicare benefits through private insurance companies approved by Medicare. It often includes additional benefits such as prescription drug coverage, as well as dental, vision, or hearing services. On the other hand, a Medicare Supplement plan works in conjunction with your Original Medicare benefits. This is to help pay for the costs not covered by Original Medicare, such as copayments, coinsurance, and deductibles. You cannot have both a Medicare Advantage plan and a Medicare Supplement plan at the same time. It’s paramount to consider the differences, costs, and benefits of these options to make the best decision based on your healthcare needs and financial situation.

Understanding the different components of Medicare Part C coverage

Understanding Medicare Part C coverage is crucial for those who qualify for this program. Made available through private insurance companies, it combines the benefits of both Medicare Part A and Medicare Part B. Medicare Part A primarily covers inpatient hospital care, hospice care, and skilled nursing facility care. Medicare Part B, on the other hand, covers outpatient services, preventative services, and medical equipment. With Medicare Part C, you get an opportunity to customize your coverage by selecting a plan that fits your individual needs as well as budget. It can provide additional benefits, such as prescription drug coverage, vision, dental, and hearing care. By understanding the different components of Medicare Part C coverage, you can make an informed decision regarding which plan is right for you.

Factors that affect the cost of Medicare Part C

When it comes to Medicare Part C, many factors can influence the cost of coverage. The first thing to consider is the plan itself. Different Medicare Advantage plans have varying benefits, co-payments, and deductibles, all of which affect the monthly premium cost. Another factor is location. Insurance companies can charge different rates in various parts of the country, based on the cost of medical care in that region. Age, health status, and income level can also affect the cost, particularly for those who qualify for financial assistance. For those with a chronic health condition, there are plans designed just for those conditions. Some of these conditions include diabetes and heart complications. Ultimately, it’s essential to carefully evaluate all of these factors before choosing a Medicare Part C plan to ensure that you are getting the coverage you need at a price that fits your budget.

How to choose a plan based on your budget and needs

Choosing the right plan for your budget and needs can be overwhelming. With the help from an informed advisor it doesn’t have to be. First, assess your needs and priorities. Do you prioritize flexibility or a lower monthly cost? If provider flexibility is a priority, then a Medicare Advantage plan that uses a Preferred Provider Organization (PPO) network will allow you to see providers in and out of network. If your priority is cost then a plan that uses a Health Maintenance Organization (HMO) network will likely give you the lowest co-pays and premium costs. Next, take stock of your current health and lifestyle. Are you relatively healthy and rarely need to visit the doctor, or do you have ongoing medical needs? Once you understand your priorities and needs, your advisor can find a plan that aligns with them. This may include assessing factors like premiums, deductibles, and co-pays. Taking the time to choose the right plan can save you both time and money in the long run.

Common Misconceptions about Medicare Part C

Despite the widespread use of Medicare Part C, multiple misconceptions continue to circulate, which can make the decision-making process more challenging for individuals. One common misconception is that Medicare Advantage (Part C) plans are fully comprehensive and eliminate all out-of-pocket costs. Indeed, these plans often surpass Original Medicare in coverage, but they usually come with deductibles, co-pays, and other costs. Depending on things such as what state and county you reside in, you will hear about different Maximum Out Of Pocket (MOOP) costs. There are plans in some states and counties that have a $3,000 MOOP for a calendar year, but in another state and county that MOOP could be well over $7,000 for a calendar year.

Misconception 2

Another misconception is that all Medicare Part C plans are the same. In reality, plans can differ significantly, with various offerings, premiums, and out-of-pocket costs, depending on the insurance company and location. It’s crucial to investigate the specifics of any plan you’re considering to ensure it will truly meet your needs. Some plans offer a gym membership such as Silver Sneakers, but another may not. While some plans may offer dental benefits of up to $1,000 at no additional cost, another plan may offer $2,000. Now keep in mind that the Medicare Advantage plan offering the gym membership might only offer up to $1,000 in dental benefits. If you don’t need or want the gym membership but really want more dental benefits, then you would likely want to go with the plan that offers up to $2,000 in dental benefits. If you really want both the gym membership and the maximum dental benefits, you might want to consider getting the plan with the gym membership and adding on additional dental benefits with a stand alone dental plan.

Misconception 3

A third misconception is that Medicare Part C enrollees can see any healthcare provider. However, most Medicare Advantage plans are network-based, meaning your provider options may be limited. It’s important to make sure your preferred providers are in-network or be comfortable with the network providers before choosing a plan. As we discussed earlier, most plans will use either a PPO or HMO network. If you join a plan that uses an HMO network, then you MUST see only providers who participate in that plan’s network. If you go with a PPO plan then you will have the lowest out of pocket costs when going to a provider in their network, but you do have the option of seeing a provider who is not in that network. “Keep in mind, choosing an out-of-network provider often means facing a separate deductible and higher coinsurance payments.”

Misconception 4

Finally, some believe that once enrolled in Medicare Part C, they are locked in forever. The reality is, enrollees have the option to change plans during the annual enrollment period. This flexibility allows individuals to adapt their coverage as their healthcare needs evolve. Each year the annual enrollment period (AEP) begins October 15th and ends December 7th. During this time you can switch Medicare Advantage plans or leave Medicare Part C completely and return to original Medicare. Remember that if you return to original Medicare and want a Medicare Supplement you may be subject to underwriting. This means you will have to medically qualify for the Medicare Supplement. There are provisions for certain situations where you could obtain a Medicare Supplement plan without underwriting.

By dispelling common misconceptions, you can make informed decisions and maximize your Medicare Part C coverage.

Tips for saving money on Medicare Part C coverage

Medicare Part C can be a great way to get comprehensive health coverage. However, it can also be costly. If you’re looking for ways to save money on your Part C coverage, one option to consider is hospital indemnity insurance. This type of insurance provides additional coverage for hospital stays, which can be a major source of expense when it comes to healthcare. Did you know that daily hospital co-pays can vary from $200 per day to over $400 per day? At $400 per day a 5 day inpatient hospital stay would amount to a $2,000 exposure that would need to be paid out of pocket.

By adding hospital indemnity to your Part C plan, you can help avoid paying unexpected costs out of pocket. Learn how a hospital indemnity plan could pay your daily hospital co-pays for pennies on the dollar.

Indeed, Medicare Part C outshines regular Part A and B by providing coverage as a valuable alternative to original Medicare. It is important research your plan’s components and understand your monthly and out-of-pocket costs. There are a variety of options available from private companies, so it’s worth considering which one will cover your needs best. Doing this allows you to save time and money while finding the right plan for your situation. Additionally, there are several strategies you can use to save money on your out of pocket expenses. Learn more about Medicare Part C; call (800) 924-4727 to find the best plan.

Many folks wonder about how Medicare Advantage plan’s hospital coverage works.

Medicare Advantage plans are a great way to get health coverage for senior individuals and those on Medicare due to disability who qualify. But did you know that supplementing your Medicare Advantage plan with a hospital indemnity plan can provide even more comprehensive coverage? Let’s look at how this works and why it may be beneficial to you.

What is a Hospital Indemnity Plan?

A hospital indemnity plan is an insurance policy that pays out cash benefits for covered medical expenses due to illness or injury. This type of policy provides financial assistance for the costs associated with inpatient care and can also cover other related expenses such as medications, outpatient services, doctors’ visits, and more. It is important to note that these plans do not cover all medical expenses—that’s where Medicare Advantage comes in.

How Does a Hospital Indemnity Plan Supplement Medicare Advantage?

Medicare Advantage plans are designed to cover most of the same things as traditional Medicare Part A and Part B, but sometimes there are gaps in coverage. These gaps can include deductibles, copayments, coinsurance, or other out-of-pocket costs associated with health care services. That’s where a hospital indemnity plan comes in—it helps to fill those gaps in coverage by providing additional financial protection against unforeseen medical expenses.

For example, if you were hospitalized due to an unexpected illness or injury, your hospital indemnity plan would pay out cash benefits to help cover any out-of-pocket costs that your Medicare Advantage plan doesn’t cover.  To better understand this, let’s take a look at the following case study combining a hospital indemnity plan with Medicare Advantage hospital coverage:

Jane is a 67-year-old female who has a Medicare Advantage plan that requires her to pay the first $300 per day that she is in the hospital.  She must pay the $300 co-payment for the first 5 days she is an inpatient.

Jane is admitted into the hospital on March 2^nd due to an accident that has damaged her knee and shoulder.  It is determined that Jane needs to have a full knee replacement done and will also need physical therapy for her shoulder.  Jane spends 4 nights in the hospital before being sent to a skilled nursing facility to get rehab for her knee and shoulder.

Jane will owe the hospital $1,200 for her stay ($300 x 4 days = $1,200).  The good news for Jane is that her insurance agent helped her obtain a hospital indemnity plan that will cover $300 per day for up to 10 days each calendar year for only $29.00 per month.  This means that Jane will receive a cash payment of $1,200 that she can in turn use to pay for her hospital bill.

It Gets Even Better!

Here’s the great news…if Jane were to go back into the hospital during the same calendar year, she would still have 6 days of benefits left on her hospital indemnity plan.  So even if her Medicare Advantage plan covered all the hospital expenses, her hospital indemnity plan would continue to pay cash benefits directly to her.  That extra money could be used anyway that Jane wants.

Why Should You Consider Adding a Hospital Indemnity Plan?

Adding a hospital indemnity plan to your existing Medicare Advantage plan can provide peace of mind and greater financial security for a very small monthly premium. Having both types of coverage means that you will have more comprehensive protection against unexpected hospital expenses due to illness or injury—which can help save money in the long run. Plus, many hospital indemnity plans come with additional options such as ambulance trip coverage, skilled nursing facility coverage, and even outpatient surgical expense coverage—so adding one could be well worth the cost!

Conclusion:

Hospital indemnity plans can be an excellent way for individuals who qualify for Medicare Advantage to further protect their finances from unexpected medical costs due to illness or injury. If you are looking for additional peace of mind and financial security when it comes to health care costs and Medicare Advantage hospital coverage, then consider adding a hospital indemnity plan today! With its cash benefits, it could prove invaluable over time.  To find out more about how a hospital indemnity plan could benefit you personally, call Senior Benefit Services at (800)924-4727.

Medicare out-of-network confusion continues to remain a big issue with Medicare Advantage plans.  A recent letter that was sent out by The Mayo Clinic (Florida location) has caused quite a bit of uproar due to the facility urging Medicare beneficiaries to reevaluate staying in a Medicare Advantage plan.  In addition, the letter reminded Mayo Clinic patients that they do not participate as an in-network facility and will no longer schedule patients who have a Medicare Advantage plan that would classify The Mayo Clinic as ‘out-of-network”.

Earlier this year a survey released by MedicareGuide.com found that 4 out of 10 Medicare Advantage enrollees believed that they do not have to stay in-network for care.  This is very alarming since the network restrictions are one of the key ways that Medicare Advantage plans keep overall costs down.  Consumers are not understanding that you are trading the flexibility of provider access for low to no premiums and being restricted to use only providers in the plan’s network.

Many retirees who enroll in a Medicare Advantage plan do so for the low-cost premiums and ‘extra benefits’ they would receive not typically found in Original Medicare.  A large percentage of those retirees do not understand that they are in essence signing over their Medicare benefits for Parts A & B to a private insurance company.  Those amounts typically come in around $1,000 per month on average (before bonuses that the insurance company may get) for non-special needs plans (SNPs) or dual eligible plans (DSNPs).  Both SNP and DSNP plans get paid an even higher amount from Medicare.  According to the Medicare Trustees report, in 2019 payments to private Medicare Advantage plans were approximately $321 per enrollee higher than what Medicare would have spent on these same folks if they had been in traditional Medicare (Parts A & B).  While $321 per enrollee for the year might not seem like a large amount of money, the total for increased spending by Medicare for these folks equates to an estimated $7,000,000,000.00 (seven billion dollars) in additional costs to the Medicare program.  For 2022 it is expected to swell to $12,000,000,000.00

DENY…DENY…DENY!

Be careful of going out of network in a Medicare Advantage plan!

With this much additional money being spent, one would assume that more benefits are being paid out on behalf of enrollees.  That assumption is wrong.  In fact, one of the most common reasons for Medicare Advantage enrollees wanting to return to original Medicare comes when a prior approval for a procedure is delayed or even denied.  In the 2022 Office of The Inspector General (OIG) report there was a concern for “the incentive for Medicare Advantage plans to deny beneficiary access to services and deny payments to providers in an attempt to increase profits.”  One would think with all the additional money coming into Medicare Advantage plans that there would be a focus on reducing the out-of-pocket costs enrollees face.  Sorry to say that is not always the case.

Did you know in a Kaiser Family Foundation report, over 50% of the Medicare Advantage enrollees would incur higher out of pocket costs for a 7-day hospital stay than those with Original Medicare?

Takeaway

As we have said many times over, Medicare Advantage plans are not bad if enrollees fully understand the tradeoffs.  For those younger Medicare beneficiaries who are possibly in better health, the likelihood of them needing prior approval for a high costing procedure or facing a lengthy stay in the hospital are lower than older Medicare beneficiaries whose health is likely to continue to decline.  It is vitally important that Medicare Advantage enrollees understand that their coverage is being provided by private insurance companies and not Medicare itself.  Unlike Original Medicare, where they would not face having to get prior approval for most services or be limited to a certain network of doctors, Medicare Advantage plans use these to reduce costs and increase profits.  We believe that there is nothing wrong with this since private insurance companies are a business that must make a profit.  Where we find issues is when the enrollees do not fully understand the limitations and restrictions of these Medicare Advantage plans and how the benefits are affected in an out of network situation.  To discuss what plan options work best for your individual needs, contact us at (800)924-4727 to get a dedicated advisor to review your current situation.