Important to know the basics of Medicare Advantage Plans

Published Sep 24, 2017 at 9:00am

In May I wrote a column about Medicare Advantage Plans (Advantage Plans). However, the focus of that column was on why physicians are leaving some of the plans.

This column focuses on how Advantage Plans work. Slightly under 70 percent of those eligible for Medicare are covered by Parts A and B and receive their Part D drug benefits through separate “stand alone” drug plans.

The remainder, slightly over 30 percent of those eligible receive their benefits through Advantage Plans. Even for those who are long-time members of Advantage Plans, many questions still remain about how these plans work. 

What do Medicare Advantage Plans cover? Advantage Plans cover all costs of medically necessary services. However, a plan may choose not to cover all the costs of those services that are not deemed medically necessary under Medicare. This is one of the things that you clearly need to investigate before you make any changes in your current coverage.

If you choose an Advantage Plan, you will still be covered by Original Medicare for the cost of hospice care, some new Medicare benefits and the costs of clinical research studies you may want to become involved in. Regardless of the type of plan you choose, you will always be covered for any emergency and urgently needed medical care.

Several things make Advantage Plans attractive to many beneficiaries. First, as noted above, many plans offer extra coverage for a number of things not covered by traditional Medicare, such as hearing, vision and wellness benefits.

Second, the idea of having one single plan and only having to present one insurance card appeals to many.

In terms of cost, in addition to the standard Part B premium as determined by your income most beneficiaries pay an additional monthly premium for their Advantage Plan. Keep in mind that, in most cases, these additional premium costs also cover your prescription drug coverage.

How do Advantage Plans work?  Each month Medicare pays the plan a fixed amount for each person enrolled in their plan. So, how do plans control costs in order to not exceed the amount of this fixed payment? One way is that plans can charge different amounts for out-of-pocket costs.

Also, they have rules to cover whether or not you need a referral to see a specialist. Plans may also charge you additional co-pays for seeing a health care provider who does not participate in their network. And, these rules can, and generally do, change every year.

Costs for Medicare Advantage Plans? Each Advantage Plan can charge different rates for out-of-pocket costs. Each plan can have different rules on how beneficiaries access various services, including (1) whether or not you need a referral to consult with a specialist and (2) if you must go to doctors or facilities that belong to the plan (referred to as a network). As is pointed out in much more detail on the Medicare.gov website, what you pay in the way of out-of-pocket costs depends on: 

Whether or not your Advantage Plan charges an additional monthly premium.

Whether or not your Plan pays any of your monthly Medicare Part B premium.

The amount of your yearly or any other deductibles. 

How much you pay for each visit or service, known as a copayment or coinsurance. An example would be when you pay $10 or $20 for each doctor visit. These amounts can be different from the copayments charged under Original Medicare. 

The type of health care services you receive and how often you receive them.

Whether you follow the plan’s rules concerning using only providers within their network or whether you choose to use providers that are outside the network.

Whether you need extra benefits for which you can be charged. 

By Jan. 1 of each year, Advantage Plans must publish the amounts they will charge for premiums, deductibles, and services. So, keep in mind that it is the Advantage Plan, and not Medicare, that determines how much you will pay for the services that you need. What is covered beyond what is required by Medicare and the amount of your premium is determined by the Plan.  

If you are already enrolled in an Advantage Plan every fall you will receive an Evidence of Coverage (EOC) as well as an Annual Notice of Change (ANOC) from you plan. First, the EOC will provide you with details about what your plan will cover, how much it will cost as well as additional information.

The ANOC outlines any changes in coverage, services or costs that will take effect in January. If you have any questions about the information in either document call the HIICAP program for assistance. If you decide to make a change in your coverage and wish to talk with a HIICAP counselor, be sure to bring both the EOC and ANOC notices with you. 

Open Enrollment is Right Around the Corner. The annual fall Open Enrollment Period opens on Oct. 15. However, the Oneida County HIICAP program is available every weekday to answer your questions or to assist in enrolling in the coverage of your choice. 

Who do I contact in Oneida County for help with my Medicare Advantage plan? The Oneida County Office for the Aging/Continuing Care/NY Connects Health Insurance Information, Counseling and Assistance program (HIICAP) offices provide their services at no cost to Medicare beneficiaries. HIICAP offices are found at the following locations:

Ava Dorfman Senior Citizens Civic Center, 305 E. Locust St., with hours of operation on Tuesday and Thursday from 10 a.m. to 2 p.m. Again, while consumers are seen on a “first come, first served” basis you may call the Dorfman Center at 315-337-1648 to see if there are long wait times.

North Utica Senior Citizens Community Center, 50 Riverside Drive, Utica with hours of operation on Monday, Wednesday and Friday from 10 a.m. to 2 p.m. Consumers are counseled on a “first come, first served” basis. However, if you want to call ahead to see how busy the office is you may call the center’s HIICAP program at 315-724-8680.

HIICAP services are provided by Oneida County Office for Aging and Continuing Care/NY Connects.

Anyone with questions about HIICAP, including issues with your Medicare Advantage Plan, should call the program directly at 315-798-5456 and press 4 in the choice list. It will direct you to someone who can assist you.

Dr. William Lane is the owner of William Lane Associates, a gerontological firm which located in Homer, NY. He writes a monthly column on HIICAP related issues for the OFA. Dr. Lane does not sell insurance, work for any insurance company or recommend any insurance products.