Consider Medicare coverage options; advantage plans

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As we continue to have an ever-increasing number of Oneida County residents become eligible for Medicare benefits, there is never a wrong time to consider your coverage options.

A majority of Americans continue to choose Original Medicare, opting for coverage through Medicare Parts A and B along with a Part D drug plan. However, Medicare Advantage plans continue to gain in popularity. These plans, which are formally known as Medicare Part C plans, are offered by private insurance companies and cover the same health care services as Original Medicare. One of the reasons for their popularity is that they may also offer additional services not covered under Original Medicare. The primary examples of Medicare Advantage plans are Health Maintenance Organizations (HMO) and Preferred Provider Organizations (PPO). Those enrolled in a Medicare Advantage plan usually pay a co-payment when they visit a doctor or other provider.

As a general rule, plan enrollees can only go to the doctors, specialists and hospitals on the plan’s list which is referred to as network. If you receive service outside this network of providers you will generally pay more and, in some cases, your care may not be covered at all. The exception is emergency or urgent care. For these cases, your Medicare Advantage will pay for the services you receive.

The special Medicare Advantage Open Enrollment Period, which runs from Jan. 1 to March 31, has just closed. This period should really be considered as an exchange period and not enrollment period. First, it is only for those who are already enrolled in an Advantage plan. During this period, you can only (1) switch from one Advantage plan or another or (2) switch from an Advantage plan back to Original Medicare along with a Part D prescription drug plan. Your new plan goes into effect one month later. 

Despite the popularity of Advantage plans, a number of problems have recently been reported. While Advantage plans are a viable choice for many, here are some of the most often reported problems and pitfalls. It should be noted that not all the reported problems apply equally to all types of plans and overall satisfaction with Advantage plans remains high.

Limiting Health Care Providers. Most researchers and policy makers seem to agree that this is more of a problem with HMOs, who tend to offer the least expensive but most restrictive Advantage plans. Outside of emergency care, many of the plans will pay nothing if you use a provider who is not part your network. In theory, when you enroll in an Advantage plan you can review lists of in-network providers before you sign on the dotted line.

But, according to a recent study by the Kaiser Family Foundation (KKF), the provider information is often very difficult to review, may be out of date or contain inaccurate information.

Blocking Referrals or Discharging Early. This is another problem that seems to apply more to HMOS as opposed to PPOs. HMOs have been reported to encourage the patients primary care provider to provide all possible care rather than to do a referral to a specialist. In many cases the physician must obtain plan approval before making the referral. 

Rate Hikes. Because the government does not regulate premiums and co-pays in the same way as Original Medicare, a plan can make changes at any time during the year. Raising co-payments for specific services and prescription drugs has become an all too common practice among some providers.

Dropping of Providers or Geographic Coverage. Instability in the insurance market has been reported as a nation-wide problem. Physicians are dropped by plans for such things as making too many referrals. Physicians themselves may drop out of a plan because of too many restrictions on the scope of their practice. Almost every month one or more plans drop their coverage in New York. 

Despite the problems listed above, enrollment in Advantage plans continues to climb. According to the General Accounting Office, by 2026 it expected that almost 40 percent of all Medicare beneficiaries with be enrolled in an Advantage plan. This is up from roughly 10 percent in 2010.

As noted earlier, plans are popular because they often offer extra benefits, including dental and vision care as well as health club memberships. Also, cost-sharing is often lower and Part D drug coverage is included in the premium. Advantage plans are therefore very attractive to many, especially those who are on fixed incomes where budgeting and predictability in health care costs are very important. 

Who do I contact in Oneida County for help with my Advantage plan? The Oneida County Office for the Aging/Continuing Care/NY Connects Health Insurance Information, Counseling and Assistance program (HIICAP) offices can help you with all your Advantage plan needs, from selecting a plan to handling any problems you may encounter. All HIICAP services are provided at no cost to Medicare beneficiaries. HIICAP offices are found at the following locations:

Copper City Community Connection (formally the Ava Dorfman Senior Center), 305 E. Locust St., with hours of operation on Tuesday and Thursday from 10 a.m. to 2 p.m. Consumers are seen on a “first come, first served” basis you may call CCCC 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.

Dr. William Lane is the owner of William Lane Associates, a gerontological firm 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. 

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