How Medicare Advantage Manages Cost
Medicare Advantage plans work in the same way as employer-provided group insurance. You must select health care providers within the insurance companys network to be covered. If the plan is a HMO , it may be quite narrow or more extensive if it is a PPO . Preapproval may be required for certain types or referrals to specialists. You may have to pay extra if you are out of your network. You might not be notified even if your doctor is currently in-network.
Medicare Advantage plans are usually regional. You may not be covered if you move outside the region or to another state.
The devil is in the details. Medicare Advantage plans are full of details. According to the Kaiser Family Foundation, an average Medicare beneficiary can choose from 28 Medicare Advantage options. These include varying networks, coverages, copays, and coinsurance. Medicare Advantage is generally cheaper upfront, and may cost more if you require a lot of medical care. While Medigap plans can have higher upfront costs, they will cover the majority of your care when you are in need.
Why Choose A $0 Premium Medicare Advantage Plan
If you sign up for a Medicare Advantage plan, youll pay any applicable Part A and Part B premiumsand possibly a separate Medicare Advantage premium. If you choose a $0 premium plan, you could get more benefits than Original Medicare provides, at no additional cost.
- Prescription drug coverage
- Hearing aids
- A fitness plan
Other benefits could include transportation to and from doctor appointments and allowances to purchase over-the-counter items like compression socks and blood-pressure cuffs.
With any Medicare Advantage plan, youll still pay the Part B premium. And if you didnt earn premium-free Part A through your or your spouses work record, youll need to pay that premium as well. But if you choose a $0 premium plan, you could receive these additional benefits, as well as others, for no extra cost.
It sounds like a dream, right? Lets dive into how Medicare Advantage plans work to see how insurance companies can offer these perks without charging a premium.
Medicare Advantage Plans Have Hidden Costs
What most people describe as hidden costs are often the deductibles, coinsurance or copayments built into the plan. Original Medicare also has deductibles, coinsurance and copayments for both Part A and Part B coverage.
Be sure to go over the deductibles and cost-sharing requirements for any plan prior to enrolling so you know what to expect when you use the policy. When you see Medicare Advantage plans marketed as having $0 monthly premiums, keep in mind that you likely still have other costs to pay when using the plan, such as those coinsurance or copay costs.
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Original Medicare: A Quick Overview
The government health insurance program created in 1965 is called Original Medicare. Its made up of:
- Part A, which is hospital insurance and generally covers care at skilled nursing facilities and sometimes nursing homes
- Part B, which is medical insurance and generally covers preventive care, doctor visits, lab tests, durable medical equipment, and more.
Part A and Part B come with deductible amounts, coinsurance, and/or copayments for most services.
If youre automatically enrolled in Medicare, as many people are, youre usually enrolled in Part A and Part B. If youre already getting Social Security benefits when you turn 65 or qualify by disability, youre usually enrolled automatically.
How And When Can You Join A Five Star Medicare Advantage Plan
You can make this switch during the Five Star Special Enrollment Period , which takes place from December 8 to November 30. Its in addition to the main Medicare Advantage Open Enrollment Period, when you can switch to all types of Medicare Advantage plans.
Speak with a licensed Medicare agentto help you switch coverage using the Five Star SEP.
If youre unable to sign up online, contact the plan directly for enrollment paperwork.
If you already know a five-star plan is available in your area, make sure to check if it comes with Part D prescription drug benefits. An excellent, five-star rating doesnt mean drug coverage is automatically included.
Here are some things to keep in mind:
- If youre leaving a Medicare Advantage plan that includes prescription drug coverage and joining a five star MA plan that doesnt offer this benefit, you may end up losing your drug coverage.
- If you lose your drug coverage, you may have to wait until the next time youre eligible to enroll in drug benefits but you could face paying a Part D late enrollment penalty.
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Providence Medicare Advantage Plan Options
Providence offers nearly 20 Medicare Advantage Plans. Options differ in each part of its 11-county service area. Coverage gives members access to the companys group of HMO providers. Staying in the network helps members reduce their copays or coinsurance rates. All plans include medical care. Some include prescription drug benefits plus optional dental supplements and many free perks. Monthly premiums range from $0 up to $173 depending on the coverage tier selected. The company also offers a Medicare Advantage Special Needs Plan for Medicaid-qualified dual enrollees in select areas.
Heres an example of some of the 2022 Providence Medicare Advantage Plans that may be available in your area.
*Based on pricing in Washington County, Oregon in 2022
Best Medicare Advantage Providers Ratings
- Over-the-counter drug coverage
- Other services that promote health and wellness
You cant be enrolled in a Medicare Advantage plan and Original Medicare at the same time. To obtain Medicare benefits youve earned through payroll deductions before retirement, you must choose one of these plans.
During the open enrollment period, which runs from Oct.15 to Dec. 7 each year, you can join, switch or drop a plan for your coverage to begin on Jan. 1. If youre already enrolled in a Medicare Advantage plan, you can switch to a different Medicare Advantage plan or Original Medicare during the Medicare Advantage open enrollment period, which starts on Jan. 1 and ends on March 31 annually. You can only make one switch during that time period.
If youre already enrolled in Original Medicare , you may be eligible to switch to a Medicare Advantage plan . You must be at least 65 years old or have certain disabilities, such as permanent kidney failure or amyotrophic lateral sclerosis . If the Medicare Advantage plan you choose doesnt already have prescription drug coverage, you will have the option to enroll in Part D.
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Why Dental Care Is Important For Your Health
When Medicare beneficiaries forego dental care, they may be putting more than just their teeth at risk.
Numerous studies have found and confirmed direct connections between oral health and overall health.6 Just a few of the complications that can be associated with poor dental hygiene include:
- Erectile dysfunction
Your mouth is full of bacteria, most of which is harmless when proper dental care is practiced. But when oral health is compromised, so too is the mouths ability to serve as a gatekeeper to the rest of the body.
A weakened level of oral health can mean more harmful bacteria is able to pass through and enter the body, leading to other health complications.
Unhealthy teeth can also make it harder to eat a nutritious diet, as chewing fruits or meat can become difficult with weakened teeth. This can lead to increasingly poor diet choices, which in turn can factor into multiple other health concerns.
Poor dental health can also lead to social anxiety and isolation because of feelings of embarrassment when speaking or smiling.
Medicare beneficiaries may want to consider their dental coverage options in order to help ensure their overall health is protected.
Choosing Traditional Medicare Plus A Medigap Plan
As noted above, Original Medicare comprises Part A and Part B . You can supplement this coverage with a stand-alone Medicare Part D prescription drug plan and a Medigap supplemental insurance plan. While signing up for Medicare gets you into Parts A and B, you have to take action on your own to buy these supplemental policies.
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Medicare Advantage Plans Require Referrals To See Specialists
In the case of HMO plans, this is typically true. But it isnt always the case with PPO plans and some other types of Medicare Advantage plans.
Requiring a referral to see a specialist is one common aspect of a managed care approach, in which health care providers work as a team to coordinate your care. Studies have shown that Medicare beneficiaries in managed care plans experience better health outcomes and lower costs than their fee-for-service counterparts who are enrolled in Original Medicare.
How Medicare Advantage Plans Work
First, it will help to review a few basics. Medicare comes in four parts, with Part A covering inpatient hospital care, and skilled nursing. Theres no premium if you or your spouse have earned at least 40 Social Security credits.
Part B covers doctor services and outpatient hospital care. You have to pay a monthly premium for this coverage, which is $170.10 in 2022, with a deductible of $233. High earners pay more.
The other parts of MedicarePart C, aka Medicare Advantage, and Part D, prescription drug coverageare optional and offered by private insurers.
Medicare Advantage is an all-in-one managed care plan, typically an HMO or PPO. Advantage plans provide the benefits of Part A and B, and most also include Part D, or prescription drug coverage. Some offer extra benefits not available through Original Medicare, such as fitness classes or vision and dental care.
If you opt for Medicare Advantage, you typically continue to pay your Part B premium as usual, but you will pay little or no additional premiums for your coverage. You generally have copays or coinsurance, but once you reach your out-of-pocket limit, the plan will pay 100 percent of your medical costs covered under Medicare for the rest of the year. The out-of-pocket limit does not apply to prescription drugs or extra benefits.
With Medigap, youll pay more in monthly premiums compared with Advantage plans . Youll also have a bit more work choosing your Part D plan.
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Consider Premiumsand Your Other Costs
To see how a Medicare Advantage Plan cherry-picks its patients, carefully review the copays in the summary of benefits for every plan you are considering. To give you an example of the types of copays you may find, here are some details of in-network services from a popular Humana Medicare Advantage Plan in Florida:
- Hospital stay$175 per day for the first 10 days
- Diabetes suppliesup to 20% copay
- Diagnostic radiologyup to $125 copay
- Lab servicesup to $100 copay
- Outpatient x-raysup to $100 copay
- Renal dialysisup to 20% copay
As this non-exhaustive list of copays demonstrates, out-of-pocket costs will 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.”
Medigap Plans Cover Some Of The 20% Gap In Orginal Medicare
There are 10 lettered Medicare supplement plans . Each lettered plan represents a standardized insurance policy and covers the nine gaps in Medicare. These gaps include:
Medicare Part A is your hospital inpatient coverageMedicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care…. and Medicare Part B is your medical coverage. Without additional coverage, you are responsible for the shared costs listed above. This surprises many people getting their Medicare benefits for the first time. And thats why its so important to understand one basic fact.
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Medicare Advantage Plans May Cost You Less
If you enroll in a Medicare Advantage plan, you continue to pay your Medicare Part B premium and you may pay an additional premium. The insurer determines the Medicare Advantage plans premium, which can vary from one Medicare Advantage plan to another. Some Medicare Advantage plans may have premiums as low as $0.
Your cost sharing may also be less under Medicare Advantage. For, example, if you visit a primary care physician under Medicare Advantage, you may pay a copayment of $10. However, if you visit a primary care physician under Original Medicare, you may have a coinsurance of 20%, which could be more than $10.
Also, a Medicare Advantage plan limits your maximum out-of-pocket expense. Once you have spent that maximum, you pay nothing for covered medical services for the remainder of the year. Original Medicare does not provide a maximum out-of-pocket cap, so your potential expenses are limitless.
Often a Medicare Advantage plan can be less expensive than comparable coverage you would receive if you stayed with Original Medicare. To get all the benefits of Medicare Advantage with Original Medicare, you would also need to enroll in a stand-alone Medicare Part D Prescription Drug Plan as well as a Medicare Supplement plan.
Medicare Advantage Is A For
Over 100 Democratic lawmakers last week introduced legislation to lower the Medicare eligibility age to 60. There is one small problem that needs fixing, though: so-called “Medicare Advantage.”
This week my new book, The Hidden History of American Healthcare: Why Sickness Bankrupts You and Makes Others Insanely Richis officially available in bookstores nationwide and online. Here’s a chapter excerpt I think you’ll find interesting, particularly after all those awful TV ads with former football and sitcom stars we’ve had to endure the past few years
The “Advantage” War against Medicare
Medicare Advantage is a massive, trillion-dollar rip-off, of the federal government and of taxpayers, and of many of the people buying the so-called Advantage plans.
It’s also one of the most effective ways that insurance companies could try to kill Medicare For All, since about a third of all people who think they’re on Medicare are actually on these privatized plans instead.
Nearly from its beginning, Medicare has allowed private companies to offer plans that essentially compete with it, but they were an obscure corner of the market and didn’t really take off until the Bush administration and Republicans in Congress rolled out the Medicare Modernization Act of 2003. This was the GOP’s big chance to finally privatize Medicare, albeit one bite at a time.
Here are a few quotes from the report:
You Are Locked in to Medicare Advantage
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Medicare Advantage Is More Expensive But It May Be Worth It
- Read in app
By Austin Frakt
Medicare Advantage plans private plans that serve as alternatives to the traditional, public program for those that qualify for it underperform traditional Medicare in one respect: They cost 6 percent more.
But they outperform traditional Medicare in another way: They offer higher quality. Thats according to research summarized recently by the Harvard health economistsJoseph Newhouse and Thomas McGuire, and it raises a difficult question: Is the extra quality worth the extra cost?
It used to be easier to assess the value of Medicare Advantage. In the early 2000s, Medicare Advantage plans also cost taxpayers more than traditional Medicare. It also seemed that they provided poorer quality, making the case against Medicare Advantage easy. It was a bad deal.
At that time, Medicare beneficiaries could switch between a Medicare Advantage plan and traditional Medicare each month. In that setting, the Medicare Payment Advisory Commission found that relatively healthier beneficiaries were switching into Medicare Advantage and relatively sicker ones were switching out.
This suggested that Medicare Advantage didnt provide the type of coverage or the access to services that unhealthier beneficiaries wanted or needed. Since the point of insurance is to pay for needed care when one is sick, it was tempting to condemn the program as having poor quality and failing to fulfill a basic requirement of coverage.
How Does $0 Medicare Advantage Plans Work
If your Medicare Advantage plan has a premium, youll pay that premium directly to the insurer. But youll also pay the Social Security Administration any Part A and Part B premiums youre responsible for. If youre receiving Social Security benefits, these premiums automatically come out of your monthly checks.
If you have Original Medicare, your premiums go directly to the Medicare program. However, if you enroll in Medicare Advantage, a portion of these funds are paid to your plan provider to pay for your care. Whether you pay an extra premium for Medicare Advantage or not, the insurer still earns income when you enroll.
If an insurer can provide all the required benefits using only funds from Medicare, it can choose to forego charging an additional premium. Many $0 premium plans squeeze in some of the extra benefits mentioned above without costing you a penny.
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