Why a Medicare Advantage Plan is wrong for you..or is it?
When looking at Medicare coverage options, many folks ask the medical professionals they see,friends or neighbors what plans are good and which plans are not. With a Medicare Advantage Plan being a little more complex than original Medicare, some folks may think it’s the wrong plan for them, and it may be. We’ll go over why some think these plans aren’t the best, and what might make them a good fit after all!
Medicare Advantage Plans have a network of providers
In our opinion, this factor of a Medicare Advantage Plans can be the biggest issue. With some Medical providers accepting Medicare Advantage and some not, it can be confusing. Add in that there are insurance carriers that offer both Medicare Advantage Plans and Medicare Supplement, that can add to the confusion.
With a Medicare Advantage Plan, you have a limited network based on where you live. If you’re out of town and not able to go to your network providers, only Emergency services will be covered. Compare this to Original Medicare with a Medicare Supplement plan where you have no network and your plan is accepted Nationwide, you can see which plan offers more freedom of choice, which you will pay for.
There are currently 40 different Medicare Advantage Plans available in San Diego county. Choosing the most appropriate plan you want to ensure that any providers you want to see or use are not only in the specific network but also in the same medical group. If the providers are in different medical groups, they will not be able to refer to each other. This is very important!!
The best and easiest way to check providers in network is to either call the plan your thinking of joining, looking online at their provider directory or, you can work with us! We can help you find the plan that ticks all the boxes.
I thought my Medicare Advantage Plan was free!?
Some folks for whatever reason, think that their Medicare Advantage plan is free.
This is a common misconception and can be confusing and maddening!! In some areas, San Diego included there are many plans with “Zero Dollar Premiums” meaning that other than your Medicare Part B premium, you’ll pay no extra PREMIUM monthly. That doesn’t make them free though!!
Medicare Advantage Plans have other co pays, deductible and charges for services that are absolutely NOT FREE!!
These amounts vary from plan to plan and service to service. Think of a Medicare Advantage Plan as more of a pay as you go type program.
At San Diego Medicare Broker, we can help you find the plan with the lowest co pays, deductibles, out of pocket maximums all while ensuring your providers are in network, all at NO COST to you for these services!!
Annual Plan Changes
Another component to keep in mind is that every year, Medicare Advantage Plans change. Those changes can be minor, such as an increase in a primary care physician co pays from $10 to $15 a visit or they could be more significant, such as the plan dropping coverage for a medication you need. It super important to be aware of these changes and if need be, look at new plan options.
If you’re on a Medicare Advantage Plan, every September, you will get an Annual Notice of Change from your insurance carrier. This document goes over any plan changes that will take effect January 1st the following year. It’s very important to go over this document and make sure any changes aren’t going to effect you negatively. If you ever need help in going over this document, or never received one, Contact Us and we can go over the changes with you and make sure all will be as it should in the coming year.
Large Out of Pocket Maximums
Each medicare Advantage Plan, by law must have a “maximum out of pocket” which is the most someone would pay through the calendar year, regardless of actual charges. In San Diego, these vary for 2020 from $900 all the way to $6700.
These charges are set on an annual basis. Something that does happen, is if you needed some major medical coverage towards the end of the year, say in November and hit your maximum, then something else major happened in January you may end up hitting both maximums in just a few months! This could be a problem for most Medicare beneficiaries and can really add up depending on what your plans Maximum out of pocket is.
It seems that everyone “should” just go for the plan with the lowest out of pocket maximum but a lot of times, there could be a better plan when taking into account the providers you want to see and how your medications are covered. If it only were so simple!!
There are referrals needed to see a specialist
With most Medicare Advantange Plans in San Diego being an HMO, referrals are part of the makeup of these plans.
If you’ve never had this type of health insurance before, what you can expect is that you will need to see your primary care physician before you can see any specialist. They act as sort of a “gate keeper” to seeing other providers. Once you see your primary Doctor and they think you should see a specialist, the request for referral gets sent usually to the medical group they are affiliated with, then if the medical group agrees that the referral is needed, it will get sent to the insurance company for their approval.
Depending on the medical group, insurance company and the urgency of the issue, this process can take anywhere from a few days to several weeks. These delays can be frustrating and even dangerous at times. We think this is the worst thing about being covered by a Medicare Advantage Plan.
With some PPO Medicare Advantage Plans, as long as the specialist is in the network, you can ‘self-refer’ meaning you don’t need approval from the insurance company. With a Medicare Supplement, there is NO approval or referral process at all and you can see any specialist who accepts Medicare assignment at your own discretion.
Feeling like you're being nickled and dimed...
While generally in San Diego, Medicare Advantage Plans have no extra monthly premium, there are co pays for most if not all services, depending on the plan.
Commonly, you’ll see co pays of anywhere from $0 to $30 to see your Primary Care Physician, specialists range from $20-$50, and then if you were to be admitted to the Hospital, your daily co pay may be $295 a day for 6 days! It’s not hard to see how these co pays can add up quickly!
On the other hand, if you decided that your Medicare coverage would be more suited to Original Medicare with a Medicare Supplement Plan F*, you would have NO CO PAYS whatsoever for any of the services above!
In summation..
A Medicare Advantage Plan is a fine way to get your Medicare coverage IF you are aware of how they work and what to expect. You need to be aware of plan changes annually and be prepared to pay co pays and other charges through the year which resets every year.If you’re needing help in picking a plan, still aren’t sure which way to go or need help making sure plan changes aren’t going to effect you negatively next year, Contact Us! It’s a free, no charge to you service for expert advice from a local San Diego based broker.
Thanks for reading!!
Best regards,
Steve Korts