Evaluating Medicare Plans
Published: 2009-01-09 : (Rev. 2013-06-17)
Synopsis and Key Points:
Examines points to look for when choosing a medicare plan and healthcare for people with disabilities.
Main DigestKnowing your healthcare priorities makes selecting a Medicare plan easier.
While the Medicare enrollment period is supposed to be a time to allow people to choose the plan that best meets their healthcare needs, many people are simply overwhelmed by the task and uncertain how to evaluate them, according to Allsup, a leading provider of Social Security disability, financial and healthcare-related services to people with disabilities.
"It's good that people have a lot of options to choose from because they have different needs and preferences. But many have a difficult time determining which plans to eliminate so they can focus on the few that fit them best," said Paul Gada, personal financial planning director and product manager for Allsup Medicare AdviserSM. The service helps people with disabilities choose the best, most affordable Medicare plan to meet their specific needs.
According to Gada, a good way to begin is to identify and prioritize what you want. Here are a few key questions to help:
What plans are available to me
Most people have dozens of plans from which to choose, depending on where they live. These include traditional Medicare, which is overseen by the federal government, and Medicare Advantage plans, which are provided by private companies approved by Medicare. Because traditional Medicare has fairly high deductibles, co-payments and co-insurance, many people also purchase Medigap supplemental coverage. You do not need Medigap coverage with Medicare Advantage plans.
Does the plan cover pre-existing conditions
Generally, Medigap does not cover pre-existing conditions. As a result, for many people with disabilities, traditional Medicare with Medigap supplemental coverage is not the best option. Medicare Advantage plans, conversely, are required to cover pre-existing conditions.
Do my doctors accept the plan
Physicians and hospitals are required to accept traditional Medicare, but they choose whether or not to participate in Medicare Advantage plans. Within Medicare Advantage plans, people selecting Preferred Provider Organization (PPO) plans will have more flexibility in selecting doctors or hospitals than those choosing Health Maintenance Organization (HMO) plans. However, HMOs may be more cost effective if a beneficiary's chosen physician is a part of an available HMO plan.
Does the plan cover my preion drugs
Individuals with traditional Medicare do not have preion drug coverage unless they also enroll in and pay an additional fee for a Medicare prescription drug plan (PDP). Most Medicare Advantage plans incorporate prescription drug coverage. Beyond the prescription drug premium cost, individuals need to look carefully at plan co-pays, deductibles and co-insurance to determine the extent that medications are covered. Additionally, they should find out if drug coverage is offered during the Medicare prescription drug donut hole. Find more information about the donut hole at Allsup.com.
Does the plan cover medical equipment
Traditional Medicare covers durable medical equipment (e.g., reusable medical equipment such as walkers, wheelchairs and hospital beds) so long as it's medically necessary. Medicare Advantage plans are required to cover the same things as traditional Medicare. However, costs between plans vary and may be lower with Medicare Advantage plans. Check the plans you are considering to determine the array of equipment covered because some plans may have broader offerings than traditional Medicare.
Does the plan cover dental, vision, hearing and other care
Traditional Medicare does not cover most types of dental, vision, hearing or other care beyond basic medical. Some Medicare Advantage plans offer this additional coverage, for example, covering dentist visits and dentures, hearing aids, routine eye exams and eyeglasses.
What are the premium costs
The Medicare premium is only one portion of the healthcare cost. Individuals in traditional Medicare as well as Medicare Advantage plans pay the same base monthly Medicare Part B premium. However, besides the premium, out-of-pocket costs for things such as co-pays and deductibles can vary significantly. While providing extra coverage, Medicare Advantage plans are available with no additional monthly premium and generally have lower out-of-pocket costs when compared with traditional Medicare.
Keep in mind, though, that as the amount of coverage increases, so can the extra monthly Medicare Advantage premiums on top of the base or co-pays. You can best control the costs by choosing the level of coverage you need.
What other costs do I need to know about
Beyond the premium, it's important for people selecting among plans to know the various out-of-pocket costs they could face with different Medicare plans. These include:
Deductible, which is the amount an individual is responsible for paying for healthcare services before Medicare begins to pay. For Medicare Part A (hospital), the deductible must be paid each benefit period. For Medicare Part B (physician), the deductible must be paid each year.
Co-insurance, which is the portion of the payment for medical services that an individual must pay. For example, with traditional Medicare after the deductible is met, your health coverage generally pays for 80 percent of the costs of a service, while you will have to pay the remaining 20 percent.
Co-payment, which is the set amount an individual must pay upon receiving medical services in combination with the amount paid by the insurer. For example, with a Medicare Advantage plan, you may have to pay $10 each time you visit the doctor.
How are the plans rated
In evaluating plans, it's important to consider their overall quality. The Centers for Medicare & Medicaid Services rates the plans based on a variety of factors, including how well the plans perform in detecting and preventing illness, how quickly plan participants can see physicians, how well the plan helps people with chronic conditions and how well a plan handles appeals.
What if I don't make any choice
If you are already enrolled in a plan, you will be automatically re-enrolled. The majority of individuals continue to be in traditional Medicare. Many may benefit from savings offered by Medicare Advantage plans.
However, if you are not enrolled in a Medicare plan, but are eligible to participate and do not enroll, the consequences can be more costly. Specifically, if you don't sign up for Medicare Part B (physician) when originally eligible, there is a premium surcharge, or penalty, of 10 percent for each 12-month period you could have had it, but didn't. This charge begins after you sign up for Part B coverage, and the costs can really add up you must pay the extra surcharge for as long as you have Part B.
There is a similar late enrollment penalty for not joining a Medicare Part D (preion drug) plan if you later decide to get Part D coverage. This will result in a higher premium for as long as you have Medicare drug coverage.
"As people go through the list of different criteria, it's important they identify their priorities," Gada said. "For example, if they want to see a particular doctor or they need prescription drug coverage during the Medicare donut hole they can use these priorities to zero in on the plans that are best for them."
Reference: Allsup, Belleville, Ill., is a leading nationwide provider of financial and healthcare-related services to people with disabilities. Founded in 1984, Allsup has helped more than 100,000 people receive their entitled Social Security Disability Insurance and Medicare benefits. Allsup employs more than 550 professionals who deliver services directly to consumers and their families, or through their employers and long-term disability insurance carriers.
The Allsup Medicare Adviser service provides customized support to help individuals with disabilities navigate the complexities of Medicare and Medicare Advantage programs, analyze the best plan coverage and provider options based on individual preferences, better understand healthcare cost information, and simplify the confusing process of enrolling in a Medicare Advantage plan. For more information, visit www.Allsup.com
The information provided is not intended as a substitute for legal or other professional services. Legal or other expert assistance should be sought before making any decision that may affect your situation.
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- 3 - Medicare and Medicaid Services Not to Go Forward With Part B Payment Proposal : American College of Rheumatology (2016/12/17)
- 4 - U.S. Medicare and Telehealth Services During COVID-19 Pandemic : Disabled World (2020/03/22)
- 5 - Center for Medicare and Medicaid Innovation Must Implement Payment Reforms Rapidly : Commonwealth Fund (2010/06/08)
- 6 - What is Covered by Medicare : Steve Wynler (2009/03/12)
- 7 - Medicare Recipients Can Be Denied Supplemental Medigap Coverage Due to Pre-Existing Conditions : The Senior Citizens League (2018/11/15)
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