The In’s and Out’s of Medicare Open Enrollment Part 2: Medicare Advantage Plans


Christina Bach, MSW, LCSW, OSW-C
Christina Bach, MSW, LCSW, OSW-C

Hi again everyone! I hope you are finding this series helpful! If you have specific questions PLEASE join our WEBCHAT, Tuesday November 8th at 12 noon ET where social workers (including me!) will be available LIVE to help guide you through this very important decision making process.

This week we are going to tackle Medicare Advantage (MA) plans. Medicare Advantage plans are sometimes referred to as Medicare Part C. However, there are some dramatic differences between traditional or “original” Medicare A & B coverage and coverage through a Medicare Advantage Plan.

When you enroll in a Medicare Advantage plan, you are essentially selling your Medicare A & B coverage to a private company (e.g. Blue Cross, Aetna, Bravo, Humana). This company then manages your health care insurance claims and costs. These plans must offer you the same coverage as traditional Medicare A & B. Most also include other additional services including prescription drug coverage (Medicare Part D), vision, hearing, dental and/or other health and wellness programs that are not included in traditional Medicare A & B coverage.  There are different kinds of Medicare Advantage plans including, PPO’s, Private Fee for Service (PFFS) and HMO plans. Each of these types of plans varies DRAMTICALLY in the types of coverage they offer as well as the out of pocket expenses for the consumer.

They do not NECESSARILY include coverage for the 20% out of pocket expense included in traditional and YOU CANNOT purchase a secondary plan if you are enrolled in a Medicare Advantage Plan. You CAN be dual enrolled in a Medicare Advantage plan and Medicaid/Medical Assistance, though this is for the lower income (<$900 per month) individuals.

So, what is the advantage of a Medicare Advantage plan?

Medicare Advantage plans essentially offer one stop shopping. Your claims will be processed by one company for inpatient, outpatient and pharmaceutical needs. There can also be lower out of pocket costs if you elect to participate in an HMO plan. Some plans even offer free transportation to medical appointments.

However, Medicare Advantage plans often have enormous coverage gaps and out of pocket expenses for patients with complex medical conditions like Cancer. Let’s look at an example:

Suzy is contemplating enrolling in a Medicare Advantage plan. She is getting chemotherapy monthly for Lung Cancer. This chemotherapy is covered by the Medicare Advantage plan at 80%. However, this plan does have a $6700 annual out of pocket maximum. Once she pays $6700, her chemotherapy will be covered at 100%. Also, the Medicare Advantage plan requires $30 co-pays for specialist office visits. Suzy sees her oncologist twice a month and her pulmonologist once a month. She follows up with radiation oncology every other month.

To break down Suzy’s out of pocket costs, we must include the $6700 annual out of pocket maximum as well as the costs for visits to her physicians, which are at least $90 per month. Suzy also has out of pocket expenses related to her prescription drug costs (we will look more at this in next week’s blog).

As you can see, Medicare Advantage enrollment looks like a disadvantage for Suzy; especially if you look at the cost of Medicare A & B and a private secondary (Gap) plan (see last week’s blog Medicare Open Enrollment Part 1) which was $4620; still significantly less than the Advantage plan alone.

But if Suzy also needed dental care and vision, the Medicare Advantage plan may be a viable alternative.

The bottom line: choosing between traditional Medicare with secondary coverage and a Medicare advantage plan is a personal decision that MUST be guided by your current health care needs, costs from the current year, anticipated costs for future treatments AND catastrophic coverage in case of progressive disease or new diagnosis. Specifically, you want to look at the following when comparing costs:

  • Does the plan charge a monthly premium? (if so, how much?)
  • Does the plan cover any of your monthly part B premiums?
  • Does the plan have an annual deductible or out of pocket maximum?
  • How much are co-pays for specialist’s visits or services?
  • Can I see ANY doctor or do I need to see clinicians within a specific network?
  • If I go out of network, what will the difference in cost be?
  • What is the plan’s annual limit on my out of pocket expenses (for both medical and prescription drug coverage)

You can access great information about the various plans offered by Medicare Advantage plans through the medicare.gov website or by calling Call 1-800-MEDICARE and say “agent.” Help is available 24 hours a day, 7 days a week.

Next week we will focus our attention of Medicare Part D prescription coverage; when I’ll try my best to explain that pesky “donut hole” of drug coverage!