“Most beneficiaries who are in Medicare Advantage plans are in HMOs, the longest standing private plans in Medicare,” says Michele Strollo, Dr.P.H., principal policy analyst at the Kaiser Family Foundation.
Typically, HMOs have a group of providers that you must see to receive care, and you need referrals from your doctor to see specialists. This can help coordinate care because your primary care doctor will know what other medical professionals you are seeing.
“If you want to stay with your current doctor, you might want a PPO,” Schulz says. “Members can see providers outside of the PPO network—it just costs more.”
Nearly 1.6 million Medicare beneficiaries have chosen PFFS plans. “PFFS plans are fairly new to Medicare but have experienced rapid growth in recent years and now account for 18% of all Medicare Advantage enrollment,” Strollo says.
“The premiums for a PFFS plan can look attractive, but each time you need health care, you have to verify that your doctor will accept payment for that service. It can change at any time,” says Michelle Holzer, Senior Health Insurance Assistance Program manager at the Maryland Department of Aging. Doctors decide on a patient-by-patient and service-by-service basis whether they will accept payment from a PFFS plan.
If you have a medical condition like asthma or diabetes, a Special Needs plan might be appropriate for you. These plans typically offer extra benefits for specialized health needs and for people living in extended care.
Looking for the right plan
When you select a plan, Holzer says, “It’s like looking into a crystal ball and asking, ‘What’s my health going to be like this year? Will I be in the hospital?’ Remember, the best plan for you may not be the one that is best for your friend or spouse.
“Figure out what kind of health care consumer you are,” Holzer adds. For example, count the number of times you might see your doctor(s) and how many medications you might take this year. Then calculate what it will cost with a certain plan.
To find the right plan, ask the right questions. What are the premiums and out-of-pocket costs? Are there extra benefits (like dental care)? What are the choices for doctors and hospitals? Where are they located? Are your prescription drugs covered by the plan? What pharmacies can you use?
“Understand what happens if you decide you don’t want to be in the plan,” Holzer says. “When can you make a change, and when would it take effect? Above all, don’t jump into anything. Read, review, think about it carefully, and understand it fully before joining.”
Finding assistance
Understanding health insurance is no simple task. But there is help. “During Medicare’s open enrollment period, senior centers and the Senior Health Insurance Assistance Program (SHIP) bring in extra personnel who can help you pick your way through different plans,” Schulz says.
To find your local SHIP office, contact your state’s Department of Aging or Insurance Administration. “Depending on the nature of the question or problem, you may be able to have your questions answered over the phone,” Holzer says. “If we need to look at paperwork, we will make an appointment for you to come in.”
With open enrollment starting on November 15, be sure to sign up for the plan that is right for you! For more information, visit www.medicare.gov, or call 1-800-MEDICARE.
Editor’s note: Next month, the Tribune will explore the benefits of Medicare Advantage plans.