By Martine G. Brousse (not AI!)
"The Medical Bill Whisperer"™
Patient Advocate, Certified Mediator
AdvimedPro
November 19, 2024
Every year, October 15 comes along in the same dilemma: keep Medicare Original and switch to Medicare Advantage, or vice versa? What are the differences? Pluses and minuses?Let's explore.
A. Medicare
It is the government health agency/insurance that is available for folks over 65 years old, or those who are disabled have chronic kidney disease or ALS
It has 2 basic plans to choose from:
B. Major Differences
Admnistration
CMS - or Federal Government - processes Original Medicare claims, determine coverage and benefits, and pays providers. Claims for services rendered are sent directly to regional administrators, that have 14 days to issue an Explanation Of Benefits (and payment). Complaints or appeals are usually rare, as detailed medical policies and conditions of coverage are readily available to patients and providers.
Medicare Advantage plans are administered by commercial private insurance companies, often the same as those for younger folks (Aetna, BCBS, United HealthCare, Humana etc). They have the right to determine how coverage will be applied, where services should be rendered and by whom, and restrict benefits for out of network providers. Their networks are local, restricted and fall under PPO, HMO or POS types. Restriction of access and authorization requirements are common.
Coverage
* Medicare coverage in general is extensive, and well-defined. It is always possible to know in advance whether a service is covered, and often at what price. However, it does not cover Part D (drug coverage) which must be purchased separately. It does not cover vision, dental and hearing services either.
*Although Medicare Advantage plans MUST cover the same services as Original Medicare, they often include Part D (drugs), Vision, dental and hearing coverage for free, or a small add-on fee.
Pluses
Original Medicare: you cannot make it easier. The Medicare network is by far the largest in the country, with over 90% of all medical professionals and facilities participating. There is no requirement for authorizations or no restriction on who a patient can see. Access to care is uniform across the country, and may even offer emergency coverage when overseas. Providers enjoy a simple claim submission process, clarity of what is covered and what fee to expect, payment within 2 weeks and claims paid correctly without any attempt at delaying or denying payments. Because of the share of cost, members can purchase a Medigap (or "supplemental") policy to cover such liability as the yearly deductible, 20% copay for Part B or Part A co-insurance.
Medicare Advantage plans offer convenience: one PCP provides, monitors, refers and orders most medical care. If already familiar with this type of plan, you would see little change, especially if staying with the same insurance Carrier. MA plans also include part D. Vision, hearing and dental coverage is often included or offered for a low fee, as are extras such as gym memberships or wellness programs. Another plus is that CMS limits the yearly out of pocket for MA members, whether under the form of a deductible, office copays or "share of cost".
Minuses
Original Medicare has 2 major disadvantages: it does not cover Part D (prescription drugs), dental, vision or hearing care. All these must be purchased separately. Supplemental / Medigap coverage must also be purchased separately, or, for those on a low income, must be applied for with Medicaid.
Advantage plans have resulted in a large number of complaints: difficult or delayed access to providers, very small and restricted networks, requirement for authorizations or referrals, care refused ("medical necessity"), non-covered services when out of network, excessive scrutiny and interference on clinical matters, need to jump through administrative hoops to get things done or paid. The same issues Commercial patients have with their insurance carries over. Because it is covered under Medicare does not mean automatic approval. For these reasons, many providers refuse Medicare Advantage patients, or treat them as "self-pay".
C. Tips
PPO or HMO?
If you pick a Medicare Advantage plan, you will need to choose a type of plan as well. HMO plans offer convenience and localized services, but restrict access and ease. PPO plans may be more expensive but afford easier access to more providers.
Enrollment Deadline
The Open Enrollment Period is October 15 to December 7 each year. Don't miss and don't wait too long! Insurance agents and Medicare navigators are overwhelmed with demands for assistance and advice, so plan ahead. It is also the only time you can switch from MA to Original Medicare or vice versa, change your Part D plan, find a Medigap policy.
One exception
If you already have a Medicare Advantage or have become eligible for Medicare in the past 3 months, you may switch to another MA plan or return to Original Medicare between January 1st and March 31st.
Help is available!
Medicare.gov is simply awesome! The website can help you pick new policies, explain what is covered, advise you on finding the best provider, explain how things work under different parts, let you compare plans as well as providers, and more.
Trained and specialized Navigators are available to offer advice and help you with applications.
There is no better place to get answers to your questions and to speak to a real person who can present your options and help you make the best choice.
Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.
(424) 999 4705 - F (424) 226 1330
@martine brousse 2024 @ the medical bill whisperer 2024™
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