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Medicare Advantage: How to Evaluate the Best Plan for You

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Medicare Advantage open enrollment ended March 31st. So why are we bringing the topic of Medicare Advantage back for another discussion now?

The reason is simple: demographics tell us that about 10,000 Americans turn 65 every day. That makes them eligible for Medicare – which, if you’re among those who have recently crossed that age threshold, means you have a choice to make. Should you choose a Medicare Advantage plan, or stick with standard Medicare, augmented by a Medicare Supplement plan?

Much of what you’re about to read speaks to some of the questions beneficiaries need to ask themselves during open enrollment, so if you’re diving into the Medicare waters for the first time, this info applies to you. (For a brief comparison of Medicare Advantage versus what’s known as Medigap coverage, we also invite you to check out this recent article on the topic which we posted some time back here on the Blog.)

Consider this as part of your homework to guide you into making a well-informed choice.

For Those Newly Eligible, Open Enrollment is Now

For people already enrolled, Medicare actually has two open enrollment periods each year. Most people know about the open enrollment plan in the fall, running from mid-October through early December. But for those already on a Medicare Advantage plan – like about half of all enrollees – there’s also an open enrollment period running January through March, allowing you to change plans with some limitations.

But if you’re newly eligible for Medicare, your “open enrollment” has already begun.   

How should you evaluate Medicare Advantage coverage to determine what makes sense for you? That’s the subject of this NerdWallet article from a few months back, written by finance reporter Kate Ashford. While the experts she consulted don’t recommend changing plans lightly, they agree that there are reasons when a change makes sense. Let’s see what Ashford suggests. Remember, this article is targeted at those choosing plans during open enrollment, but the advice seems very relevant to those selecting Medicare coverage for the first time.

Choosing a Medicare Advantage Plan Carelessly

Ashford writes, “Many people choose Medicare Advantage plans without exploring their options or noticing what changes their plan may have made, according to research from KFF, a health policy nonprofit.” There are plenty of reasons why this can happen, we would add – chief among them being the fact that the majority of seniors ignore open enrollment altogether.

For whatever reason, Ashford (writing in early 2024) goes on, “now that a new year has started, you may realize the plan you picked during Medicare’s fall open enrollment doesn’t work for you. Or maybe you stuck with your old plan and it changed this year. (That can happen, too.)”

Does the MA Plan You Like Actually Meet Your Needs?

Ashford points out that many of us have never been forced to “try out” our Medicare Plans in a real-world situation of hospitalization, specialists, and tests. “Even if you haven’t had a chance to stress test your plan yet,” she emphasizes, “do some research while you still have time to change your mind.”

The two key questions involve providers and prescriptions, says NerdWallet.  Make sure the providers and specialists you want to see are in your network – and remember that this can change unexpectedly from year to year. “Also,” says Ashford, “check your medications, particularly if you’re on a newer drug that may be covered differently by different plans. How much do your prescriptions cost under your plan?”

This advice definitely applies to those enrolling for the first time. To make certain you can get prescriptions covered and see your preferred physician, it’s vital to choose plans with care.

Looking Into Your Health Care Crystal Ball

Ashford goes on to advise her readers to think ahead about their health situation in the remainder of the year. She spoke with Medicare insurance professional Christopher Fong from Mesa, Arizona, who urges people to do their best to male an educated guess about the health care they might need.

“Are there any procedures, like a surgery that’s coming up,” asks Fong?  “Is it outpatient? Inpatient? How many emergency room visits do you have? Do you need an electric scooter?” Ashford agrees. “The more you can predict your health care usage,” she states, “the more accurately you can determine whether you’re in the right plan.”

Your lifestyle considerations may have changed since you last reviewed your MA plan. “Do you travel or plan to spend part of the year in another state,” Ashford asks? “Make sure your insurance offers an extended network or travel benefit. Or consider Original Medicare, which allows you to see any doctor in the country who accepts Medicare.” (We’ll have a bit more to say on that in a moment.)

Choices During Medicare Advantage Open Enrollment

As noted above, Medicare Advantage open enrollment provides opportunities to change plans, but those choices are somewhat limited. (If you’re a new enrollee, this information could be relevant for you in early 2025.)

“During this [open enrollment] time,” says Ashford, “people who are already enrolled in a Medicare Advantage plan can switch — once — to another Medicare Advantage plan, or they can return to Original Medicare and purchase a Medicare Part D prescription drug plan. But if you don’t already have Medicare Advantage, you can’t join a plan now.”

You May Have Trouble Switching from MA to Medigap

The article notes that policy holders have the option to leave Medicare Advantage and shift to original Medicare plus a Part D drug plan. But here’s an important restriction: you may not be able to sign up for Medicare Supplement Insurance, commonly called Medigap.

“Medigap’s open enrollment period — when insurance companies must offer you a plan at the same price as everyone else, regardless of health issues — lasts for six months after you’re 65 and have Medicare Part B,” Ashford explains. “After that, aside from a few states and situations, you’ll be subject to medical underwriting to qualify.”

“While you can get in and out of a Medicare Advantage plan on an annual basis, your rights to purchase a Medigap policy are usually far more restrictive,” David Lipschutz of the Center for Medicare Advo9cacy told Ashford. Without a Medigap plan, you face higher co-pays and uncapped out-of-pocket costs. It’s essential to do your research and talk to an expert before choosing a plan.

So, Should You Switch Medicare Advantage Plans?

There are some circumstances – Ashford calls them “red flags” – that mean you should probably change your coverage. “If your primary care physician or primary hospital system is now out of network, for instance, you’ll want to look for a plan that includes them,” she writes.

We would add a strong recommendation from Rajiv Nagaich that your plan should allow you to see a geriatrician as your primary care doctor. If you find a doctor you want to start seeing, check his or her website or call the office and ask about Medicare Advantage coverage and which insurance plans they honor.

As noted above, inadequate prescription coverage may also be a reason to switch plans. “If an expensive medication isn’t covered, see if there’s a plan that includes it,” says Ashford. “You can input your medications into the plan finder on Medicare.gov to see options.”  Make sure, when you’re estimating drug costs, that you check details such as dosage and generic versus name brand options carefully and accurately.

Get Good Advice and Seek Out Free Assistance

Regardless of your situation, Ashford and the experts she spoke with do not advocate switching plans without good, solid reasons. But whatever you decide, she concludes, “do your homework during Medicare’s fall open enrollment from October 15th to December 7th.  The research you do today will help you avoid surprises in 2025.

Remember, too, that states have free advice available through a program called the State Health Insurance Assistance Program. Here in Washington State the program with its network of regional offices is run through the Office of the Insurance Commissioner.

Breaking News: Rajiv’s New Book is Here!

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(originally reported at www.nerdwallet.com)

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