You can always tell when it is Medicare open enrollment season. Constant television commercials, non-stop emails and even physical mail ads coming from dozens of insurance companies all vying for your business. Promises of cheaper monthly premiums with more benefits are offered by every company, and when it comes to yourself or your loved one how do you choose? Current living arrangements and past medical history both play a major role in which insurance sign up for but making sure you understand the implications of your choice may be harder to understand.
Open enrollment is a time when Medicare eligible recipients are offered the opportunity to switch their insurance to another insurance plan, also known as a Medicare Advantage Plan. Once switched this plan will be in effect for an entire year unless a special circumstance takes place (there are multiple situations where this can occur, check out medicare.gov for more information). Changing your insurance during open enrollment may be fueled by the desire to save money, receive different discounts or benefits, or out of displeasure from your current plan. There are steps you should take, however, to ensure that the plan you have signed up for is appropriate for your needs.
Step 1: Check-in for Physician and Nursing Facility Coverage
Prior to changing your insurance you should contact your primary physician’s office along with any specialists and ask them if they are in-network with the plan you are looking to switch to. Medicare Advantage Plans also offer you the opportunity to look up in-network physicians on their website, but peace of mind may be found as physician practices may add or drop contracts before the information has been updated online. If you are currently a resident in a skilled nursing facility, or have applied to enter one for care, you will want to check with the billing office that the facility has a contract with the specific plan you are looking at. Just like with physicians’ offices, nursing homes must also have up to date contracts with each Medicare advantage plan in order to receive reimbursement.
Step 2: Medication and Treatment Coverage
Each Medicare Advantage Plan classifies their medications differently and may have requirements that Medicare Part D plans do not. This can mean that the medications you are currently taking are not covered as well as any future medications you may be prescribed. Certain Medicare advantage plans will have you try generic medications before covering the name brand manufacturer of your medication, even if you know the generic medication does not work as well for you. They may also require cheaper medications to be trialed, even if you tried them previously under another insurance plan. So just like ensuring that your physician or nursing facility accepts the insurance plan you will also want to ensure that you will not be paying more out of pocket to receive the medications you need. Choosing an insurance plan that covers the most medications possible is the goal.
Step 3: Are the extra benefits a fit for me
Traditional Medicare offers Parts A, B, and D. This encompasses inpatient services, outpatient services, and medication coverage. Medicare advantage plans also offer these services along with the potential for more. Gym membership discounts is often the biggest advertised benefit of Medicare advantage plans, although not every gym bills your insurance for membership. If you are already a member of a gym or would like to join one you will need to reach out to the gym to ensure that they accept your insurance plan.
Step 4: What are the downfalls
Lower monthly premiums often draw Medicare eligible recipients to switch their plan to a Medicare Advantage Plan, but what does that mean when emergency care is needed? Medicare advantage plans are cheaper each month than traditional Medicare because they often cover less during a hospital stay. While nobody ever wants to find themselves hospitalized with an illness, choosing a Medicare advantage plan may come with the need to set extra money aside each month just in case an emergency happens. The extra money set aside may also have to be utilized for medical testing outside of a hospitalization due to the higher out-of-pocket costs.
If you are hospitalized you may need physical rehabilitation in an acute or sub-acute facility. Medicare offers up to 100 days of physical rehabilitation following a 3 day qualifying inpatient hospital stay if the individual is able to participate in therapy. The first 20 days will be covered at 100% while days 21-100 will have a copayment. Having 100 days of rehabilitation is not guaranteed but the continuation of the therapy is at the discretion of the facility providers as long as the individual makes progress. Medicare advantage plans require prior authorization, however, and authorization does not guarantee payment. Before being admitted into a facility for rehabilitation the hospital will need to request prior authorization, meaning they submit your medical records to an individual through your Medicare advantage plan and that individual decides whether or not you are a good candidate for rehabilitation. Once that authorization is received you will be transferred to a facility that is contracted with the Medicare advantage plan. Five to seven days after your admission the Medicare advantage plan will request an update that includes medical documentation and therapy notes. From this documentation they will determine if you should continue with therapy or if the benefits will be cut. If the benefit is continued, then each authorization will occur every couple of days. Authorization does not cover out of pocket costs, though, and those costs are at the discretion of the insurance plan. The Medicare advantage plan also has the ability to rescind payment from the acute or subacute facility meaning the facility may also bill you separately for payment that the Medicare advantage plan took back. Rescinding of payment may occur due to the facility providing services or medications that the Medicare advantage plan did not feel was necessary or related to your stay.
Extra information to be aware of
Prior to switching to a Medicare advantage plan individuals may have supplemental insurance to their traditional Medicare, also known as a Medigap plan. This plan is an addition to Medicare that is not required but can help cover co-insurance costs and travel expenses. Medigap plans have higher monthly premiums, and just like Medicare advantage plans participants have to find the plan that works best for them. You cannot have a Medicare advantage plan and a Medigap plan at the same time. Signing up for a Medigap plan may include a comprehensive review of your past medical history and possibly a physical examination. Once unenrolled from a Medigap plan you must start over to reenroll, and Medigap plans are not required to offer you coverage. That means that once you are disenrolled from a Medigap plan you may struggle in the future to get that coverage again with the largest determining factors being your past medical history and treatments. You will always have the option to switch back to traditional Medicare but you may not always have the option to get a supplement to that Medicare.
All of this information is to help you make an informed decision about which insurance is best for you. Every person is different, and what works for one person may not work for another. Finding the best insurance coverage can be a gamble. You can pay less each month and hope that a crisis that requires high out of pocket costs does not occur , or you can pay a high premium each month to never need it. Extensive research is needed prior to changing insurance coverage to ensure that needs can be met in the most affordable manner.
*This article does not look at individuals eligible for Medical Assistance