Health Care

Medicare Advantage plans are very popular. But read the fine print carefully.

Elisa Perez and her husband, Horacio, look over a Medicare Advantage booklet in their home in Miami.  When Elisa Perez, a retired school principal, was ready to sign up for Medicare three years ago, she chose a Medicare Advantage plan that was comprehensive but relatively inexpensive.
Elisa Perez and her husband, Horacio, look over a Medicare Advantage booklet in their home in Miami. When Elisa Perez, a retired school principal, was ready to sign up for Medicare three years ago, she chose a Medicare Advantage plan that was comprehensive but relatively inexpensive. jiglesias@elnuevoherald.com

When Elisa Perez, a retired school principal, was ready to sign up for Medicare three years ago, she studied her options carefully and then arrived at a decision she has yet to regret. She chose a Medicare Advantage plan that was comprehensive but relatively inexpensive.

“The plan had my doctors and the nearby hospital I wanted,” said Perez, now 68. “I have dental and vision, and they have Silver Sneakers [which covers gym membership]. It was pretty much everything I needed in one place.”

Medicare Advantage plans, also known as Medicare Part C, are offered by private insurers as an alternative to traditional Medicare. They include both Health Maintenance Organizations (HMO) and Preferred Provider Organizations (PPO), and like traditional Medicare, they cover the same health care services while also offering such extras as dental, hearing and vision coverage. Many consider this one-stop healthcare shopping easier and, in certain cases, more affordable.

In fact, Medicare Advantage plans have become so popular that about one-third of all Medicare beneficiaries, or about 20 million seniors, are enrolled in MA plans nationally, and the number of plans offered has been increasing steadily every year.

Florida is among the six states where more than 40 percent of Medicare beneficiaries are enrolled in these private plans, according to the Kaiser Family Foundation. In Miami-Dade, MA plans are even more popular, with two-thirds of all Medicare beneficiaries enrolled in them.

After this year’s open enrollment for the 2019 plans, which kicked off Oct. 15 and runs through Dec. 7, experts predict these numbers will grow, fueled in part by changes announced by the Centers for Medicare and Medicaid Services (CMS) for 2019. Starting in January, MA plans can offer certain extra options, from transportation to a physician’s office to safety features like wheelchair ramps, adult day-care programs, bathroom grab bars and home health aides to help with dressing, eating and personal care.

The idea is to provide preventive care that will help cut back on injuries and conditions that often lead seniors to the emergency room. Though Medicare now pays for wheelchairs, canes and walkers, it doesn’t cover modifications to a home or paid transportation to a doctor. These enhanced benefits are expected to help those with chronic conditions remain at home.

Many welcome the change. “It’s potentially exciting that we’re thinking of healthcare not just in acute care terms but also looking at what is needed for a healthy environment,” says AARP Florida state director Jeff Johnson.

This expansion of options combined with changing demographics — 10,000 people turn 65 every day, adding to the more than 50 million Americans now 65 and over — has attracted the interest of heavyweight insurers.

Indianapolis-based Anthem, for instance, bought Florida-based plans Health Sun and America’s 1st Choice to grow its Advantage membership. In August, Google-parent Alphabet announced it would invest $375 million in Oscar Health to help with the start-up’s expansion into the Medicare Advantage market. That same month another start-up that uses technology and data analytics to deliver healthcare, Clover Health, also announced that it was launching Medicare Advantage plans in six new markets.

The commitment by big players to the MA market gives some enrollees confidence in their choices. In 2012, UnitedHealthcare decided to purchase Preferred Care Partners and Medica HealthCare Plans, both senior-focused health plans operating primarily in South and Central Florida.

This was a factor when Elisa Perez decided to sign up for Medica’s HMO plan. She felt the UnitedHealthcare purchase would improve the offerings even more.

CMS also has loosened other restrictions. Now MA enrollees can switch out from a plan after trying it for three months. Unlike previous years, a beneficiary will have until March 31 to change to another Medicare Advantage plan or over to traditional Medicare if she or he doesn’t like the one originally chosen.

“It’s like a test run,” said Gretchen Jacobson, associate director for the Kaiser Family Foundation. “It gives people more time to try out a decision that can be initially confusing and overwhelming.”

But even this test run is not enough to convince some healthcare advocates that the enhanced changes coming in 2019 are perfect or that all beneficiaries will have access to them. The extra benefits must be ordered by a licensed provider for a patient who has specific healthcare needs that require them.

In other words, not all MA plan participants will be able to receive money for home health aides or bathroom grab bars simply because they want it.

“On one hand, it’s good that people who need these things will now be able to have them,” says David Lipschutz, senior policy lawyer with the Center for Medicare Advocacy. “On the other, there are so few guidelines that it will be a lot more difficult for people to figure out what is being offered and if they qualify for it. I think some will hear and read about these changes and automatically think they will be eligible for them even though they don’t have the specific health care needs required or that their specific plan doesn’t offer them.”

In addition, Lipschutz worries that the government has no way of overseeing the plan providers. “We don’t have the confidence that these guidelines will be implemented in the correct way or that regulators will be able to monitor them.”

Traditional Medicare enrollees, who are the majority nationally, don’t have access to the same benefits either. “What this does is steer people to Medicare Advantage plans. Is this good?” he asks rhetorically.

Lupe Bruneman, regional business manager for Advocate Health LLC, is an insurance broker who does a lot of public speaking to educate seniors about their Medicare options. In September she spoke to a group of consumers who signed up for an information session sponsored by Continue United, a group within Miami’s United Way that brings retirees and pre-retirees together to contribute their time and talent to the community.

Bruneman has found that those who pick traditional Medicare “don’t want to get a referral. They want to go anywhere at any time. They want more freedom.”

But those who choose this route must also decide if they have the economic wherewithal to buy supplemental insurance to cover what traditional Medicare doesn’t offer, as well as a Part D drug plan.

In contrast, HMOs are less expensive. Most in Miami-Dade require no monthly premiums. But they’re also more restrictive. For Elisa Perez and husband Horacio, this was not a deal breaker.

“I’ve found getting referrals to be pretty simple. I’ve never really had a problem.”

In the end, however, “the Medicare plan people choose is determined by what they can afford,” AARP’s Johnson says. “Seniors are on a fixed income and they want to know with some certainty what their healthcare costs will be. It’s a pocketbook issue.”

HOW TO PICK A MEDICARE ADVANTAGE PLAN:

1. Identify the type of Medicare insurance you need. Comparison shop. It’s not enough to choose one with a low or no monthly premium. Find out what your TOTAL out-of-pocket expenses might be. Remember that most seniors must pay the $134 Part B premium, regardless of whether they sign up for original Medicare or Medicare Advantage. (High-income seniors pay more.)

2. Make sure that the providers you want are in the list provided by the plan. Also check the plan’s formulary to see if your prescriptions are included and how much they will cost you.

3. Ask for help. The SHINE (Serving Health Insurance Needs of Elders) program, offered by the Florida Department of Elder Affairs and the local area agencies on aging, provides trained volunteers to answer Medicare questions and one-on-one counseling. In Miami-Dade and Monroe counties, phone the Alliance for Aging at 305-670-6500, extension 11256 (for English) and 305-670-6500, extension 11276 (for Spanish). In Broward: 954.745.9567. For statewide questions, try 1-800-963-5337

4. Healthcare brokers can also offer guidance by conducting a needs analysis, but when hiring one always ask how the broker is being compensated. Does one plan offer a larger commission than another?

5. Check out other resources. These include your Medicare & You annual handbook as well as the online Medicare Plan Finder. By answering several questions about your location and health, this online tool can help you compare plans, including total cost of premiums and co-payments. Visit https://www.medicare.gov/find-a-plan/questions/home.aspx

6. Don’t make any assumptions about your plan if you are currently in MA. Networks change from year to year as do drug lists. and contracts MA plans have with rehab centers and skilled nursing facilities. Double-check with your doctor and your insurance company.

7. Remember that it’s not just about the money. Look for top government ratings on the Medicare Plan Finder. While few plans receive five stars, there are plenty with four stars.

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