Is Medicare C really an ‘Advantage?’

Oct. 23--Editor's note: This story has been amended to reflect the accurate fall open enrollment period of Oct. 15 to Dec. 7.

FRAMINGHAM -- There are many questions to consider when it comes to Medicare Advantage plans: What are they? Are they right for me? Is there a financial risk if I sign up?

Questions such as these are especially important as the fall open enrollment period for Medicare Advantage is upon us. The period runs from Oct. 15 to Dec. 7.

To help Daily News readers make sense of Medicare Advantage, Stephen Lemire recently offered a few tips. Lemire is program coordinator and senior visiting instructor of the Master of Healthcare Administration at Framingham State University.

What is Medicare Advantage?

Medicare is a federal health insurance program for those 65 and older. It is grouped into four parts -- A, B, C, D.

Medicare Part A covers hospital visits; Part B is outpatient care; Part C is Medicare Advantage; and Part D is prescription drugs.

Private companies offer Medicare Advantage plans, and the companies are approved by the Centers for Medicare and Medicaid Services, a federal agency within the U.S. Department of Health and Human Services that administers the Medicare program.

Open enrollment

This is an important time of year for millions of Americans, Lemire said, because they can change their Medicare coverage. Options include picking a new Medicare Advantage Plan, or switch between original Medicare and Medicare Advantage.

A trade-off

Medicare Advantage could be a less expensive option, Lemire said, because it can result in lower premiums and overall health costs. However, like any insurance, there's a compromise.

"When you have lower costs, the trade-off is usually lower choice (of medical providers)," Lemire said.

Do your homework

When considering Medicare Advantage, Lemire said it's important to research all options before making a commitment.

Sit down with a family member, or trusted caretaker, and compare plans to determine if possible Medicare Advantage savings are worth it. Make sure to determine if your primary care physician (PCP) is in the advantage plan's network, especially if you have a trusted relationship with your PCP developed over a number of years.

"(That relationship) is so important," Lemire said. "As you age, one tends to be more of a user of the health care system," which makes the established PCP-patient relationship even more critical.

Also, look to see if the advantage plan's network includes various medical specialists and hospitals, including tertiary and community health centers.

Drug coverage is also critical when doing your due diligence, according to Lemire, because all plans cover pharmaceuticals at different levels.

Bottom line

After all the analysis is done, Lemire said the bottom line is -- if you're still relatively young and in good health, which means you're not using the health care system much, then maybe it's worth it to sign up for Medicare Advantage for lower premiums and other costs.

However, if you're older and frequently visiting the doctor, then "it's probably not worth it," Lemire said.

He offered another caveat, citing anyone who received generous health benefits from an employer's plan, but elected not to stay with it during retirement. To save a few bucks on premiums, these people signed up for Medicare Advantage. But what they didn't consider was Lemire's general rule of thumb -- with lower costs comes the possibility of less choice of medical providers.

"Beware for a big surprise," Lemire said.

Henry Schwan is the health reporter for the Daily News. Follow Henry on Twitter @henrymetrowest. He can be reached at [email protected] or 508-626-3964.

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