Medicare Advantage plans -- what you need to know before signing up in open enrollment

Medicare Advantage plans, health policies from private insurers that provide benefits beyond basic Medicare, have been expanding briskly across the nation, and especially in Florida.While the plans can lower out-of-pocket costs, members can only go to the doctors, rehab facilities and skilled nursing centers that are in the plans' networks, or pay significantly higher costs when they go out of network.

In Miami-Dade County, about 78 percent of people with Medicare this year have Medicare Advantage policies, or Medicare Part C, according to the Kaiser Family Foundation (KFF), which studies national health issues. That's up from 66 percent in 2018.

Medicare Advantage penetration in Broward County is 67 percent, KFF reported. And statewide, 56 percent of Florida's 4.6 million Medicare beneficiaries hold Medicare Advantage policies.

Demand for Medicare Advantage PPO policies in Florida "is growing like a weed," said Kathy Feeny, president of Florida Blue Medicare, the local division of Blue Cross Blue Shield. "HMOs and PPOs are the most popular Medicare Advantage policies, and Miami has about 20 competitors offering Advantage plans," said Feeny, whose company has been operating in Florida for 75 years and launched its first Advantage plan in South Florida in 2003.

How do Medicare Advantage plans work?

These plans, sometimes just called MA, offer people the same benefits as Medicare Parts A and B (except for hospice care), plus a variety of additional benefits like vision, prescription drugs, hearing and dental services (routine checkups and cleanings), gym memberships or discounts, transportation to doctor's offices and over-the-counter medications.

The range of benefits depends on the type of plan, and expanded benefits cost more.

Medicare Part A basically covers hospitalization, skilled nursing and home health, hospice care and some medications. This coverage is limited, however, and patients are responsible for co-payments, deductibles and non-covered services.

Medicare Part B is insurance that covers visits to doctors, outpatient care, medical supplies and preventive services like screening and vaccines against flu and COVID-19. People with Original Medicare can choose doctors, hospitals and other healthcare providers who accept Medicare, and the government health program generally covers about 80 percent of healthcare expenses.

Also, people with Medicare can sign up for a Medicare Prescription Drug Plan (Medicare Part D) supplied through a private company, or find an Advantage policy that offers coverage for prescription medications. There is a penalty if an individual does not opt for Medicare Part D when he or she becomes eligible for Medicare, and decides to sign up at a later date.

Advantage plans are sold by private insurance companies that follow Medicare rules. Each plan typically has a network of doctors, hospitals and other care centers and can charge different premiums and set different out-of-pocket costs. The insurance company also can make rules on whether patients need referrals to see specialists. Plans usually charge more for doctors, facilities or emergency service out of network.

Types of plans

Currently, there are 583 Medicare Advantage plans available in Florida.

The main options are HMOs, PPOs, Private Fee-for-Service plans (PFFS) and Special Needs Plans (SNP).

HMOs and PPOs are familiar to most people, and are the most popular.

PFFS plans are different from Original Medicare and Medigap. The plans set limits on how much they will pay physicians, hospitals and other providers, and how much the patient must pay, according to Medicare. In some cases, patients can choose any plan member for services.

Special Needs Plans (SNP) are limited to people with specific diseases or conditions, like chronic alcohol or other dependence, end-stage liver disease and dementia.

There are also policies that combine Medicaid and Medicare benefits, Point of Service plans and Medicare Medical Savings Account plans.

How much do MA plans cost?

The average monthly premium for MA policies in Florida this year is $8.54, according to Medicare.gov, up 2 percent over 2021.

People with Medicare Advantage plans must pay a monthly premium for Medicare Part B, which is $170.10 this year. This premium is usually subtracted monthly from Social Security benefits.

The Centers for Medicare & Medicaid Services (CMA), the federal entity that decides on annual premiums, has not yet released a figure for 2023.

Premiums for Medicare Advantage plans -- paid to the health insurance company that issues a plan -- can go from zero to over $100 per month. And there are often co-payments and coinsurance.

Some examples:

(Prescription medication costs not included or calculated for each plan.)

Humana Gold Plus HMO with health and drug coverage has a $0 monthly premium, and zero health and drug deductible, plus a maximum out-of-pocket cost of $2,500 for in-network health services. Benefits include vision, dental, hearing, transportation, fitness options, worldwide emergency, OTC drugs, in-home support and telehealth. Co-pays for primary doctor and specialist are zero.

Blue Medicare Value PPO (Florida Blue) with health and drug coverage has a zero monthly premium and a zero drug and premium cost. Health and drug deductibles are zero, maximum in-network cost $3,451 and $10,000 for in and out of network. Benefits include vision, dental, hearing, fitness plans, worldwide emergency, telehealth, OTC drugs and in-home support. Primary doctor $0-$10 per visit and specialist $35-$48 per visit.

AARP Medicare Advantage Choice PPO (United Healthcare) with health and drug coverage has a zero monthly premium and zero yearly drug and premium cost. Also there is zero health deductible, $150 drug deductible, maximum cost $3,400 in network and $5,100 in and out of network. Benefits include vision, dental, hearing, fitness plans, worldwide emergency, telehealth and OTC drugs. Primary doctor, zero copay; specialist, $35 per visit.

(Check costs of all available Medicare Advantage policies at https://www.medicare.gov/plan-compare/#/coverage-options?year=2022&lang=en)

Can I drop Medicare Advantage and return to Medicare?

People who move out of a specific coverage area can usually drop a policy without any penalties, and sign up for coverage in their new location.

During the annual Medicare open enrollment period (Oct. 15-Dec. 7), people can join, switch or drop a plan. New coverage begins on Jan. 1 of the new year.

Also, the Medicare Advantage open enrollment period runs from Jan. 1 to March 31 each year. People enrolled in an Advantage plan can switch to a different Advantage plan or back to Original Medicare (and join a separate Medicare drug plan) -- but only one time. The choice is locked in for the year.

Be sure to read the rules on dropping an Advantage plan and losing drug coverage, because if an individual goes 63 days without this coverage, he or she could be hit with a lifelong late-enrollment penalty added to monthly premiums.

Can I stay with my doctor?

All these factors depend on the type of plan you choose. Most plans have coverage for a particular network of healthcare providers, and going outside the network will raise costs significantly.

Will the Inflation Reduction Act change Advantage plans?

"There are provisions of the recently enacted Inflation Reduction Act of 2022 that will impact both Part D plans and Medicare Advantage plans that offer Part D coverage," said David A Lipschutz, associate director/senior policy attorney at the Center for Medicare Advocacy, a nonprofit that helps older people and people with disabilities access Medicare and necessary healthcare nationwide.

"Starting in 2023, co-pays for insulin will be limited to $35 per month and cost-sharing for adult vaccines, such as shingles, will be eliminated," he said in an email responding to Miami Herald questions. There will also be a change in maximum out-of-pocket amounts in Medicare Advantage plans that "will make it more confusing to compare plans."

How do I choose a plan?

Kathleen Sarmiento, program director at the Miami-based Alliance for Aging, offered some questions for elderly consumers to ask insurance companies when looking at Medicare Advantage plans:

"I would first want to know if my doctors and my hospital are part of the MA's network, so I could continue to go to my doctors," she said.

"I would also want to know how many doctors are in the network, because HMOs require a referral from the primary care doctor to see a specialist. So, more specialists mean a shorter wait to see a specialist.

"I would also want to know what my co-payments are going to be for going to a doctor, a specialist, chemotherapy and my prescription medicine. Does the plan have additional benefits such as Silver Sneakers [a fitness program], comprehensive dental coverage, payments for expensive hearing aids or transportation to and from doctors?"

Original Medicare and private insurance companies providing Medicare Advantage can make changes in coverage, premiums and rules each year. Enrollees and policy holders should examine their coverage so they can make changes during the stipulated enrollment periods and avoid penalties.

"When shopping for a plan, start by assessing your own health care needs, developing your priorities for health insurance coverage and then comparing those with the actual plans offered in your area," said Jane Sung, senior strategic policy advisor with AARP's Public Policy Institute in an email.

"In some markets, there are a large number of plans to choose from," she said. "While choice is usually a good thing, in some cases too much choice can make it challenging, or even overwhelming, for people to focus on the priorities most important to them and make meaningful plan comparisons. For people who need more help, it's a good idea to seek out unbiased assistance such as through State Health Insurance Assistance Programs (SHIPS).

"It's important to know that what may be the best plan for one person may not be the best for someone else."

Information on Medicare Advantage policies:

Medicare.gov

https://www.medicare.gov/sign-upchange-plans/types-of-medicare-health-plans/medicare-advantage-plans

https://www.medicare.gov/plan-compare/#/coverage-options?year=2022&lang=en

Medicare Handbook -- Medicare & You

https://www.medicare.gov/basics/get-started-with-medicare/get-more-coverage/your-coverage-options

Alliance for Aging Miami

Main: 305-670-6500

Elder Helpline: 305-670-HELP

Toll free: 1-800-96-ELDER (35337)

https://allianceforaging.org/