Medicare Advantage season comes with tough choices. Here’s a breakdown

The federal health insurance program will cover his hospitalization expenses, should he need them, but insurance from his employer covers most of the cost for other medical needs.

Roughly 28 million Americans choose a different route. They stop working full time, take Medicare hospitalization coverage and select a Medicare Advantage plan to help keep them out of the hospital.

This time of year, many in their golden years might think Daniels took the easy way out.

From Oct. 15 through Dec. 7, they must navigate the onslaught of pitches from private insurers who offer a multitude of the federally funded plans. Then they must pick one and file an application for coverage next year.

The most common Medicare coverage includes help with hospitalizations (Medicare Part A); doctor visits, health screenings and physical, occupational or mental health therapy (Part B); and in many but not all cases, medications (Part D).

Cost matters because most who apply for Medicare are on a fixed income. What gets covered — and how — should matter, too.

Those who are healthy can roll the dice and choose a plan with a high deductible and high copays because their monthly premium costs will be lower, if they have any at all.

A major health setback, however, can spell financial as well as personal doom.

It helps explain why Daniels keeps working.

He has been coordinator of insurance outreach and counseling with the Erie County Department of Senior Services since 1995.

As many as 15 part-time staffers and volunteers help him provide free Medicare advice during the busy fall season for healthy seniors as well as those with chronic diseases who already require expensive medications, therapies and medical devices.

The same holds true for 3 million Americans below age 65 who are disabled and on Medicare.

"I always advise people never just get original Medicare alone because there's no limit to your out-of-pocket expenses," Daniels said this week. "Never go without prescription drug coverage. I don't care if you've never taken medication in your life. You've got to look at future needs.

"The weak point with the Medicare Advantage plans is the high cost of meds," added Daniels, age 70. "For a lot of them, it's a 20% co-insurance. You're talking thousands and thousands of dollars" if you come down with cancer or another condition that gets costly to treat.

He and leaders with the three largest regional health insurance companies answered some of the key questions those eligible for Medicare Advantage plans need to consider during the next several weeks, while the window is open to sign up for 2023 coverage.

Q: What are the big changes this year?

A: The standard monthly premium for Medicare Part B enrollees will be $164.90, a drop of $5.20, from $170.10 from this year. The annual deductible next year for all Medicare Part B beneficiaries is $226, $7 less than in 2022.

"Most people pay 25% of the cost of the Medicare Part B benefit and the cost is dropping for next year," Daniels said. "It's not a big drop but that's something people will be happy about."

The federal government has raised the maximum office visit and hospital out-of-pocket costs for enrollees to $8,300, which is $750 more than this year. Most Advantage plans feature caps below that threshold.

Low-income seniors and adults with disabilities may qualify to receive financial assistance from Medicare savings programs that help cover some premium costs, deductibles and copays. Only half of those eligible for this supplemental assistance take advantage of it, Medicare officials report.

"We anticipate a big increase in that," Daniels said. "Right now, it's $954 a month. If you're elderly or disabled, we anticipate that going up to maybe $1,500."

There is no asset limit to get this benefit in New York, he said, as is the case in many other states.

Q: Does the pandemic continue to throw any wrinkles into Medicare and Medicare Advantage programs?

A: The pandemic froze income-based Medicare and Medicaid benefits that remain in place through the end of the year. That could change next year, Daniels said, although most younger Americans can expect greater financial pain. The cost for some regional employer-paid health insurance plans will climb more than 30%.

Q: What are the strengths and weaknesses of the three most common types of Medicare Advantage plans?

A: A Health Maintenance Organization plan (MA-HMO, the most popular in the region) tends to be the most restrictive and least-expensive form of coverage, Daniels said. You must see a doctor in the plan's network except for emergency or urgent care and may find you need preauthorization for medical procedures and other care. Providers also can drop you as a patient if you fail to follow treatment protocols, say by not taking medications as directed.

Because HMO members are required to use hospitals and service providers within the plan's network, they usually pay lower premiums. Out-of-pocket costs also can be lower, said Amber Hartmann, speaking for Highmark BlueCross BlueShield of WNY.

A Preferred Provider Organization (PPO) "is a nice model, in that the doctors are not restricted as much by the influence of the insurance company," Daniels said, though these plans can cost more. "The copays can be higher," he said, "but there are zero premium PPOs out there."

Private Fee For Service (PFFS) plans are traditional Medicare plans that generally cost more and provide those who choose them greater latitude to pick doctors and get better out-of-region health cost reimbursements.

Individual health needs, avoiding crippling debt should a health emergency strike and financial security should dictate choices.

"The whole idea for insurance companies is controlling costs," Daniels said. "Usually, if it's a higher premium, it's lower copays. You've got to watch the copays."

Q: What do the highest-rated plans tend to have in common?

A: The ratings scale runs from 1 to a high of 5. Medicare gives more money to private insurance plans that offer Medicare Advantage plans and rate higher by performing better on screenings, managing chronic health conditions and other quality clinical outcomes. Insurers also are rated on the experience, pro and con, of their members.

Many insurers provide extra incentives that can beef up those ratings, including partial coverage for dental care, hearing aids and eyeglasses. Many also offer a free fitness club membership, Daniels said, because healthier people tend to exercise more.

The three largest regional insurers offer most of the highly rated options for next year.

The Centers for Medicaid & Medicare Services (CMS) awarded 5-star ratings to Univera SeniorChoice Basic and Extra HMO plans, and SeniorChoice Advanced, Value Plus and Secure HMO-POS plans. Most HMOs provide care through a network of doctors, hospitals and other medical professionals that plan members must use to be covered for care. You can go outside the network with an HMO-POS, but expect to pay more.

Highmark's 5-star rated offerings include Freedom Valor, Freedom Nation, Forever Blue Value and Forever Blue 751 PPO plans.

Independent Health hit the high mark with its Encompass 65, 65 Element, 65 Edge, 65 Core and 65 Basic HMO plans and Medicare Passport Advantage and Passport Prime PPO plans.

Other top-rated programs in Erie County include MVP Medicare Preferred Gold without Part D, Medicare Secure with Part D and Preferred Gold with Part D, all HMO-POS plans.

Most of the highly rated plans in the county are available across the region, Daniels said.

Q: What assumptions for 2023 can those on Medicare make with the plans they are on this year?

A: "Premiums are dropping for Medicare Part B," Daniels said, "but prescription drugs are still an issue. They're going to be for a while."

That is why those already on an Advantage plan need to know in advance what they should expect with copays for medications they take or may take next year — or if those drugs will be covered at all. Premiums, deductibles, copays and covered drug lists, called formularies, can change from year to year on the same plan. So can in-network doctors.

The variance makes vital the direct access to trusted experts who can answer questions before and after you're an Advantage plan member, said Cathy Aquino, vice president for Sales, Consumer & Small Business Markets with Independent Health.

The reputation of the plan, including opinions from friends and family, and the ability to talk with someone locally and in-person should be considered, Aquino said.

Those meetings make it easier to ensure doctors and other health care providers participate with the plan you choose, she said, and that pharmacies, labs and hospitals are in-network, "since you may have to pay much higher costs to see a non-participating or a non-preferred provider."

"Look for a plan that's designed for Western New Yorkers, not a cookie-cutter plan sold across the country," said Andrew Napierala, vice president Medicare & Individual Market Sales with Univera Healthcare. Also consider the value of dental, vision and hearing care.

Most importantly, you need a Medical plan that meets your budget and your needs.

Q: Would supplemental policies be good for those who need medical services fairly often?

A: "These are good for folks who may have more complex health care needs," Daniels said.

Some major insurers are not pushing supplemental prescription drug policies this year, he said, even though many Medicare enrollees with chronic health conditions would likely to save money with them.

Dialysis, drugs administered by infusion and cancer therapies can cost insurance companies "thousands and thousands of dollars a month," Daniels said, which means they tend to make less money on these policies. Infusion medications, for instance, can cost up to $15,000 a month; a 20% copay would mean $3,000 out of pocket.

"A Medicare supplement will pick that up," Daniels said.

The plans run from $199 to $463 a month and tend to be higher downstate than upstate, he said.

"Most people call me because of the high co-insurance or high copays that they have with Medicare Advantage," he said. "Sometimes I can scramble to get them into a supplemental policy. You don't find anybody advertising those. You sleep better if you buy a supplemental, but profit drives business."

Q: Dental health is an important part of good overall health. Do Medicare Advantage plans help cover the cost of preventive dental work?

A: Dental benefits within Medicare Advantage plans continue to expand, said Hartmann, with Highmark. "Consumers should look for coverage that is comprehensive, helping to pay for the basics, like cleanings and X-rays, as well as restorative work."

Q: Can a plan be worth dental, vision, hearing or fitness benefits?

A: It depends on the individual and family needs, interests and financial means.

The bottom line for Daniels?

"You try to buy insurance for things you can't afford to pay out of pocket," he said. "My agent, who I've had for at least 40 years, says, 'Don't look at the little things. Look at the big things you get that might otherwise drive you into bankruptcy.' The No. 1 reason people are in bankruptcy is medical expenses."

MEDICARE SUPPORT

Medicare: Medicare.gov can help you file for Medicare and Medicare Advantage plans, compare plans and find a health care provider. You also can find the "Medicare and You 2023" handbook.

Talk with support staff anytime except holidays by phone at 800-633-4227.

Medicare Rights Center: This nonprofit organization, based in New York City, provides free counseling and advocacy in English and Spanish for those who need help applying for Medicare plans. Visit medicarerights.org or call its national helpline at 800-333-4114 to learn more.

Medicare Interactive: Powered by the Medicare Rights Center, the website at medicareinteractive.org includes answers more than 3 million questions about Medicare.

Erie County Department of Senior Services: Its Insurance Outreach and Counseling Program can help eligible residents apply for Medicare and provide a free, unbiased comparison of Medicare Advantage plans for those shopping for one. Call 716-858-7883 to arrange online, phone or in-person counseling.

211: Call the number or visit 211wny.org to find agencies in your county that can answer Medicare questions.

Medicare Savings Programs: Income-eligible state residents on Medicare can call the state Department of Health at 800 — 505 — 5678 or their local office for aging or senior services to learn more and sign up.

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