Open season for your health coverage

The other night I ran into a friend at Flat Creek who asked me to write once again about Medicare and Medicare Advantage since it is open season enrollment through December 7, 2023.

Some of you will remember I wrote about this when my husband John was sick. He had switched from regular Medicare to a Medicare Advantage plan and I outlined the difficulties we had with it.

The best advice anyone can give about Medicare and Medicare Advantage is to know what you're getting, the pros and cons of both. Even if you read and saw all the television and radio ads, the emails, texts and promotional mailers we get during open season, you might not know what your best coverage is. Some of the Advantage promotions are misleading. For example, some send Medicare beneficiaries flyers or brochures that look like government letters. And the television ads show a "Medicare hotline" phone number which does not belong to Medicare. They also use official Medicare logos and cards in the mailers that were not approved by Medicare.

Television ads for Medicare Advantage usually show healthy, active seniors playing tennis and hiking. There are no ads with any disabilities or illness, even though approximately one-fifth of Medicare beneficiaries have serious health issues. But if you like William Shatner, or Joe Namath you can see them over and over on television promoting Advantage plans during open season.

There are approximately 65 million Americans deciding what kind of health coverage they want. More than half of regular Medicare participants have left traditional Medicare and opted for a Medicare Advantage plan. There are an estimated 43 Advantage plans to choose from, with Humana and United Healthcare being the biggest providers. The Kaiser Family Foundation reported that, "Both Medicare Advantage and traditional Medicare beneficiaries reported that they were satisfied with their care—a large majority in both groups."

Traditional Medicare has been around since 1965, thanks to President Lyndon B. Johnson.

When first introduced, Medicare had only two parts: Medicare Part A and Medicare Part B. That's why you'll often see those two parts referred to as Original Medicare today. Parts A and B looked pretty similar to original Medicare as you may know it, although the costs have changed over time. Just like today, Medicare Part A was hospital insurance and Medicare Part B was medical insurance. Most people don't pay a premium for Part A but do need to pay one for Part B. In 1966, the monthly Part B premium was $3. In 2021, the Part B premium is $148.50.

Medicare has seen many changes over the past 5 decades. In 1972 Medicare expanded coverage to include people with disabilities who receive Social Security Disability Insurance, and people with end stage renal disease (ESRD) also received immediate coverage.

In 1980 Medigap, also known as Medicare supplement insurance, was offered, which helps you pay the out-of-pocket costs of original Medicare, like copays and deductibles. These plans are sold by private insurance companies and must meet certain standards.

In 1982 hospice care for people with a terminal diagnosis was added and is still covered under Medicare Part A.

Medicare Part C was introduced in 1997. These are the Medicare Advantage plans, sold by private insurance companies that contract with Medicare and must follow rules set by Medicare.

Medicare Advantage plans work with a network of providers. Their coverage model is more similar to employer coverage than original Medicare and they often include additional coverage for services that Medicare doesn't cover, such as dental, vision, and prescription drug costs.

Part D Medicare was added in 2003. This is prescription drug coverage.

Advantage plans offer simplicity and appear to be cheaper because many charge low or no monthly premiums and also cap out-of-pocket expenses, excluding drugs, whereas traditional Medicare usually calls for a separate supplemental policy for drugs.

Advantage plans use preferred provider networks, meaning you can't go to whatever doctor or hospital you want; you must go to only their participating doctors and hospitals, and you must receive approval in advance for many procedures, drugs or facilities.

Traditional Medicare permits you to use any physician or hospital or testing service that accepts Medicare—almost all of them do—and you don't need prior authorization.

Nationally recognized expert on personal finances and the markets, Terry Savage wrote this in the Chicago Tribune.

"Be careful about switching to a Medicare Advantage plan. More than half of Medicare participants have left traditional Medicare. Traditional Medicare comes with one big advantage: You can use any physician or hospital or testing that accepts Medicare. Period. And most do accept Medicare."

With Advantage and its low-cost monthly premiums, things may look attractive. But if you get sick, then co-insurance or flat-fee copayments may apply. You may not be able to get authorization to go to the best hospital that specializes in your illness. And your claim can get denied too, in which case you can appeal it.

A study performed by the Department of Health and Human Services said that in 2021 Advantage plans denied more than 2 million prior authorization requests and wrongly denied 18 percent of payment claims.

Resources to help with your decision include:

Medicare.gov website

Toll-free 1-8—MEDICARE number

State Health Insurance Assistance Programs (SHIP) where volunteers help you decide and offer impartial advice. Go to ship.help.org