Medicare Advantage Shopping: 10 Rules

Janet Mills is a veteran in the Medicare Advantage marketplace.

At Florida’s SHINE program for 13 years, Mills has provided unbiased counseling to thousands of seniors trying to make difficult choices about their Medicare coverage.  Now an area coordinator, she also fields questions from volunteer counselors at SHINE – the Serving the Health Insurance Needs of Elders program – in Pinellas and Pasco counties, which include St. Petersburg and Clearwater.

It can be difficult for retirees with multiple Medicare Advantage options to distinguish one plan’s benefits from another plan’s and pull the right one off the shelf. But based on her experience, Mills said, the decision retirees make during open enrollment for Medicare Advantage plans is crucial to controlling their health care costs. One in three Medicare beneficiaries is now enrolled in an Advantage plan, according to the Henry J. Kaiser Family Foundation. Their growing appeal centers on premiums that are lower than Medigap premiums.  But retirees in Advantage plans also face the potential for up to $6,700 in out-of-pocket costs annually, the legal maximum allowed in the plans.  The out-of-pocket U.S. average is $5,219, according to Kaiser.

“You really don’t want to sleep through the annual enrollment period,” Mills said.

Here are her pearls of wisdom for those preparing to launch into their comparison shopping for Medicare Advantage plans, which go on sale Oct. 15:

1. People who have been in a Medicare Advantage plan this year should open their mail. You should receive a plan change letter from your Advantage insurer if your policy will change on Jan. 1. These plan changes can affect deductibles, the doctors who participate in the plan, the list of prescriptions covered, and the copayments and premiums for the health or drug parts of the Advantage plan – or both.  (Some Advantage Plans, depending on how they’re designed, have combined premiums or no premiums.) The federal Medicare agency also issues a rating for each Advantage plan, though some have questioned the quality of these ratings.

2. First-time Medicare enrollees might want to be strategic, Mills said. Sixty-five-year-olds who want to play it safe could choose a Medigap supplement initially, because they cannot be refused coverage by Medigap during the first six months after they first sign up for Part B.  Medigap isn’t always available to people who’ve already been enrolled in an Advantage plan, because Medigap can deny coverage based on pre-existing conditions.  Perhaps enroll in Medigap the first year to “play out the scenario and learn how it works,” she said. Enrollees can easily switch from Medigap to an Advantage plan during the next open enrollment period, which is always Oct. 15 through Dec. 7. The plans become effective Jan. 1.

3. Don’t be complacent. Research on Advantage plans has found that once people choose a plan, they are reluctant to change – even when their premiums go up. But Mills said that if last year’s Advantage plan worked well, you still won’t be certain it continues to be your best option until you shop around.  Unlike Medigap, with its restrictions, it’s easy to switch from one Advantage plan to a new one.“After you evaluate the market, you may come back and realize that you are indeed enrolled in the best plan for you,” she said.

4. To find the Medicare Advantage plans sold in your area, she said the Medicare.gov website does a good job – click the green button that says “Find health & drug plans.” You can also call your state’s SHIP or SHINE program for assistance from a Medicare expert, and she suggests some people ask a trusted friend or family member to call the state program for help with this complex process.

5. Start your search for an Advantage plan by prioritizing your doctors. Advantage plans that are HMOs provide retirees with access to a limited network of physicians.  Advantage plans that are PPOs also have networks, but they are less restrictive.  Since it may be difficult to find a network with all your doctors, Mills suggests starting your search with a call to the doctor “you would never ever leave”– whether a general physician or specialist.  Find out which plans he or she participates in in your area, scratch the other plans off your list, and see whether the plans that remain standing can work for you. Medicare.gov does not include physician networks on its website; the physicians covered in each plan are on insurance company websites.

6. Be mindful of new physicians and new prescriptions you’ve added over the past year. See if they will be covered either in your existing Advantage plan or the plans you’re considering switching to in the new year. “Not checking your drugs every year can make a difference of hundreds, if not thousands of dollars,” Mills said.

7. One issue with Advantage plans is that they sometimes limit the hospitals, including cancer centers, that can be used, which means increased costs for patients who have to go to a facility out of their network. “Check your doctors, drugs, the facilities you would normally go to, including hospitals, or even a favorite lab or radiology facility,” she said. “A place can be very meaningful, depending on one’s medical needs.”

8. Be aware that 147 mostly rural counties do not offer Advantage plans, usually because they have fewer people on Medicare and fewer health care providers to support the market. They are primarily in the West, including Alaska, where no Advantage plans are sold to individual buyers. (Alaska does, however, offer Advantage plans to some employers and other groups.)

9. Lower-income seniors should check whether their gross income and asset amounts make them eligible for financial help in the form of reduced Part B premiums, Medicaid, or financial assistance to pay for prescriptions. Counselors for your state’s SHIP program can help you apply. “There are large numbers of people who may be eligible for help but never apply, and we can help you,” Mill said.

10. High-income retirees with second homes should be aware that a Medicare Advantage HMO plan that works in the area where they legally reside can’t be used elsewhere – emergency room visits are the exception. However, Advantage PPO plans provide both in-network and out-of-network coverage options.  Medigap plans also provide coverage nationally.

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