Are You an Informed Medicare Consumer?

Laura Floor
December 6, 2017
Medicare Benefits

Changes in Medicare coverage occur every year for people enrolled in Original Medicare and Medicare Advantage plans. Yet, most enrollees only seek help in choosing among the various options available under Medicare when they first enroll in this government insurance program. According to a Kaiser Family Foundation report, many studies have shown that very few Medicare beneficiaries actually revisit their coverage decisions on an annual basis.

Do You Understand Your Current Medicare Coverage Parameters?

Do you know whether your Medicare Advantage plan still covers dental visits? Does your Part D (prescription drug plan) still include your medications in its formulary? If you cannot answer these questions, it is advisable that you review your coverage before you need to utilize it!

Over 49 million seniors are currently enrolled in Medicare (according to the website of the Alliance for Retired Americans). However, understanding its options and costs can be confusing. For enrollees in Original Medicare, there are specific coverage parameters and costs associated with each individual part—as well as financial penalties for delaying enrollment in a particular part.

For example, an enrollee in Original Medicare’s Part A is not required to also enroll in Part B (medical insurance)—but financial penalties accrue for delaying Part B enrollment. Meanwhile, Part D (prescription drug coverage) is optional under Original Medicare. However, not having this coverage can result in huge out-of-pocket expenditures if you need a daily medication.

How Medicare Can Help You to Choose a Plan

In order to assist Medicare enrollees to choose coverage that meets their needs, Medicare offers a tool on its website called the Medicare Plan Finder. This online tool can assist you to find plans available in your geographic area, and based on your health needs and preferences. Additionally, one-to-one counseling services are available to low-income beneficiaries through federally-funded State Health Insurance Assistance Programs (SHIPs). (However, SHIPs may be de-funded in 2018.)

Actions You Can Take as a Medicare Beneficiary

Four recommended actions that you can take as a Medicare beneficiary to empower yourself are described by HealthMarkets.com, and these are:

  1. Informing yourself to see if your current Medicare plan still meets your needs.
  2. Knowing your legal rights as a Medicare beneficiary.
  3. Protecting yourself from identity theft.
  4. Aid in fighting Medicare fraud.

Understanding Medicare’s Different Parts

There are four parts to Medicare, and Medicare’s Part A (hospitalization insurance) is just one of them. While most people who are enrolled in Original Medicare are automatically enrolled in Part A, not all Medicare enrollees are enrolled in Part B (medical insurance). One reason is the monthly premium cost and annual deductible.

If provided by a Medicare-enrolled provider, Original Medicare’s Part B covers such services as:

  • Physician office visits;
  • Outpatient physical, speech, and occupational therapy;
  • Outpatient x-rays and lab tests;
  • Durable medical equipment;
  • Ambulance services;
  • Outpatient mental health and substance abuse services

It is a good idea to enroll in Part B (or enroll in a Medicare Advantage plan inclusive of outpatient services) because—even if you are healthy—you never know when you will need healthcare services! According to an AARPreport, around 75 percent of all Medicare beneficiaries use their Medicare coverage in any given year!

When Medicare Advantage is Preferable to Original Medicare

You may prefer to enroll in a Medicare Plan C (Medicare Advantage) health plan rather than Original Medicare if you have a chronic health disorder that incurs high annual medical costs. This is because Medicare Advantage plans include a “cap” on enrollees’ annual out-of-pocket expenditures, while Original Medicare does not have such an out-of-pocket “cap”.

People who have Multiple Sclerosis (MS), Amyotrophic Lateral Sclerosis (ALS), and blood cancers often have astronomically-high annual expenses due to their higher need for outpatient provider services and high-cost medications. Their retirement savings can become quickly depleted—even when insured under Medicare—so enrolling in a Medicare Advantage plan with an out-of-pocket “cap” can prevent these patients from becoming bankrupt due to medical bills.

Additionally, Medicare Advantage plans typically include prescription drug coverage—which is only covered by Part D under Original Medicare. Whether Original Medicare or Medicare Advantage is best for you really depends in great measure upon your personal healthcare circumstances in tandem with the health plans offered in your locale.

Medicare Supplemental Insurance (MSI) – Medigap Plans

Medigap is privately-offered insurance that supplements Original Medicare coverage—and it is not available to enrollees in Medicare Advantage plans. Medigap plans are currently offered in 10 standardized benefits packages in all but the three states of Massachusetts, Minnesota, and Wisconsin (per an article in Consumer Reports).

Since the monthly premiums can vary between Medigap plans, it is crucial to compare the ones available in your locale to determine if any of the available plans makes sense for you. A key factor to consider is your income (i.e., your monthly Social Security check). If your total income falls below the Federal Poverty Level (FPL), you may be dually-eligible for Medicare and Medicaid coverage.

Medicare Coverage Confusion – Frequent Complaints

One of the areas that generates the largest number of complaints to Medicare is that an increasing number of physicians are refusing to accept new Medicare patients. The reason is that Medicare’s financial reimbursement to healthcare providers is generally less than their potential reimbursements from private insurers.

Meanwhile, enrollees in Medicare Advantage plans all too often find that their insurer does not inform them when a preferred specialist leaves the health plan’s “network” of providers. The result can be that the Medicare Advantage enrollee has to switch to receiving care from a different specialist who is still in the “network”.

Still other complaints to Medicare stem from a patient receiving an unexpected bill for healthcare services that the patient expected Medicare to pay. This is because Part B has an annual deductible that must be met before coverage ensues.

Options for Taking Action as a Consumer

Options for taking consumer action related to Medicare include getting involved with the following:

  • Senior Medicare Patrol – This is a group dedicated to assisting Medicare recipients when they experience Medicare-related fraud, error, and/or abuse.
  • National Consumer Protection Week – Under the auspicies of the US Federal Trade Commission, this was started to assist people to understand their rights as consumers. (In 2018, this week is scheduled for March 4-10.)
  • My Medicare Matters – This resource of the National Council on Aging is aimed at helping Medicare enrollees better understand their Medicare options.

As a Medicare consumer, it is vital for you to be informed of your Medicare options so that you can make the best choices. Besides reading the information available on the Medicare.gov website, the National Council on Aging has an online Medicare Questionnaire that can aid you in selecting Medicare options that make sense for your needs. If you are still confused, contacting a senior center in your community can be good place to start in order to locate someone knowledgeable to help you.

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