It’s that time of year once again. The open enrollment period for Medicare is open through Dec. 7. When enrolling in Medicare or making a change to your plan, there are several options available, which can often feel overwhelming. Steve Pantaleo, RN, a certified application counselor for Phelps Health EnrollU, breaks down the differences between Original Medicare and Medicare Advantage.
• What is Medicare Advantage, and how does it compare to – or supplement – Medicare?
Medicare Advantage Plans are another way to get your Medicare Part A and Part B coverage. Medicare Advantage Plans, sometimes called Part C or MA Plans, are offered by Medicare-approved private companies that must follow rules set by Medicare. If you join a Medicare Advantage Plan, you'll still have Medicare, but you'll get most of your Part A and Part B coverage from your Medicare Advantage Plan, not Original Medicare.
With Original Medicare, patients can go to any doctor or hospital in the US that accepts Medicare. With Medicare Advantage, however, you can only use doctors and providers who are in the plan’s network and service area (in most instances, for non-emergency care).
• Does Phelps Health accept Medicare Advantage?
Yes. Phelps Health is in-network with the following Medicare Advantage Plans: Anthem Blue Cross Blue Shield, Humana, UnitedHealthcare and Wellcare. If a person has a PPO (Preferred Provider Organizations)-type Medicare Advantage plan with another carrier, they can be seen at Phelps Health, but in most cases, they would have to pay an out-of-network rate. Some plans, like HMOs (Health Maintenance Organizations), are even more restrictive; in general, patients would not be covered if they went out of network.
• Will Medicare Advantage cap my out-of-pocket costs?
Yes. In 2022, the out-of-pocket limit may not exceed $7,550 for in-network services and $11,300 for in-network and out-of-network services combined. These limits will increase to $8,300 for in-network services and $12,450 for in-network and out-of-network services combined in 2023.
In contrast, there is no limit on out-of-pocket expenses with Original Medicare, if you do not have a Medigap Plan or Medicare Advantage (or retiree plan).
• What are the main benefits and drawbacks of Medicare Advantage?
Benefits of Medicare Advantage Plans
With a Medicare Advantage Plan, you may have coverage for things Original Medicare doesn't cover, like fitness programs (gym memberships or discounts) and some vision, hearing and dental services (like routine checkups or cleanings). Plans can also choose to cover even more benefits.
Drawbacks of Medicare Advantage Plans
• In general, Medicare Advantage Plans don’t offer the same level of choice as a Medicare plus Medigap combination. Most plans require you to go to their network of doctors and health providers.
• Since Medicare Advantage Plans can’t select their customers (they must accept any Medicare-eligible participant), they discourage people who are sick by the way they structure their copays and deductibles. Many enrollees have been hit with unexpected costs and denial of benefits for various types of care deemed not medically necessary.
• Out-of-pocket costs can quickly build up over the year if you get sick. The Medicare Advantage Plan may offer a $0 premium, but the out-of-pocket surprises may not be worth those initial savings if you get sick. “The best candidate for Medicare Advantage is someone who's healthy," says Mary Ashkar, senior attorney for the Center for Medicare Advocacy. "We see trouble when someone gets sick."
• When can I enroll in Medicare Advantage?
You can join, switch or drop a Medicare health plan or a Medicare Advantage Plan (Part C) with or without drug coverage during these times:
• Initial Enrollment Period: When you first become eligible for Medicare, you can join a plan.
• Open Enrollment Period: From Oct. 15 – Dec. 7 each year, you can join, switch or drop a plan. Your coverage will begin on Jan. 1, as long as the plan has your request by December 7.
• Medicare Advantage Open Enrollment Period: From Jan. 1 – March 31 each year. If you’re enrolled in a Medicare Advantage Plan, you can switch to a different Medicare Advantage Plan or switch to Original Medicare (and join a separate Medicare drug plan) once during this time. Note: You can only switch plans once during this period.
• What resources are available at Phelps Health? Who can I speak with to determine if Medicare Advantage is right for me? Is there a cost for these services?
The Phelps Health EnrollU team is here to help with any questions you may have about Medicare and Medicare Advantage. Our certified and licensed navigators and counselors are ready to assist you. In addition, staff can provide information on Medigap plans, Original Medicare and healthcare insurance through the Marketplace.
You don’t have to be a Phelps Health patient to receive assistance with EnrollU. We provide this service free to the community. Call (573) 458-3676 or email EnrollU@phelpshealth.org to speak with an EnrollU team member or to schedule an in-person appointment. Learn more about Medicare Advantage at phelpshealth.org.
About Phelps Health
Phelps Health serves over 200,000 residents in south-central Missouri. Phelps Health is county-owned, non-tax supported and is overseen by a five-member elected board. Phelps Health employs more than 1,900 people, including 100-plus providers. Phelps Health, which includes a hospital licensed for 242 patient beds, serves a six-county area, with its main campus and several clinics located in Rolla, Missouri. Phelps Health also has clinics in Salem, St. James, Vienna and Waynesville, Missouri. For more information, visit phelpshealth.org.
