As a registered nurse and hospital CEO serving this community, I understand the challenges facing seniors when it comes to accessible, affordable health care. Choosing the right Medicare health plan helps overcome those challenges, but how do you know which plan is best when there are different cost and coverage options to choose from?
During Open Enrollment (October 15 – December 7, 2024), making the right choice for you starts with knowing the differences between Original Medicare and Medicare Advantage. Open Enrollment periods allow seniors to change their health care insurance and prescription drug plans on an annual basis, so it’s a good idea to schedule your annual insurance “check-in”. I know when my husband went on Medicare this year, we worked with our local SHIIP volunteers and our local insurance agent, whom we know and trust, to help us determine which supplemental insurance and Part D drug plan would be best to supplement his Original Medicare Parts A and B plan.
Original Medicare is a federally funded program that offers broad access to health care providers nationwide. Beneficiaries can see any doctor or visit any hospital that accepts Medicare, offering flexibility and peace of mind. Medicare Advantage plans, which are offered by private insurers, cover the same services as Original Medicare, but often include additional benefits, such as discount drug programs, vision and dental coverage, and even healthy amenities like wellness plans or gym memberships.
While Medicare Advantage plans often have lower premiums than Original Medicare, additional costs may arise, including copayments, coinsurance, and deductibles, which can vary significantly between plans. Medicare Advantage plans may seem appealing, but a word of caution: please review the details closely, as these plans can carry hidden risks, especially for people with health conditions.
Another consideration, specifically for seniors living in rural areas, is that Medicare Advantage plans require beneficiaries to rely on in-network doctors and hospitals. For patients in medically underserved areas, limited provider networks can be a significant barrier to care. And, for seniors that plan to travel, finding yourself in an out of network area is a very real concern. This means that the physician or specialist you need may not be in your plan network. In fact, Kossuth Regional Health Center doesn’t participate in all Medicare Advantage plans. KRHC currently participates in the following plans: (Please note these are subject to change.)
- Original Medicare
- United Healthcare Advantage Plan
- Wellmark Advantage Plan
- Medical Associates North Iowa Senior Plan
- MercyOne Health Plan – formerly known as MediGold
- Iowa Health Advantage
- Humana
Medicare Advantage plans negotiate reimbursement rates with providers and health systems, which are often lower than original Medicare rates. That may not seem like a concern for patients, but there’s a hidden ripple effect: low reimbursements add to the financial strain that leads to service and facility closures, further impacting the availability of affordable, convenient, and quality health care. And, to maintain financial viability, health care systems are limiting contracts with Medicare Advantage plans. The administrative burdens these plans can place on hospitals and doctors are very real, and unlike original Medicare, most Medicare Advantage plans require health care providers to seek approval to see a specialist for treatments or other services. The coverage determinations can take some time to receive, and ultimately the care is not covered if the member is denied authorization for the service. Determining whether you are comfortable having your plan determine your care over your own doctor is a key consideration when making your decision.
Unlike original Medicare, Medicare Advantage plans often require approval for many prescription drugs, inpatient hospital stays, skilled nursing stays including in a nursing facility, therapy, dialysis, diagnostic services and lab tests. The care remains uncovered if the plan denies approval for these services.
Choosing a Medicare plan requires careful consideration of your health needs and financial circumstances, especially for seniors with fixed incomes and increased health concerns. Knowing your comfort level in allowing your plan to make coverage decisions on your behalf, rather you’re your health care provider, should be an important decision. Remember, our SHIIP Counselors are here to help and can answer questions, so discuss your Medicare options with us.
- If there are no recommended changes to your plan, a SHIIP counselor will send a letter saying that you will be a rollover for 2025.
- If you WOULD benefit from changing plans, SHIIP will call you to schedule an appointment for a review of your plan options. A counselor will begin calling to set up appointments the week of October 7. Please make sure your phone number is correct and able to receive a message.
- If you have not received a phone call or letter by November 15th informing you of your 2025 drug plan, please contact the SHIIP office (515-295-4658) and leave a message.
Once you have your appointment, if for some reason, you need to reschedule or cancel your appointment, please contact the SHIIP office (515-295-4658) and leave a message.
You can also visit medicare.gov for more information or call 1–800-MEDICARE to speak to a knowledgeable Medicare representative about coverage options.
For more information including what to know before you sign up and understanding the details of each option, you can visit the SHIIP page on our website at www.krhc.com
