6 Simple Ways to Tell If Medicare Advantage Is Right For You
Medicare Advantage hasn’t been a popular choice here in Decatur, IL because there haven’t been very many choices. It’s pretty typical for smaller cities to have fewer choices than metropolitan areas.
Head up to Chicago, and there are 22 PPO or HMO plans to choose from. But here in Decatur? There are only 4.
And the ones we get access to aren’t typically the most attractive plans of the bunch. That’s why nearly all of our Medicare-aged client here at Sams/Hockaday choose a Medicare Supplement instead.
However, as the popularity of Medicare Advantage grows, many local individuals are starting to wonder: could it be right for me? That’s why we’ve put together 6 simple ways to tell if a Medicare Advantage plan is going to fit your needs and budget.
1. What’s your budget?
When it comes to Medicare Advantage, most of the time you’re looking at a very low premium. Two of the four PPOs available in Decatur are $0 premium, another is $26 per month, and the last one is $117 per month.
The flip side is that you’re going to have out-of-pocket costs every time you use the plan. For example, you’ll pay $15 for every doctor visit, $45 to see a specialist, $250 for outpatient surgery, $265 per day for inpatient hospital care, and $265 for an ambulance.
Essentially, Medicare Advantage plans are like “pay as you go” plans.
If you have a $0 premium and you’re healthy as a horse, you’re looking at around $30 per year to see your doctor semi-annually for a basic checkup. If that sounds like you, you may benefit financially from an MA plan, but be sure to read the rest of this article for the rest of the considerations.
2. Do you travel?
If you’re a snowbird, an HMO or PPO Medicare Advantage plan is not for you. A Medicare Advantage plan is going to have a list of in-network providers and hospitals, and they’re generally within a radius of your zip code.
If you do travel out of your area, or even out of state, you’ll be subject to out-of-network costs, which can be very expensive.
It’s very common for out-of-network services to have a 50% coinsurance, which means you’ll be footing half of the bill for everything from a doctor visit to an overnight hospital stay.
Some plans won’t offer any coverage for out-of-network services, which means you’d essentially be going without insurance entirely.
This is a huge factor when considering if Medicare Advantage is right for you. If you do travel, it’s best to look at Medicare Supplement or a Medicare Medical Savings Account (MSA), both of which do not have provider or hospital networks.
3. Do you take prescriptions?
Medicare Advantage plans can be problematic when it comes to prescription drug coverage. The plans that do come with prescription benefits are actually called MAPDs, or Medicare Advantage Prescription Drug plans.
The particular benefits that come with the plan may or may not be in your best interest, but you’re stuck with it and cannot choose a different drug plan.
The biggest consideration when looking at a drug plan is the formulary. First of all, are your drugs covered? Secondly, if they are, what tier are they in? Tier 1 drugs are considered “preferred generic” drugs with only a $3 copay, while Tier 5 drugs are considered “specialty tier” and require you to pay a 33% coinsurance.
That 33% coinsurance is not be overlooked! For example, Trulicity is $826 to fill, which means each time you need a refill, you’d be paying over $250 out of pocket.
If the planets align and the Medicare Advantage plan you want does cater to the drugs you take, it can work out well. If all you take is common generic drugs, you likely won’t have any issues.
However, there are also Medicare Advantage plans that do not come with prescription drug coverage, and for whatever reason, you are not allowed to purchase a Part D drug plan. If you do enroll in a Part D plan, it would automatically disenroll you from your Medicare Advantage plan.
The only time an MA plan without drug coverage makes sense is if you’re getting drug coverage from another source.
You are allowed to choose your own Part D drug plan if you have a Medicare Supplement or a Medicare Medical Savings Account (MSA). That Part D plan can be catered to your exact prescriptions, which allows you to save as much money as possible.
4. Do you want to keep your current doctor?
We mentioned earlier that if you travel at all, a Medicare Advantage plan will not be for you. That’s because of the network restrictions.
Even if you plan to stay in your area, the other part of the issue is that only certain doctors, hospitals, and pharmacies are going to be in the plan’s network.
The Medicare Advantage plans available here in Decatur, IL are either Local PPOs or Regional PPOs.
Local PPOs service a single county or group of counties selected by that particular plan. These plans have the least amount of choices.
Regional PPOs service a single state or multi-state areas determined by Medicare. These plans have a little more wiggle room.
In both cases, it’s possible that your current doctor or hospital is not in the plan’s network. If that’s the case, and you want to keep your current doctor, you will pay more to see that out-of-network provider.
In this scenario, it generally makes more sense to look at Medicare Supplements or a Medicare Medical Savings Account, both of which do NOT have restrictive networks.
5. Are you interested in “extras”?
One of the biggest draws to Medicare Advantage plans is the extras that often come with the plan.
For example, Humana offers extra benefits that you would not get with Medicare, such as:
- Annual vision exam
- Routine dental exams
- Silver Sneakers program (free gym membership to select gyms)
- Allowance for over the counter drugs and supplies ($25 per month, must be mail delivery)
- Nurse hotline (advice from a nurse available all day, every day)
Another example would be from Aetna. Aetna offers the following benefits that don’t come with Original Medicare:
- Up to $2,000 per year for non-Medicare covered preventive dental services
- Two oral exams and cleanings per year
- Silver Sneakers program (free gym membership to select gyms)
- One hearing exam per year
- Allowance for over the counter drugs and supplies (up to $25 per month, must be from CVS and ordered online through their link)
- One eye exam per year
- $400 maximum benefit for eyewear per year
If these extras are important to you, it may be worthwhile to take a look at a Medicare Advantage plan.
If a Medicare Supplement or Medicare Medical Savings Account is a better fit for you, you can still purchase Dental, Vision, and Hearing insurance to cover the costs of exams and more.
6. What’s your risk profile?
While insurance isn’t all about the price, it’s probably one of the most important factors.
Since Medicare Advantage plans are pay-as-you-go plans, it’s important to understand how comfortable you are with the risk of paying thousands of dollars out of pocket. If a major medical event happened, you would be paying quite a bit out of your pocket.
With a Medicare Supplement, for instance, you’re paying the same monthly premium each month and do not experience any out-of-pocket costs at all, and if you do, it’s generally the Part B deductible which is less than $200.
Many are more comfortable with the predictability of a Medicare Supplement, while others want to take the gamble of a Medicare Advantage plan. If you are very healthy and are comfortable with the potential risk of out-of-pocket costs, you may also be a great for the Medicare Medical Savings Account.
In any case, risk profile is one of the most important factors to consider if you want to look into Medicare Advantage plans.
What’s right for you?
At this point, you might have a clear understanding of whether or not a Medicare Advantage plan is right for you. If you’re interested, don’t hesitate to give us a call at 217-423-8000.
If you’re still unsure and want to consult with an agent, that’s what we are here for! Please give us a call or schedule an appointment using our online system!
Finally, if you think you’re better suited for a Medicare Supplement or a Medicare Medical Savings Account, we can help with that, too.
Don’t wait to reach out to us – we love helping people save time, money, and hassle.
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