Medicare Beneficiaries Can Pick From More Than 30 Advantage Plans. How to Get It Right

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  • Generally speaking, the lower the plan's premium, the more you'll pay in cost-sharing.
  • Of the plans that include prescription drug coverage, more than half (54%) charge no premium.
  • One thing that can catch enrollees by surprise is the cost of hospitalization under an Advantage Plan.

There's a chance that if you're enrolled in Medicare, an Advantage Plan is on your radar as a supplemental coverage option.

While these plans continue growing in popularity and availability, there are some things to watch for.

And whether you're mulling over switching to another plan or adding one to original Medicare (Part A hospital coverage and Part B outpatient care), now is the time to take action. The program's annual open enrollment period, currently underway, ends Dec. 7. 

"The benefits change from year to year in Advantage Plans, and what's covered can change, especially with prescription drugs," said Jeannie Fuglesten Biniek, senior policy analyst for the Medicare policy program at the Kaiser Family Foundation. 

Source: Kaiser Family Foundation

Roughly 62.8 million individuals are enrolled in Medicare, the majority are age 65 or older, according to the Centers for Medicare & Medicaid Services. The remainder are younger with disabilities or individuals with end-stage renal disease.

About a third choose to get their benefits delivered through Advantage Plans, which are offered by private insurers and typically include Part D prescription drug coverage. The remainder stick with original Medicare (Parts A and B). Those beneficiaries often pair that with a stand-alone Part D plan and a Medicare supplemental plan (aka Medigap), both of which also are offered by private insurance companies.

For 2021, the average beneficiary has access to 33 Advantage Plans, Kaiser research shows. Altogether, 3,550 such plans will be available, up 13% from this year.

In addition to prescription drug coverage, many plans offer benefits unavailable through original Medicare, including dental, vision, hearing and even fitness programs. Telehealth services also are more broadly available, a trend brought on by the coronavirus pandemic.

In rural areas, availability of Advantage Plans tends to be more limited. And in 82 counties in the U.S., none is available.

The average beneficiary can choose from plans offered by eight insurers in 2021. Enrollment is concentrated in those operated by UnitedHealthcare, Humana and Blue Cross Blue Shield affiliates, according to Kaiser.

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Of the plans that include prescription drug coverage, more than half (54%) charge no premium, and 96% of beneficiaries will have access to one of them in 2021, according to Kaiser.

"That's definitely not the only thing to look at," said Fuglesten Biniek. "There are financial and nonfinancial aspects of the plan to consider."

For example, you likely will have to see a doctor or other provider in the plan's network. This means if you have a health crisis, you might not have coverage for seeing the specialist you want.

Advantage Plans also come with out-of-pocket maximums (unlike original Medicare), which can be as high as $7,550 in 2021 for in-network coverage before the plan pays 100% of covered services. The combined in- and out-of-network maximum is $11,300.

Also keep in mind that, generally speaking, the lower the premium, the more you'll pay in cost-sharing. And the specifics of that — whether out-of-pocket limit, deductibles, copays or coinsurance — differ from plan to plan.

"Depending on the services you use, your financial exposure could vary under different plans," Fuglesten Biniek said.

 And regardless of whether there's a premium, you still would be responsible for the Part B premium (the standard 2021 amount is $148.50 per month).

Some plans may allow you to see providers across the country, while others limit that to emergency-only coverage if you're outside of your coverage area.

"If you travel, you want to find a plan that will travel with you," said Elizabeth Gavino, founder of Lewin & Gavino and an independent broker and general agent for Medicare plans.

One 2021 change worth noting is that people with end-stage renal disease can enroll in Advantage Plans. Before, that was largely off the table.

An aspect of coverage that can catch people by surprise is the hospitalization cost under an Advantage Plan, experts say. While original Medicare comes with a Part A deductible ($1,484 for 2021) when you're admitted to the hospital, there are no copays for the first 60 days of that inpatient care. In contrast, Advantage Plans often have a daily copay, which can result in a higher cost.

For a hospital stay of five days or more, at least half of Advantage enrollees would pay more than beneficiaries who have original Medicare, Kaiser research shows.

The good news is that if you enroll in an Advantage Plan during fall enrollment and realize afterward that it's not a good fit, you can change your coverage between Jan. 1 and March 31. You'll be able to switch to either another Advantage Plan or drop it in favor of original Medicare.

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