Pandemic throws wrinkles into Medicare Advantage planning

Oct. 22--This can be a tricky time of year for the 44 million Americans who depend on Medicare to cover all or part of their health care costs.

Choosing the right coverage plan requires those who apply to consider their overall health, the medications they use and, this year, how carefully they plan to protect themselves from the novel coronavirus.

All can influence the cost of care for those 65 and older, as well as others on the massive federal program -- particularly those with chronic health conditions.

"Coverage varies from plan to plan and, unfortunately, a lot of people who get Covid-19 are on Medicare," said Bill Daniels, coordinator of insurance outreach and counseling with the Erie County Department of Senior Services.

Those eligible for Medicare -- which includes almost 3 million Americans with disabilities -- can apply to the program any time. Daniels, however, fields more questions this time of year as the window opens for people who might want to choose a new Medicare Advantage plan or Medicare Part D standalone prescription drug coverage.

Private insurers who offer these federally funded plans already have started to advertise and send mailings during the application period, which started last week and runs through Dec. 7. Plans go into effect at the start of the new year.

Older Americans aren't required to buy prescription drug coverage -- "but people who do sleep better," Daniels said.

They can do so through a standalone plan -- there are 28 to choose from in Erie County -- or through Medicare Advantage, which also provides other Medicare services; 48 of those plans are available to county residents. Many of these plans are available in other regional counties, too.

It takes time, effort and a reality check to choose well. Otherwise, you risk a combined health and financial crisis.

Here is what you need to know if you are applying for these Medicare benefits.

Medicare changes

The federal government has raised the maximum office visit and hospital out-of-pocket costs enrollees have to pay to $7,550 for next year before copays (Medicare parts A and B).

Part B premium deductibles also are climbing to a projected $153.30 per month, compared to $144.60 this year.

Better news? For the first time, all Medicare insurers must cover those with end-stage renal disease. Medicare patients will pay less for insulin and receive up to 12 acupuncture treatments for lower back pain. And the pandemic came with at least one silver lining. The Centers for Medicare and Medicaid Services (CMS) has made it easier for hospital patients to get into a nursing home -- whether for rehabilitation or longer-term stay -- by waiving a three-day prior hospitalization rule.

Part C and D coverage varies

Medicare Advantage plans fall into three types.

A Health Maintenance Organization plan (MA-HMO, the most popular in the region) tends to be the most restrictive and least-expensive form of coverage, Daniels said. You must see a doctor in the plan's network except for emergency care and may find you need preauthorization for medical procedures and other care. Providers also can drop you as a patient if you fail to follow treatment protocols, say by not taking medications as directed.

A Preferred Provider Organization (PPO) "is a nice model, in that the doctors are not restricted as much by the influence of the insurance company," Daniels said, though these plans can cost more.

Private Fee For Service (PFFS) plans are traditional Medicare plans that generally cost more and provide those who choose them greater latitude to choose doctors and get better out-of-region health cost reimbursements.

Individual health needs, avoiding crippling debt should a health emergency strike and financial security should dictate choices.

"Usually, if it's a higher premium, it's lower copays," Daniels said. "You've got to watch the copays."

Ratings count

The ratings scale runs from 1 to a high of 5 -- and Medicare gives more money to private insurance plans that rate higher by performing better on screenings, managing chronic health conditions and other quality clinical outcomes, as well as the experience, pro and con, of its members.

Many insurers provide extra incentives that can beef up those ratings, including partial coverage for dental care, hearing aids and eyeglasses. Many also offer a free fitness club membership, Daniels said, "because healthier people have a tendency of exercising."

The three largest regional insurers offer many of the most highly rated options.

A 4-star rated $0 premium HMO plan from BlueCross BlueShield of Western New York has been the insurer's fastest growing plan in the region three years running, said Andrew Napierala, company sales manager for Medicare.

Three PPO plans offered by the largest insurer in the region tout 5-star ratings, including a new $25 Freedom Nation PPO plan for next year that features robust in-region and extended out-of-network access through the national BlueCard network designed to work best for those who travel extensively, live part of the year elsewhere or visit providers in nearby Pennsylvania.

"I had not seen a 5-star Medicare Advantage in this area in many years," Daniels said.

Independent Health is the Medicare Advantage leader in the region with 66,000 members, spokesman Frank Sava said, and its most popular plans are Encompass 65 Core HMO ($65 a month) and Encompass 65 Element HMO ($0 for next year).

More than 17,000 people in the region enjoy the two most popular Medicare Advantage options Univera Healthcare provides: Senior Choice Basic, at $0 premium, and the $33Univera Senior Choice Advanced, spokesman Peter Kates said. Both plans come with $0 copays on preferred generic drugs, $0 copays on vaccines including flu and shingles, and preventive dental.

All those plans are rated at 4.5 stars or higher.

Highly rated plans from national insurers in the region include three MVP plans with 4.5-star ratings and two MVP, three Aetna and four UnitedHealthcare plans rated at 4 stars.

Fidelis Medicare has three plans too new to be rated.

Prescription drugs are key

"The weak point with the Medicare Advantage plans is the high cost of meds," Daniels said. "For a lot of them, it's a 20% co-insurance and you're talking thousands and thousands of dollars" if you come down with cancer or another condition that becomes expensive to treat.

Prescription drugs account for nearly 30% of health costs in Medicare programs. Insurers who run Advantage plans often annually change copays for the generic and brand name medications covered, Daniels said, as well as in some cases which medications they will cover at all. Some plans also require members to try a certain drug for a specific ailment before agreeing to pay for a preferred drug that treats the same condition but is more expensive.

This is why it's so important for those who plan to keep the same prescription drug plan or Medicare Advantage plan in the coming year find out what changes will be made -- particularly ones that could impact the drugs they use and health care providers they visit.

Do the math

You can stay on the same Medicare plan each year as long as the same plan remains available.

Medicare Advantage plan premium costs, deductibles, co-insurance and copays -- including for drugs you may take, and which doctor and hospital services are covered -- also might change every year, so you have to pay attention.

"Most people are pretty comfortable with the plan they have," Daniels said, "but should they just assume that things are gonna go along just as they have? No, no, no, no."

Last week, for example, Daniels said he helped someone diagnosed with a skin problem that required regular treatments that cost $5,600. His initial drug coverage limited copays to $47 but that changed partway through this year and now stands at 25% of the retail cost, or $1,400.

"That's why doing the math and paying attention to the fine details are important," Daniels said.

Help is available

Daniels has run the Erie County insurance outreach and counseling program since 1995. As many as 20 part-time staffers and volunteers help him during the busy season.

Call his office at 858-7883 to arrange an online or phone informational meeting. You also can compare different plans yourself at medicare.gov.

Some insurance company advisers have quotas to meet, Daniels said, "but we have no incentive to push anything. We're taxpayer supported and give you an unbiased comparison between all the plans. It's a government service."

He stressed that those who file for changes save a copy of the completed application and check for a confirmation email or letter from CMS to confirm the process was successfully completed.

email: sscanlon@buffnews.com

Twitter: @BNrefresh, @ScottBScanlon

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