Time to evaluate Medicare Advantage plans

Two years ago, Ruth Collins found herself in a quandary. The primary-care doctor she’d been seeing for 17 years was not covered by her Medicare Advantage plan, a private Medicare plan. Instead, her health insurer tried to send her to other physicians and the insurers wouldn’t accept some charges by the provider.

Medicare: An article in the Nov. 29 Health section on Medicare Advantage plans said that enrollees who wanted to shift back to original Medicare during open enrollment (Jan. 1 to Feb. 14) would not be guaranteed enrollment in a Medicare Part D plan, which provides drug benefits. Enrollees who drop a Medicare Advantage plan can enroll in original Medicare with a Part D plan during open enrollment. The article also said that the Health Assistance Partnership works with state programs on Medicare education. That group no longer performs this duty. Instead, individuals can directly contact their State Health Insurance Assistance Program (SHIP) office. —

Luckily, there were other options for Collins. She switched to a different Medicare Advantage plan and can now see her doctor in San Bernardino, where she lives. She’s happy with the change and has decided to stick with the same plan next year.

Happy or not, Medicare Advantage enrollees should make a habit of evaluating their options each year. Though experts say that beneficiaries won’t be seeing a lot of changes this time — and what changes there are will mostly be for the better — it is a good idea for people to go through this annual drill before enrollment ends Dec. 31, just to make sure their plan choice remains a good one.

Private health plans have been available in Medicare since the 1970s. Their popularity has grown in recent years, more than doubling nationwide (from 5.3 million to 11.1 million) between 2005 and 2010, according to the Kaiser Family Foundation, a nonprofit health policy organization.

In California, approximately 35% of Medicare enrollees are in these plans.


These so-called Medicare Advantage plans provide benefits through insurance companies. They offer preferred provider organizations, health maintenance organizations and private, fee-for-service options. The plans are funded by Medicare and enrollees pay small premiums, averaging about $50 per month. They’re preferred by many because they often are more robust than original Medicare, offering features such as coverage for dental and eye care.

Medicare Advantage has garnered a lot of media attention this year, much of it negative, because of rising premiums as well as insurance companies that allegedly misled consumers about providers that enrollees can access in their networks and medications that are covered in the plans.

And in October, Kaiser estimated that, nationwide, 13% of all Medicare Advantage plans would be leaving the market, leaving fewer options for enrollees. There are two reasons for this, says Cheryl Matheis, director of state affairs for AARP. The first is just business: Insurers drop from the market all the time. The second are rules that the Center for Medicare & Medicaid Services has created to make sure that all plans have an adequate number of physicians for enrollees. Those that didn’t were discontinued.

Consider your needs

Despite bad press and shrinking options, consumers should consider their own situation when deciding whether to stay in, or enroll in, a new Medicare Advantage plan, said Peter Ashkenaz, a spokesperson for the Centers for Medicare & Medicaid Services: For some people, they can be a good deal. “Each beneficiary needs to look at their own options,” Ashkenaz says. “What they are going to find … is that there is still going to be a wide range of plans.”

Will that remain the case? Beginning in 2012, Medicare will begin lowering payment to Medicare Advantage providers to even the playing field between original Medicare and Advantage plans. But plans generally aren’t leaving because of healthcare reform, experts say. The Centers for Medicare & Medicaid Services is offering bonuses to plans that perform well, which should soften the cuts and keep good providers in the marketplace.

Some facts and deadlines you should be aware of:

Anyone enrolled in plans that are terminating should have received notice by mail by Oct. 1. If these beneficiaries don’t enroll in another plan, they will be automatically switched to original Medicare.


Beneficiaries who want to drop a Medicare Advantage plan and move to original Medicare have an extended time to do so — from Jan. 1 through Feb. 14. But there’s a potential problem: Original Medicare doesn’t offer drug coverage. There is no guarantee someone would be able to pick up Part D (drug coverage for Medicare) if they drop their Medicare Advantage plans, Matheis cautions.

All plans must begin covering preventive services at 100% in 2011. Many Medicare Advantage plans already do this, but there should be no deductible (meaning the portion of charges not covered by the insurance company) for enrollees getting services such as mammograms or physicals.

Changes to plans

Out-of-pocket maximums will be added next year, another protection for enrollees. Beneficiaries will not have to pay more than $6,700 on health expenses over the course of the year, says Elaine Wong Eakin, executive director of California Health Advocates, a nonprofit Medicare Advocacy organization.


Need help finding the right Medicare Advantage plan? In Collins’ case, she found a plan that fit her needs by working with her physician’s office, which has specialists who assist people in choosing and enrolling in Medicare Advantage programs. Though most doctors’ offices don’t provide this kind of service, there are a number of other ways to get help.

The first place to go is to the Centers for Medicare & Medicaid Services’ website: Use a plan-finder tool you’ll find there to help narrow options (


.aspx). Ashkenaz says people shouldn’t base their decision strictly on the premiums they will have to pay, but on their overall healthcare needs.


Hovannes Daniels, director of senior business for Blue Shield of California, says there are five things people should consider when looking for a plan.

First, make sure your doctor is in the provider network. Second, make sure the hospitals that are covered are ones that are convenient. Third, make sure your prescriptions are covered under the plan, especially if you take sustaining drugs for a chronic disease. Fourth, consider what your out-of-pocket costs will be. And fifth, go with a trusted insurance provider — one that has been in the market for a long time or that comes well recommended.

In addition to the Centers for Medicare & Medicaid Services site, insurers such as Blue Shield offer seminars on selecting a plan. Find out more by contacting the insurance company.

Those who don’t have Internet access or a family member who can assist them can call organizations such as California Health Advocates (800) 434-0222, which provide Medicare counselors. Another resource is Health Assistance Partnership, a Washington, D.C.-based organization that works with state health programs on Medicare education. It can be reached at (202) 737-6340.


Finally, to underscore: Even if you intend to make no changes in your Medicare Advantage plan, Wong Eakin said it’s good practice to reexamine your options each year — because plans can be tweaked annually, including changes to premiums, drug benefits or providers included in the network.