Choosing a Medicare plan can be confusing, but help is available.
“The criteria seniors should look at depends on the plan they choose,” says Jason Stubbs, principal agent/owner of Oregon Insurance Company in Springfield. “If it’s a Medicare Advantage plan, then they need to look at network and benefits, not so much the cost. If it’s a Medigap plan, the lowest premium is better.”
Medigap is a secondary insurance to Original Medicare, and subscribers only must know if the health provider accepts Original Medicare, Stubbs says.
“Medigap plans are standardized so the coverage for Plan F is the same with all carriers,” he adds.
Medicare Advantage plans directly bill health providers, who are subsidized by Medicare monthly. Subscribers must use doctors within the plan’s network, and only medically-necessary health visits and procedures are covered.
“Medicare Advantage plans can opt to cover vision, dental and alternative care, but coverage is plan-specific,” Stubbs says.
Seniors turning 65 can get a comprehensive plan around $170 a month that will pay all their medical expenses with limited copays for medications, Stubbs says.
“Or they can get one for $0 with a cost share in the form of a copay or co-insurance when they use the plan,” he says. “If they had individual coverage and not Medicare, they would pay over $1,000 for a $2,500 deductible plan where they pay 30 percent of the bill.”
Michael Bredimus, owner of Bredimus Insurance Agency in Salem, says that Medicare Advantage plans, also called Medicare Part C, can include prescription drug coverage as well as other options. Seniors with end-stage renal disease generally do not qualify for this type of plan, he says.
His list of key factors in choosing a plan include: deductibles; monthly premiums; anticipated costs of routine health care and hospital services; restrictions on doctors, hospitals and pharmacies; expected costs of prescription drugs used regularly; and maximum out-of-pocket amounts.
“In Marion/Polk counties, 15 Medicare Advantage plans are available,” Bredimus says. “Costs range from $0 premium to $209 per month. There are 21 companies that sell Medigap plans, and premiums are based on age, so it’s not easy to give a generic rate.”
Medigap plans are categorized by letter — A, B, C, D, F, G, K, L, M and N — and plans of the same letter offer the same benefits, Bredimus says.
“However, insurance companies can offer plans at different prices,” he says. “Therefore, you may have different out-of-pocket costs, even if the standardized plan benefits are the same. These plans do not provide prescription drug coverage. This means that you will have to enroll in a stand-alone Medicare Prescription Drug Plan for medication coverage.”
Medigap plans help with deductibles and other expenses not paid by Original Medicare, but don’t cover services not covered by Original Medicare, Bredimus says.
“For example, they do not cover long-term care, dental care or eyeglasses,” he says. Both options, he adds, “limit the amount that a senior would pay in the event of a major surgery or hospitalization.”
Seniors may opt for a Preferred Provider Organization, a type of managed care health insurance plan that provides maximum benefits if visits are to an in-network physician or provider. A PPO, such as Providence, still provides some coverage for out-of-network providers.
Seniors may also choose a health maintenance organization, or HMO, such as Kaiser Permanente. Jody Meyer, the manager in Medicare sales for Kaiser Permanente, says seniors should consider what is most important to them when looking at options. Considerations include:
■ The ability to choose your doctor, and whether all doctors and specialists accept Medicare patients.
■ Predictable and easy to understand out-of-pocket costs, including deductibles and copays.
■ Extra coverage for fitness, dental, vision and hearing benefits.
■ How coordinated and convenient is the care you receive? Are many services under one roof, which lowers costs and adds convenience?
“There are many Medicare Advantage plans in the market and premium ranges will vary,” Meyer says. “There are also considerations regarding prescription coverage. An easy way to review the number of plans and compare premiums is to visit the Medicare.gov plan finder.”
Meyer says Medicare Advantage plans — health care options that are approved by and contracted with Medicare — must provide benefits that are as good as or better than Original Medicare.
“Medicare Advantage plans must cover all the services Medicare covers, including emergency and urgent care services,” Meyer says. “Originally, Medicare was not designed to pay for all medical services and has no maximum out-of-pocket protection. Medicare Advantage plans generally offer enhanced, more predictable coverage with out-of-pocket protection.”
Meyer says Kaiser Permanente offers Medicare Advantage plans that “focus on high quality care, including choice of physicians, preventative care and coordination of team-based care through one organization. You can often see your doctor, visit a lab, and pick up prescriptions, all in one trip.”
“We have convenient online services to help you manage your health, and we offer phone, video or in-person appointments,” she continues. “We also have convenient urgent care locations, coverage when traveling, and the option to add dental, vision and hearing benefits.”
Because of eligibility rules and the contract with Medicare, all beneficiaries on these plans must have Part A and Part B Medicare and continue to pay their Part B premium to remain on the Medicare Advantage plan they choose, Meyer says.
“There are lots of options available, and we’re here to assist with questions,” she says.
Bredimus offers Medicare Advantage plans and Medigap plans, the most popular plans his agency offers, from a variety of insurance companies including HealthNet, Atrio, Moda, United Healthcare and Providence.
“It is best to work with someone who is contracted with multiple companies as opposed to someone who can only assist you with one product or company,” Bredimus says. “I believe it is also important to work with someone local who is educated on our local networks and how that relates to access to care. For example, in our area many people will pay more for a plan if it grants them access to OHSU. If a senior were working with a 1-800 agent, they might not be aware of this.”
Bredimus offers to assist seniors with choosing and purchasing one of the many plans available in the area.
“Helping seniors find the plan that best meets their needs is our highest honor,” says Bredimus, who can be reached by calling 503-540-0042.
Serving Linn-Benton and Lane counties, Stubbs is an independent broker whose most popular plans include: Regence Blue Cross, United Health Care, Mutual of Omaha, ANTEX, Providence and Health Net. He can be reached at 541-538-2700.
For seniors who are computer savvy, online options are available for finding more information, choosing and purchasing an insurance plan. Start with Medicare.gov.