Medicare Enrollment Part 2: Before you select a plan, ask yourself these questions

Oct 27, 2023

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By Brian Barta, CPA, William Newton Hospital CEO

In my last article, I discussed the different Medicare health plans available during open enrollment. Now through December 7, seniors can make health plan elections for 2024 coverage. William Newton Hospital (WNH) finds Original Medicare works very well for our patients, but we understand you may want to consider other coverage options. I’d like to continue sharing information WNH finds helpful when choosing a health plan.

I mentioned in Part 1 that William Newton Hospital will no longer be a contracting (in-network) provider for any Medicare Advantage plans in 2024. This is due to numerous issues our patients have experienced when dealing with Medicare Advantage plans.

At first glance, it’s easy to see the appeal of Medicare Advantage. Original Medicare includes Part A, for in-patient hospital and skilled nursing care, and Part B, for doctor services. These plans typically cost about $165 a month (with the cost deducted from your social security check). Many people pay extra for Medigap, to cover copays and other out-of-pocket costs, as well as a Part D plan for drugs. Medicare Advantage plans (Part C), provide the benefits of Part A, B, and often D, usually for about the same amount, with lower copays, so there’s no need for Medigap. Some Medicare Advantage plans offer benefits not in Original Medicare, such as fitness classes or vision and dental care. This often sounds good – but review the details closely. Choosing between the two requires careful consideration of your finances and health needs.

Medicare Advantage plans can carry hidden risks, especially for people with major health issues. Some people in Medicare Advantage may end up paying unexpectedly high costs when they become ill or find their network lacks the providers they need. Non-contracted Medicare Advantage plans are required by law to reimburse William Newton Hospital as a non-contracted (out-of-network) provider for emergency care. However, if a Medicare Advantage enrollee elects to receive other non-emergent services at William Newton Hospital, then the enrollee would be responsible for paying at the standard Medicare rates. Some Medicare Advantage plans will reimburse the enrollee for a portion of the amount paid. Still, it would be the enrollee’s responsibility to know their plan coverage and the necessary reimbursement steps. A recent Kaiser study found about half of all Medicare Advantage enrollees would end up paying more than those in Original Medicare for a seven-day hospital stay. Medicare Advantage plans may be especially problematic for people in rural areas. A 2021 study found that rural Medicare Advantage plan enrollees were nearly twice as likely to switch back to Original Medicare as those in urban areas.

Ask yourself these questions when choosing a plan:

Is my hospital, clinic, AND physician in-network?

Providers often bill for services differently. Just because your doctor is in-network, doesn’t mean all services you receive at that facility are in-network. The hospital itself accepts all insurances, but higher out-of-pocket costs may result when not in-network. WNH rural health clinics (including Health Professionals of Winfield, Hillside Family Medicine, Cedar Vale, Dexter, Moline, and Sedan) DO NOT accept Medicare Advantage HMO plans. All WNH facilities, providers, and clinics accept Original Medicare. Make sure the individual healthcare providers you know and trust are in the network you are considering.

Am I enrolling in a supplement or replacement?

There is confusion surrounding different types of Medicare plans. If you’re looking for a supplement plan (Part D), make sure you are not enrolling in a replacement plan (Part C). Medicare Advantage plans (Part C) cancel and replace Original Medicare.

More questions to consider:

• Do I qualify for payment assistance or have access to other coverage such as Medicare Savings Programs, Part D Low Income Subsidy, or Medigap plans?
• Am I comfortable with my care choices being directed by my insurance company over the advice of my physician? How do I feel about a Medicare Advantage plan challenging my physician’s determination that the care I need is reasonable and necessary?
• Do I travel outside my general home area?
• What medications do I take?
• How important are limits on my annual maximum out-of-pocket costs?
• What is the value of coverage for dental, hearing, and health club memberships?
• What is the value of staying with Original Medicare knowing the services they cover versus annual monitoring for changes to networks and coverage requirements?
• Will I be more likely to seek medical care if it is:
  • Easily accessible and almost all physicians and facilities are available?
  • Convenient and coverage is available for care in most geographic areas?
  • Lower cost?

Call the insurance company directly and ask questions:

• If need to see an out-of-network physician, will the plan cover my visits? Will I pay more out-of-pocket for an out-of-network provider or facility?
• What is the service area for this insurance plan, and how far may I need to travel to find an in-network specialist or facility for specialized care?
• Does my physician need approval from the plan to admit me to a hospital?
• Do I need approval from my physician to see a specialist?
• Are there higher copays and deductibles for certain types of care, such as hospital stays, home health care, or rehabilitation care?
• Does the plan cover any services that Original Medicare does not? Are there rules, policies, or restrictions that I need to be aware of before accessing these benefits?
• Does the plan impose any coverage restrictions on prescription drugs? Can we go through my current prescriptions to determine if they are on the insurance plan’s formulary?
• How much will I have to pay for brand-name drugs?
• Will I be able to use my local pharmacy?
• Will the insurance plan cover me when I travel out of state?
• Does the plan cover skilled nursing care after hospitalization, and what rules, policies, or restrictions should I be aware of?

If you are already enrolled in Medicare Advantage and would like to switch plans, there's an annual window: January 1 to March 31. During this period, you’re allowed to do one of these things if you’re in a Medicare Advantage plan:

• Switch to another Medicare Advantage plan
• Drop it and go back to Original Medicare, and join a Medicare drug plan (also known as Medigap)

If you need assistance evaluating your options, help is available locally. Schedule a free session through your local Council on Aging to visit with a certified Senior Health Insurance Counseling for Kansas (SHICK) health counselor.

Editorial Notes: This article was submitted for the "Weekend Check-Up," a regular health column in the Cowley CourierTraveler penned by employees and friends of William Newton Hospital, and is part two of a two-part series. Brian Barta has been serving as CEO at William Newton Hospital since 2022. Prior to being named CEO, he was WNH’s Chief Financial Officer and controller at another Kansas critical access hospital. As a certified public accountant and former financial auditor of hospitals around the state, Barta is an expert world of healthcare finance.