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November 1 2016

Medicare Advantage health care plans offer benefits plus supplemental coverage for seniors

By Kathleen Nonnamaker

There really is no time like the present — literally speaking. This is the time for Medicare Advantage open enrollment, and from now through December 7, Americans who have or are eligible for Medicare coverage can choose a Medicare Advantage plan instead of traditional Medicare, or they may switch from one Medicare Advantage plan to another.

Medicare Advantage plans cover deductibles, co-payments and prescriptions, and add additional benefits such as vision and dental care in one health insurance plan. Instead of being covered by Medicare and also buying a Medicare Part D prescription drug plan as well as Medicare supplemental insurance for these expenses, those eligible for Medicare can elect to purchase a Medicare Advantage plan and have all of their health insurance needs covered by one plan.

Medicare Advantage plans are private plans that have been approved by the U.S. Centers for Medicare & Medicaid Services (CMS) to offer Medicare-type comprehensive health care coverage for seniors as an alternative to Medicare.

Medicare Advantage plan premiums can start as low as $0 per month and offer comprehensive benefit coverage for medical care and prescriptions. The plans may offer no or low-cost co-pays, routine hearing and eye exams, preventive dental care, urgent and emergency care coverage, prescription drug benefits, and even extras such as discounts on gym memberships, depending on the plan.

People who are deciding whether to purchase a Medicare Advantage plan instead of using traditional Medicare need to think carefully about their options in relation to their current and future health care needs. The Wisconsin Office of the Commissioner of Insurance recommends that anyone who is considering opting for a Medicare Advantage plan thoroughly review the plan’s 1) summary of benefits, 2) provider directory, 3) prior authorization rules for seeking care from a non-network provider, 4) governance and appeal procedures, and 5) patient confidentiality procedures. This information must be provided in writing by the plan.

A Medicare Advantage plan may offer financial advantages over the costs of paying for both Medicare Part D and Medicare supplement expenses. Medicare Advantage plans can cost significantly less than some Medicare supplement plans and you only have to keep up with one form of coverage instead of three.

The basic coverage cost should not be the only factor in your choice between Medicare and a Medicare Advantage plan. In addition to becoming familiar with the details of your supplemental insurance options, you need to understand several aspects of Medicare Advantage plans before proceeding.

Medicare Advantage plans cover everything that traditional Medicare plans cover; the out-of-pocket costs and health care provider options are different. As a potential enrollee you need to determine your anticipated costs such as co-payments for doctor’s visits and hospital stays; prescription drug needs and benefits; deductibles; and whether you can use out-of-network providers and at what cost.

A Medicare Advantage plan is designed to provide lower costs within a health care network and from specified providers. For example, a health maintenance organization (HMO) plan requires participants to use a defined list of health care providers within a local network. You need to know which providers and hospitals are within your Medicare Advantage network and verify that your plan covers out-of-network care in the case of an emergency.

If your health care needs change and you would like to opt out of your Medicare Advantage plan, re-enroll in Medicare and buy Medigap insurance, you may be unable to do so because of a preexisting health condition. Private insurers can consider preexisting conditions when determining supplemental Medicare coverage and costs. Therefore, if your health care needs change, you may not be able to buy a Medigap plan. And, even if you are eligible for a Medigap plan, the cost may be prohibitive, depending on your age and health factors. You may decide that you have to stay with a Medicare Advantage plan.

Choosing Medicare Advantage is a lasting decision for most people. However, you may switch to traditional Medicare, including adding Part D for prescription drugs, from October 15 to December 7 of each year. If you move outside of the area, or in other select situations, you may switch to a different Medicare Advantage plan outside of the annual open enrollment period.

While there are many financial advantages to a Medicare Advantage plan, it is vital that you consider all of your current and anticipated health care needs and your financial situation alongside plan options.

As an account executive for ProHealth Senior Preferred (HMO), Kathleen Nonnamaker serves as a general resource for the Medicare Advantage plan. She meets with prospective enrollees to answer questions and help them understand benefit options. She can be reached at Kathleen.Nonnamaker@phci.org.

More information about Medicare and Medicare Advantage plans is available at Medicare.gov and DHS.Wisconsin.gov/Guide/Medicare.htm.

Gundersen Health Plan and ProHealth Solutions, ProHealth Care’s accountable care organization, are offering Medicare enrollees in Waukesha County a new health insurance option for coverage beginning Jan. 1, 2017. ProHealth Senior Preferred (HMO) provides comprehensive coverage and a variety of pricing options. You can learn more by visiting SeniorPreferred.org/ProHealth or calling 800-591-4004.

Eight essential questions about Medicare Advantage plans

The Wisconsin Office of the Commissioner of Insurance recommends that people who may wish to purchase a Medicare Advantage plan answer the following questions*:

  1. What providers are available to you?

  2. Will the plan allow you to see the providers you want?

  3. Are there any additional benefits that may be offered and is there an additional charge for these benefits?

  4. What are the benefits that are excluded but would be covered under a Medicare supplement policy?

  5. What is the total cost to you, including premiums, coinsurance, copayments, deductibles or other out-of-pocket expenses?

  6. How often and by how much can the plan raise your premiums?

  7. If you have a specific health condition, is one type of plan better suited to provide the benefits you need?

  8. Will the plan coordinate with your current employment-sponsored or union plan?

* “Medicare Advantage in Wisconsin,” State of Wisconsin, Office of the Commissioner of Insurance, Sept. 2014. https://oci.wi.gov/Documents/Consumers/PI-099.pdf


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For more than a century, ProHealth Care has been the health care leader in Waukesha County and surrounding areas, providing outstanding care across a full spectrum of services. The people of ProHealth Care strive to continuously improve the health and well-being of the community by combining skill, compassion and innovation. The ProHealth family includes ProHealth Waukesha Memorial Hospital, ProHealth Oconomowoc Memorial Hospital, ProHealth Rehabilitation Hospital of Wisconsin, ProHealth Medical Group, the UW Cancer Center at ProHealth Care, Moreland Surgery Center, ProHealth AngelsGrace Hospice, ProHealth Home Care, ProHealth West Wood Health & Fitness Center and ProHealth Regency Senior Communities. Learn more at ProHealthCare.org.