ProHealth Senior Preferred (HMO) will hold a free informational seminar about its Medicare Advantage plan from 4:30 to 5:30 p.m. on May 17 in Waukesha. Call 800-394-5566 (TTY/TDD 711) for more information.
By Kathleen Nonnamaker
Why do Medicare Advantage health plans remain so popular? The reasons are many.
Medicare Advantage Plans, sometimes called "Part C" or "MA Plans," are offered by private companies approved by Medicare. When seniors join a Medicare Advantage plan they still have Medicare. They will receive their Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) coverage from the Medicare Advantage plan, not original Medicare.
Most Medicare Advantage plans also offer extra coverage such as vision, hearing and dental coverage. Seniors can choose a plan in place of combining Medicare, Medicare Part D for prescription drug coverage and Medicare supplemental insurance. Under the plans, deductibles, co-payments, prescriptions and vision and dental care options are provided in one package.
The U.S. Center for Medicare & Medicaid Services (CMS) has approved more than 3,100 Medicare Advantage plans, allowing eligible seniors to compare plans offered locally. To help people choose the best plan for them, CMS rates plan quality and performance every year.
The ratings are based on member satisfaction surveys and information provided by the plans and health care providers. CMS awards each plan one to five stars, with five-star plans providing the highest level of benefits and service. The ratings can be found at Medicare.gov/find-a-plan.
In 2018, only four percent of the available plans earned five stars. Seniors in Waukesha County have access to plans from Senior Preferred (HMO), an organization that has consistently received five-out-of-five stars. Senior Preferred (HMO) offers three plans with access to ProHealth Care physicians, clinics and hospitals. These options are the result of a partnership between Gundersen Health Plan and ProHealth Solutions, ProHealth Care’s accountable care organization.
Know your options
Along with coverage for high-quality local health care, the hybrid Medicare Advantage plans offer a variety of pricing options, with low monthly premiums (starting at $0 and often costing less than $30 a month), no or low-cost copays and additional coverage choices.
Individuals can select a plan that fits their health, lifestyle and pocketbook. With Medicare Advantage and Medicare, coverage can include everything from medical, hearing and eye exams; preventive dental care; urgent care; emergency care; hospitalization and prescription drugs, to extras such as discounts on health & fitness center memberships. Premiums, deductibles and out-of-pocket costs match the plan choices.
People who are looking to choose a Medicare Advantage plan need to learn how the plans work and the specifics of the individual plans they are researching. Some of the plans periodically offer free presentations where attendees can ask questions of plan experts.
Each Medicare Advantage plan is designed to provide lower costs within a health care network and from specified providers. For example, a health maintenance organization plan (HMO) requires participants to use a defined list of health care providers in a local network. Seniors should learn which providers and hospitals are within the network and verify whether the plan covers out-of-network care in the event of an emergency.
Seniors need to weigh their Medicare options carefully, especially if they think their health status might change. In some cases, individuals with pre-existing conditions who want to leave a Medicare Advantage plan for Medicare may not be able to get Medicare’s Medigap supplemental insurance.
Switching to another Medicare Advantage plan or back to traditional Medicare is generally only allowed during open enrollment which runs from Oct. 15 through Dec. 7. However, Medicare Advantage plans with five-star ratings, like the ProHealth Senior Preferred (HMO) plans, can enroll new members at any time throughout the year.
Do your homework
It is important for seniors to take time to understand what each plan offers and to consider the costs and benefits before making a plan selection. Medicare Advantage plans offer a number of options, and most people who enroll in one remain with it for the long term.
Potential enrollees need to estimate their own anticipated costs such as co-payments for doctor’s visits and hospital stays; prescription drug needs and benefits; deductibles; and whether the plan allows them to use an out-of-network provider and at what cost. Before making a decision, they should understand total plan costs, including premiums, coinsurance, co-payments, deductibles and out-of-pocket expenses. If they have a plan through an employer or union they also need to factor in the other plan’s coverage.
Seniors will also want to review the plan’s summary of benefits, list of network providers, prior authorization rules for out-of-network care, confidentiality policies and its appeal process. Resources about making Medicare choices can be found at Medicare.gov and DHS.Wisconsin.gov/Medicare.htm.
Kathleen Nonnamaker, ProHealth Senior Preferred marketing representative, works with seniors throughout Waukesha County to help them better understand the benefits of Medicare Advantage plans and the options available through the ProHealth Senior Preferred (HMO) plans. To learn more visit SeniorPreferred.org/ProHealth or call 800-394-5566 or TTY/TDD 711.
Senior Preferred is an HMO with a Medicare contract. Enrollment in Senior Preferred depends on contract renewal. Medicare evaluates plans based on a five-star rating system. Ratings are calculated each year and may change from one year to the next.
Customer service representatives are available Monday through Friday from 8 a.m. to 8 p.m.
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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.