What are Medicare Advantage (MA) Plans and Dual Special Needs Plans?
- Medicare Advantage (also known as part C) is a type of Medicare health plan offered by a private company that contracts with Medicare. These plans include Part A, Part B, and usually Part D. Plans may offer some extra benefits that original Medicare doesn’t cover. Medicare Advantage plans are approved by CMS (Centers for Medicare and Medicaid Services), a federal agency.
- Dual Special Needs plans: Some people qualify for both Medicare (over age 65) and Medicaid (low-income, disabled, veterans, and others) and are known as “dual eligible.” Only PacificSource offers dual-eligible special needs (D-SNP) plans in Central Oregon.
- In Central Oregon, about 26,000 seniors and people with disabilities are covered by MA plans, and nearly 2,500 people are enrolled in the dual-eligible plan.
What is the difference in benefits between a Medicare Advantage Plan and Original Medicare?
|Original Medicare||Medicare Advantage|
|Includes Part A (hospital insurance) and Part B (medical insurance). You can join a separate Medicare Part D plan (drug coverage, offered by private companies) for an additional cost.||Includes Part A, Part B, and usually Part D (drug coverage)|
|You can use any doctor or hospital that takes Medicare anywhere in the U.S. In most cases, you don’t need a referral to see a specialist.||In most cases you can only use doctors or hospitals that are in the plan network and service area, except in an emergency, and you may need a referral to a specialist depending on your plan. In many cases, you may need to get plan approval for certain drugs or services.|
To help pay your out-of-pocket costs (like your 20% coinsurance), you can also purchase supplemental coverage at an additional cost.
MA plans may have simple copays for services so you know what you will pay and may have lower out-of-pocket costs than Original Medicare.
|Does not cover routine vision, hearing, or dental.||Plans may offer some extra benefits that Original Medicare doesn’t cover—like routine vision, hearing, and dental services.|
For Part B covered services, you usually pay 20% of the Medicare-approved amount after you meet your deductible.
|Out-of-pocket costs vary.|
|You pay a monthly premium for Part B. If you join a Part D drug plan, you’ll pay a separate premium.||You pay the monthly Part B premium and may also have to pay the plan’s monthly premium. Some plans may have a $0 monthly premium and may help pay all or part of your Part B premium. Most plans include Medicare Part D. In other words, MA plans include both medical and Rx coverage in one plan.|
There’s no yearly limit on what you pay out of pocket, unless you have supplemental coverage.
Plans have a yearly limit on what you pay out of pocket for services Medicare Part A and B cover. Once you reach your plan’s limit, you’ll pay nothing for services Part A and B cover for the rest of the year.
|You can get Medigap insurance to help pay your remaining out-of-pocket costs, or you can use coverage from a former employer, union, or Medicaid if you qualify. If you want Part D coverage, you will need to buy that plan separately or pay the Part D penalty.||
You can’t buy and don’t need a Medigap policy.
If a decision is made to terminate Medicare Advantage plans, what will happen?
- Medicare Advantage (MA) plans offered by PacificSource and other plans in Central Oregon will cease to exist. The estimated 26,000 seniors and people with disabilities who currently have an MA plan in Central Oregon plan will need to purchase new plans in addition to Original Medicare, if they want a policy to help cover their 20% coinsurance.
- Additionally, the Dual-Eligible plan (D-SNP) offered by PacificSource will no longer exist, so people who have special challenges will need to find a way to purchase coverage in addition to Original Medicare. The only D-SNP plan offered in Central Oregon by PacificSource has a $0.00 premium.
If this happens, what are my options?
If a decision to terminate Medicare Advantage plans in Central Oregon is made in a timely manner, seniors and people with disabilities can make the changes to their coverage during Medicare’s Annual Election Period (AEP) of October 15th to December 7th each year. If the decision is made outside of that window of time, there is a possibility that Medicare could declare that such an event qualifies as a “Special Election Period”, although this is an unprecedented event and there is no guarantee that a special election period would be declared.
If I have a Medicare Advantage plan now, will I lose benefits?
Most current MA plan holders will lose benefits that are not included in Original Medicare coverage without purchasing additional insurance coverage. Most of the MA plans in Central Oregon currently cover “extra benefits” such as:
- Worldwide coverage for urgent, emergent, and ambulance services
- Gym memberships
- Allowance to purchase over the counter items
- Meals delivered following a hospital stay
- Care coordination for complex medical conditions
- Alternative care (chiropractic, naturopathic doctor visits, and acupuncture)
- Additionally, those currently insured by MA plans will no longer be insulated for the 20% they will be required to pay if they only have Original Medicare coverage.
How expensive will it be to buy a Medicare Supplement plan?
There are several options that current Medicare Advantage members may have if they make their decisions during Medicare’s Annual Election Period or if a Special Election Period is created:
- Replace the MA coverage with a Medigap or “supplemental policy”: Medigap policies use age, gender, zip code and tobacco use to determine the premiums. If Medicare creates a Special Election period, seniors and people with disabilities would likely be able to purchase a Medigap plan without risk of being turned down due to pre-existing health conditions. In very general terms, local health insurance brokers inform us that a premium for a 65-year-old would be about $140/month. For an 80-year-old the premium would be closer to $270/month.
- To purchase Medicare Part D Coverage (a prescription drug plan) there would be an additional monthly premium. Currently, the national average cost of a Part D plan runs about $33/month. An individual may have to purchase the Medicare Part D plan from a different carrier.
- Replacement of the dental/vision/hearing benefits are estimated to cost roughly $70/month per insured individual.
- If an individual is not able to afford a Medigap policy they would be responsible for a $1,600 deductible per hospital visit (not per year) in addition to 20% of any physician services (including surgeries, imaging, labs, office visits, in-office chemotherapy, in-office kidney dialysis, and others). There is no maximum out of pocket protection under Original Medicare.
Are Original Medicare supplemental plans required to cover me, or could I be denied due to a pre-existing condition?
Unless Medicare declares this as a Special Election Period and guarantees enrollment without pre-existing conditions, it is possible that denials could occur in purchasing supplemental plans.
Who will help me decide what the right choice is for me?
There are many resources available, such as:
- Utilizing a local broker that specializes in Medicare plan options is recommended. They are well-versed in local and national plans, and they are also aware of plans with customer service pitfalls and plans that excel. Their services are free of charge.
- Medicare.gov (1-800-Medicare)
- Depending on income, the Central Oregon Council on Aging may be of assistance. You can reach them at (541) 678-5483.
If a decision is made to eliminate Medicare Advantage plans, how much time will I have to pick a new plan?
Until such a decision is made , it is uncertain how long seniors and people with disabilities may have to reevaluate their insurance options.
Medicare is a federal, not a state program, and they determine what the rules are that insurance plans must follow. What does the Medicare administration have to say about such a decision?
- Seniors are entitled to certain rights and protections under current law. See: https://www.medicare.gov/Pubs/pdf/11534-medicare-rights-and-protections.pdf
- There has been no official event to report because a decision has not yet been made. If you would like to contact your elected federal representatives about this issue, here is their contact information:
Senator Ron Wyden Bend office (541) 330-9142 Senator Jeff Merkley Bend office (541) 318-1298 Rep. Cliff Bentz Ontario office (541) 709-2040 Rep. Lori Chavez DeRemer Redmond office (541) 604-3141
Doesn’t St. Charles receive extra funding as a critical access hospital? How could a decision to no longer accept Medicare Advantage impact this funding?
Critical Access Hospital (CAS) is a designation given to eligible rural hospitals by the Centers for Medicare & Medicaid Services (CMS). St. Charles Madras is a critical access hospital. (https://www.ruralhealthinfo.org/rural-monitor/st-charles-madras.) It is unclear at this time whether this issue is impacted by the CAS status.
St. Charles says they are concerned about potential fraud with Medicare Advantage plans. What is the evidence to support this, and is there suspicion of fraud in Central Oregon?
There is evidence of fraud with several companies and hospital systems in the eastern United States that have been reported in several news articles in the past year. The Central Oregon Health Council is unaware of any local allegations of incidents of fraud.
St. Charles is my only choice for care in rural Oregon. If I lose my Medicare Advantage plan, will I still be admitted if I need surgery or a doctor?
Under federal law, as a Medicare beneficiary, your right to access doctors, specialists and hospitals for necessary care will continue. What may change is how much you will be required to pay for those services.
How can I learn more about the reasons for the St. Charles announcement and share my concerns?
Community members can reach out directly to St. Charles at 541-382-4321 to share concerns and ask to learn more about this decision.