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Time to Decide

Scott Martin

I’LL BE TURNING 65 this year, so I’ve been researching my Medicare options. Even though I work in health care—and many of my patients are on Medicare—the task of choosing a plan is no less onerous for me.

I’ve read the information provided on Medicare.gov and watched numerous YouTube videos from insurance brokers. These brokers tend to support two types of Medicare coverage. Retirees might opt for a bundle that includes Medicare Part A, B and D, plus a supplemental private insurance plan commonly known as Medigap. Alternatively, seniors could choose Medicare Advantage, which effectively combines Medicare Part A and B, along with additional coverage for things like prescription drugs and eyeglasses, into one comprehensive policy.

For those who aren’t fluent in Medicare jargon, Medicare Part A covers inpatient hospital care and Part B outpatient care. Part D covers the cost of prescriptions not administered in a hospital. You can look up the finer points here.

Over the past three years, I’ve had some experience handling option No. 1—traditional Medicare plus supplemental insurance—for my elderly parents. During this stretch, both were in the hospital for different health issues that resulted in charges ranging from $10,000 to more than $60,000. Their traditional Medicare coverage bundle has always paid all their bills.

My stepfather passed away in 2021, but I continue to manage these bills for my 89-year-old mother. I’ve been impressed that all of the bills have been paid and there have been no additional out-of-pocket costs.

Meanwhile, many of my patients have Medicare Advantage plans. Most seem happy with the coverage. Their monthly cost is minimal and, with some policies, there are extra benefits, such as gym membership reimbursement, plus vision, hearing and dental coverage. These extras aren’t covered by traditional Medicare and can represent important savings for people on fixed incomes.

Those patients who aren’t happy with their Medicare Advantage plan generally complain about the high cost of medications or having to use in-network health care providers. These plans also require a referral from our office if the patient needs to see a specialist, and they may also need preauthorization from the insurer before getting imaging or certain branded medications.

The staff in our billing office have told me that Medicare Advantage plans tend to be more difficult to work with than traditional Medicare. For example, our office employs a medical assistant who is dedicated solely to dealing with insurance-mandated preauthorizations.

I’ve experienced the administrative burden myself. Several of the Medicare Advantage plans require me to fill out a lengthy seven-to-10-page patient history form once a year for each patient, which tends to simply repeat the extensive documentation already in our electronic medical records system. At the end of a long day, the last thing I want to do is fill out another long document that duplicates what’s already in the patient record. Traditional Medicare usually doesn’t have these requirements.

I don’t recall any patients complaining to me regarding traditional Medicare coverage, the kind my mother has. These patients can use any health care provider or hospital that accepts Medicare. They usually don’t need a referral or preauthorization from their primary care provider, either. They may have issues with medication prices at times. Drug costs and coverage seem to be a moving target for both Medicare Advantage and Medicare Part D drug insurance plans.

Recently, I had an elderly woman in our office late one afternoon with COVID symptoms that had lasted more than four weeks. She had chest pain and severe shortness of breath. She couldn’t walk across a room without having to stop due to difficulty breathing.

Based on her symptoms, and knowing that patients with COVID are at risk for blood clots, I urged her to go to one of our city’s emergency departments that day to make sure that she didn’t have a pulmonary embolism. She was hesitant to go. When I asked why, she told me that she owed money from a previous hospital visit and lives on a fixed income. She has a Medicare Advantage plan that didn’t cover all of the costs from her prior emergency department visit.

I finally convinced her to go to the hospital. Fortunately, she didn’t have any blood clots. She ended up being diagnosed with long COVID. Even though I was looking out for her best interest, I feel guilty that my recommendation added to her medical debt.

The lesson I take from this: Even though Medicare Advantage plans offer lower premiums than traditional Medicare, they often come with additional costs that can quickly add up if you’re sick. Some of these include higher deductibles, copayments and coinsurance costs than those incurred by seniors with traditional Medicare.

While not having a monthly premium for a Medicare Advantage policy might sound appealing at age 65, we might need to see a specialist in another state as we age. This can get complicated with a Medicare Advantage plan.

In fact, last fall, the Mayo Clinic—well-known for its coordinated care approach with difficult cases—warned its Medicare-eligible patients in Arizona and Florida that most Medicare Advantage plans consider the Mayo Clinic to be out-of-network. It recommended its patients instead enroll in traditional Medicare plus a Medigap policy.

All this helped guide my own decision. After weighing all the options, I’m going with traditional Medicare plus supplemental insurance, like my mother. I recently received my Medicare card in the mail. I plan to enroll in Medicare supplement Plan N, which typically covers 100% of the cost of Part B outpatient services. I also plan to buy Part D prescription drug coverage.

Which is better, traditional Medicare or Medicare Advantage? Offer your thoughts in HumbleDollar’s Voices section.

Scott Martin is a semi-retired family medicine physician associate (previously known as a physician assistant) and has been practicing medicine for the past 18 years. His previous career was in academia doing research and teaching at the University of Georgia. He and his wife enjoy traveling and spending time with family. Check out Scott’s earlier articles.

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