I am a Medicare SME — subject matter expert. At the risk of sounding like a braggart, I have over 20 years of professional health insurance experience. Educating people about Medicare is what I do.
When I turned 65 almost three years ago, I assumed my decision about the Medicare insurance products I would choose would be more of a sprint than a marathon — but it wasn’t. Like a doctor facing a devastating diagnosis, or a lawyer in the middle of a divorce, when decision-making becomes a personal choice, it gets complicated!
The most important choice I had to make was deciding between Original Medicare (Part A, Part B as my primary insurance, Part D for a prescription drug plan) and a Medicare Advantage plan, in which I would receive Medicare benefits via a private insurer.
Here are few of the factors that played into my decision:
Risk Assessment and Tolerance
I turned 65 during the pandemic. At first, it seemed my risk of contracting a serious illness had become a very real threat. However, lifestyle changes during this period left me feeling healthier than ever before! For example, I now had time to walk five miles a day and cook healthier meals. And, because I limited my exposure to the outside world, I never even got a cold! I lost weight, my blood pressure and blood sugars dropped dramatically, and I found myself asking the following questions:
- Should I save on monthly premiums by choosing a Medicare Advantage plan — one with a zero-dollar copay? The extra benefits — dental care, fitness reimbursement, eye exams and eyewear, hearing exams and hearing aids — were certainly enticing and might keep me healthier.
- Was I prepared to limit my use of medical providers due to network restrictions?
- Was I willing to deal with the administrative burdens of the managed care insurance world? As a former insurance company employee, I was all too familiar with network restrictions; prior authorization requests and denials; abbreviated hospital, skilled nursing, and rehab stays; medical decisions made by insurance company algorithms; and appeals necessitated by disagreements over clinical issues.
- Was I being overly optimistic about the future state of my health? I have always been healthy, but many members of my immediate family have complex medical histories.
I was laid off during the pandemic. Without access to employer group insurance through my own employment or that of a spouse, I had no choice but to enroll in Medicare. Now I had a whole new set of questions to ponder!
- If I enrolled in Medicare and got another job right away with employer group health insurance, should I disenroll from Medicare?
- If I did not find another job, what could I afford to pay for my health insurance? Medicare premiums are a fixed expense and with a Medicare Supplement plan, I would not face the uncertainty of copays and coinsuranceas I would on a Medicare Advantage plan. Outside of fluctuations with prescription drugs costs, my health care expenses would be fixed and predictable. Keeping Medicare as my primary insurance with a comprehensive supplement plan and a Part D drug plan would cost more upfront but mitigate my potential financial risk.
- If I had a catastrophic medical event while on a Medicare Advantage Plan, was I prepared to pay thousands of dollars to meet the out-of-pocket maximum dollar amount?
Access to Medical Care
During the pandemic, I limited my travel and had been mostly satisfied with the care received from local providers. But…
- What if I were no longer satisfied with my current medical providers? A PPO Medicare Advantage plan would certainly increase the chances I could find a network provider, but was I willing to incur the extra cost if I could not find someone in the network to meet my needs?
- With a second home in another state, would a Medicare Advantage plan allow me access to local doctors and hospitals if I were far away from my primary residence?
- What if I, like my mother, I was diagnosed with an aggressive cancer? Would my plan allow me the freedom to seek the highest quality of care?
Emotions and Outside Influences
I was determined not to let fear dictate my path. However, other voices tried to influence my decision:
- Misleading advertisements that did not disclose the full cost of Medicare Advantage plan choices
- Well-meaning friends and others who shared horror stories or pressured me to follow their lead
Initially, I Chose Medicare Advantage…
I countered any doubts by remembering the following:
- Medicare Advantage plans have a “trial right period.” During my first year, if I found my Medicare Advantage plan to be unsatisfactory, I had the right to disenroll and return to original Medicare, buy a Medicare supplement, and part D drug plan.
- My decision was not forever. Every year during Medicare Open Enrollment season, Medicare beneficiaries can make plan changes. Massachusetts, along with Maine, New York, and Connecticut, is a “guaranteed issue” state. Residents are permitted to switch back and forth between Medicare Advantage plans and Original Medicare plans without paying a higher premium due to preexisting health conditions. In the other states, if you do not enroll in a Medicare supplement plan within six months of becoming eligible for Part B, and want to enroll later, an application is reviewed by underwriters. Depending on an individual’s health history, enrollment may be denied or an extra premium required.
But Then I Switched to Original Medicare…
During my third year, I switched. My reasons were numerous, but here are just a few:
- When a screening mammogram revealed a suspicious lesion, I underwent another diagnostic mammogram, an ultrasound, a surgical biopsy, a breast MRI and, eventually, a lumpectomy. Each of these procedures had copays and they were starting to add up.
- Under an Advantage plan, it was my responsibility to ensure that all the medical professionals rendering my care were within my network. Prior to undergoing anesthesia, I was required to wear a halter monitor for a few days. I did not know that the company used to interpret the results was not in my Advantage plan network. I ended up paying out of pocket for that service. I appealed the claim denial. It took me 18 months of frustrating phone calls and letters before I prevailed and received reimbursement.
- I was fortunate that my lesion was discovered and excised early and I need no further treatment. But what if there is a next time?
I have now experienced an entire year with Medicare as the primary payer of my medical services, with a supplement plan picking up the balance. I have enjoyed the freedom of being able to see any provider who accepts Medicare, and the freedom from copays and unpredictable medical expenses.
I will admit to a brief cringe when I pay my premium each month and I miss some of the extra perks of my Medicare Advantage plan. But I am far less worried about accessing quality medical care — my decision makes financial and emotional sense.
Overall, my first-hand experience with both Medicare options has led me away from recommending Medicare Advantage plans to others — at least most of the time. Your circumstances may be different. As always, the best decisions are made with complete information and a rational weighing of the options.