Medicare vs. Medicare Advantage

I’d been under the mistaken impression that Medicare Advantage is a supplement to Medicare. I haven’t paid attention. It’s not. (You probably know better.)

Original Medicare—is federal health insurance for people 65 or older, some younger people with disabilities, and people with end-stage renal disease. It helps cover—

• Hospital, nursing facility, hospice, and home health care (Part A).
• Services from doctors and other health care providers; outpatient care; home health care; medical equipment such as wheelchairs; many preventive services, such as screenings, shots, and “wellness” visits. (Part B)

You can join a separate drug plan (Part D).

You usually pay 20% of the Medicare-approved amount after you meet your deductible. You can buy supplemental coverage (Medigap) to help pay out-of-pocket costs.

You can use any doctor or hospital that takes Medicare, anywhere in the U.S.

You don’t need a referral to see a specialist.

Medicare Advantage (Part C)

Medicare Advantage is a private sector alternative to traditional Medicare. The government pays Medicare Advantage insurers a set amount for each person who enrolls, with higher rates for sicker patients.  You can choose from 38 Advantage plans offered by private insurers such as Humana, CVS Health, Kaiser Permanente, and Cigna. These plans are “bundled,” meaning they include Part A, Part B, and usually Part D (a drug plan). Often you can also include vision, dental and hearing—one stop shopping.

Most Advantage plans allow you to go only to contracted providers— in-network providers. You may need to get a referral to see a specialist.

Researchers who have tracked Advantage users compared with similar patients in the same counties or ZIP codes, have found that 10 percent are less likely to enter the highest-quality hospitals, 4 to 8 percent are less likely to be admitted to the highest quality nursing homes and half as likely to use the highest-rated cancer centers for complex cancer surgeries. This, or course, shows the limitations of in-network and prior-authorization requirements.

Four of the five largest Advantage insurers have been accused in court of fraud, as I’ll discuss next week.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.