Patient Shares a Positive Detour to TCMH
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Open enrollment for Medicare health and drug plans begins on October 15.
Every year between October 15 and December 7, Medicare recipients must decide if their current coverage will continue to meet their needs through the upcoming year. Changes must be made by December 7, 2024, to be effective in 2025.
When enrolling in Medicare or making a change to your plan, there are several options available.
Medicare Advantage Plans are another way to get Medicare Part A and B coverage. Medicare Advantage Plans, sometimes called Part C or MA Plans, are offered by Medicare-approved private companies that must follow the rules set by Medicare. If you sign up for the Medicare Advantage Plan, you’ll still have Medicare, but you will get most of your Part A and Part B coverage from your Medicare Advantage Plan, not Original Medicare.
With Original Medicare, patients can go to any provider or healthcare facility in the US that accepts Medicare. With Medicare Advantage, however, you must use only the doctors and providers in the plan’s network and service area.
TCMH is in-network with the following Medicare Advantage Plans: Anthem Blue Cross Blue Shield, AETNA, and United Healthcare. If a person has a PPO (Preferred Provider Organizations)-type Medicare Advantage plan with another carrier, most can be seen at TCMH, but in most cases, they will have to pay an out-of-network rate. Some plans, like HMOs (Health Maintenance Organizations), are even more restrictive, where patients would not be covered if they went out of network.
In 2025, in and out-of-network limits will vary depending on which plan you choose under Medicare Advantage.
However, if you do not have a Medigap Plan or Medicare Advantage (or retiree plan), your out-of-pocket expenses with Original Medicare are not limited.
A benefit of the Medicare Advantage Plan is that you may have coverage for things Original Medicare doesn’t cover, like fitness programs and some vision, hearing, and dental services.
A drawback of the Medicare Advantage Plan, in general, is that they don’t offer the same level of choice as a Medicare plus Medigap combination. Most plans require you to go to their network of health providers.
Since Medicare Advantage Plans can’t select their customers, meaning they must accept any Medicare-eligible participant, they discourage people who are sick by structuring their copays and deductibles. Many enrollees have been hit with unexpected costs and denied benefits for various care deemed not medically necessary.
Out-of-pocket costs can quickly increase over the year if you get sick. The Medicare Advantage Plan may offer a $0 premium, but the out-of-pocket surprises may not be worth those initial savings if you get sick.
You can join, switch, or drop a Medicare health plan or a Medicare Advantage Plan (Part C) with or without drug coverage during various times. The first opportunity is during the initial enrollment period; you can join a plan when you first become eligible for Medicare. The second opportunity is during the open enrollment period between October 15 and December 7 each year; you can join, switch, or drop a plan. Your coverage will begin on Jan 1 if the program has your request by December 7. And finally, the last opportunity is during the Medicare Advantage Open Enrollment Period between January 1 and March 31 each year. If you’re enrolled in a Medicare Advantage Plan, you can switch to a different Medicare Advantage Plan or switch to Original Medicare once during this time. However, you can only change plans once during this period.
Ozark Action, LLC., a partner of the Missouri State Health Insurance Assistance Program (SHIP), will be available at TCMH to provide information about Medicare and Medicare Advantage Plans on Thursday, November 7, from 9 a.m. to 3 p.m. in the hospital’s boardroom. SHIP is certified by the federal and state governments to provide free, unbiased, and confidential Medicare counseling and education to help individuals navigate the open enrollment process. For more information or to make an appointment, call Ozark Action, Inc. at (417) 967-2036.