Medicare beneficiaries’ enrollment in Medicare Advantage insurance has grown exponentially, more than doubling since 2010. This year some 54% of beneficiaries are enrolled.

KFF (formerly Kaiser Family Foundation) counts 10 reasons for this growth, among them that some plans charge no monthly premium, many offer extra benefits, all put a cap on annual medical expenses, companies market the plans aggressively, and these plans offer a richer commission structure for insurance brokers.

Such plans are forecast to enroll 60 percent of Medicare beneficiaries by decade’s end.

So, what should one know about this type of insurance? Key questions are answered below. (Salem Reporter published an analysis of Medicare supplement, or Medigap, policies in July.)

For whom might Medicare Advantage insurance work best?

Beneficiaries give many reasons for choosing this insurance type. Among them:

•Many of the plans – 12 available in Marion and Polk counties – charge no monthly premium. This is appealing to those with limited incomes as well as the merely frugal. Insurance companies can offer “free” insurance because Medicare subsidizes the monthly premium by more than $1,000.

•With these insurance plans, co-pays for medical services and treatments often are less than with Medicare only.

•Some beneficiaries are attracted by “extras” such as gym memberships, an annual dental allowance, medical transportation, medical-alert devices, quarterly allowances for approved over-the-counter pharmacy items and post-surgery home-delivered meals.

•These plans offer protection against runaway medical costs because, unlike straight Medicare, putting a ceiling on annual medical costs.

How much are Medicare Advantage insurance premiums?

Eight companies offer Medicare Advantage insurance plans to Oregon beneficiaries with more than 25 plans that cover both medical and prescription drugs available to Salem-area residents.

Premiums range from nothing (12 plans) to $155 a month.

What sort of co-pays come with Medicare Advantage insurance?

Let’s review selected co-pays for plans that charge no premium. Here’s a sample:

•Primary-care physician: no co-pay.

•Specialist physician: $35-$50.

•Lab test: $0 to $50 (a majority of plans have no lab co-pay).

•Hospital emergency room: $90-$135.

•Urgent care: $25-$65.

•Inpatient hospitalization: $320-$450 per day, although the number of days varies from four to six.

Paying a premium should reduce co-pays. A beneficiary who expects relatively high medical costs would very likely benefit from comparing the plans’ maximum annual out-of-pocket cost, which for the zero-premium plans ranges from $3,450 to $8,850 (four plans are $5,000 or less).

Does Medicare Advantage insurance provide coverage for prescription drugs?

Most of these plans do cover prescription drugs. Premiums and benefits may be reviewed on the Medicare.gov website, which unfortunately mixes plans that cover drugs with those that don’t.

When reviewing or enrolling in plans on that site, be careful to choose the type you want (most beneficiaries want both health and drug coverage). You can use the website’s filter to restrict your review to plans that include drug coverage.

Is it difficult to change Medicare Advantage insurance?

No. Most beneficiaries may change plans during autumn open enrollment, known formally as the annual election period, which runs Oct. 15 through Dec. 7. New coverage starts Jan. 1.

If you are receiving financial assistance to pay your Medicare or prescription drug costs, you may change plans once per calendar quarter. If you would like to be screened to see if you qualify for such help, call Oregon’s Adult and Disability Resource Connection at 503-304-3420.

Does Medicare Advantage insurance cover more than Medicare does?

Yes. Although what “extras” the plans cover varies, they are competitive in offering extras.

Medicare seems a bit complicated. How best to avoid a mistake?

Beneficiaries do make mistakes from time to time. These are leading factors causing errors.

•For a Medicare Advantage plan to work, your doctor must be in network with that insurance (that is, the doctor must be able to bill the insurance plan). You can find out either by calling the doctor’s office or by calling the insurance company.

•You want to be sure the insurance you like does well in covering your prescription drugs. Enrolling in an insurance plan that fails to cover even one of your drugs could be costly. The Medicare.gov website asks you to enter your drug list to learn what plans will cover your drugs and at what cost.

•It’s both tempting and important to focus on the co-pays you will be charged for medical services. However, consider the maximum annual out-of-pocket spending that you could incur. If you experience high annual medical costs, this is vital.

•If you see something that is confusing or appears too good to be true, call the insurance company for clarification (and you might also ask to be shown confirmation on its website). Although the Medicare website is excellent, sometimes it appears to show benefits such as full benefit for eyeglasses or contacts (not likely).

How does Medicare Advantage insurance differ from Medicare supplement (Medigap) insurance?

These two types of Medicare insurance are remarkably dissimilar – the cost of monthly premiums, whether the patient can expect co-pays, whether specialist referrals are needed, how one may annually change insurance – and that’s only for starters.

For a good description of how Medicare Advantage and Medigap insurances differ, see pages 48-49 of the Oregon Guide to Medicare Insurance Plans. For a list of all companies selling Medicare Advantage insurance plans in Oregon, including their phone numbers and websites, see page 56. (For companies selling Medigap policies, see pages 40-41.)

Does PERS offer Medicare Advantage insurance?

The Public Employees Retirement System offers five such plans, all of which include coverage for prescription drugs (one of these plans is unavailable in Marion and Polk counties). These plans are available when Oregon public employees (state, city, county, school district and such) first have full Medicare. A PERS booklet shows benefits and monthly premiums for each of these insurance plans. PERS representatives (800-768-7377) can provide full information and answer questions.

Jim Sellers of Salem is a certified Medicare counselor with the Senior Health Insurance Benefits Assistance (SHIBA) program. To ask a question to be answered in this column, e-mail [email protected]. To schedule a free SHIBA phone, Zoom or in-person appointment with a volunteer Medicare counselor, call 800-722-4134.

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