For most Medicare recipients the open enrollment period feels overwhelming trying to decide whether to get their benefits through traditional Medicare or a Medicare Advantage Plan like an HMO or PPO. Here are some of the differences between Medicare and Medicare Advantage:

Traditional Medicare:

• Provided directly through Medicare
• Part A benefits (Inpatient, Skilled Nursing, Hospice or Home Health) are generally at no cost
• Part B benefits (doctors, outpatient services) require a monthly premium
• Can use any provider that participates in Medicare
• Can use in any state in U.S. but not out of country
• Authorization not required for Outpatient Services, but services must meet their criteria for medical necessity
• You are responsible for Part A & B deductibles plus 20% of billed charges at a Critical Access Hospital or Rural Health Clinic
• You can purchase a Medicare Supplement plan to help cover deductibles and co-insurance at an additional monthly premium
• You can purchase Part D benefits (pharmacy) at an additional monthly premium

Medicare Advantage:

• Provide coverage through a private insurance company
• Charge a monthly premium that includes your Part A, Part B, plus additional benefits such as dental/vision, and sometimes Part D (varies per plan)
• Each plan has different rules
• May require authorization for Outpatient Services in addition to meeting Medicare criteria medical necessity which may delay scheduling services
• Restricts usage to a limited network of providers and sometimes limited service areas. If you go outside that limited network, you may have to privately pay for those services.
• Some plans do not allow Nurse Practitioner’s or Physician’s Assistants as your Primary Care Provider
• You are responsible for your co-pays or co-insurance unless you have a secondary insurance
• Cannot use a Medicare Supplement plan with a Medicare Advantage plan

Wickenburg Community Hospital is a Critical Access Hospital and Community Hospital Clinics are Rural Health Clinics. All our providers participate with Medicare but are not contracted with all Medicare Advantage Plans.  If you prefer to use us as your provider for services, here are some questions to ask insurances when considering an Advantage plan:

1. Are my current providers and hospitals contracted with this plan?
2. Can I choose a nurse practitioner (NP) or physician’s assistant (PA) as my Primary Care Provider? (verify if your primary provider is an NP or PA)
3. How will I know my service area? (Example: If I live in Yavapai county will Wickenburg Hospital & Clinics in Maricopa County be covered as in-network)
4. What happens if I need medical coverage and I am outside my service area, out of state, or out of the country?
5. Is Medicare part D (pharmacy) included in this plan?

If you have additional questions about Medicare vs Medicare Advantage you can contact the Medicare helpline at 1-800-MEDICARE.

Although we cannot make any specific recommendations about which plans you should choose, we can provide a general list of insurance plans we are contracted with. Please visit our “choosing insurance”  webpage or come by our volunteer desk at the hospital for a copy.

 

Read: Insurance Information Series Part 3

 

Patient Access Manager
Wickenburg Community Hospital and Clinics
Michelle.brinkley@wickhosp.com