When people consider their Medicare coverage choices, it’s important to understand the differences and pros and cons of Original Medicare and Medicare Advantage (MA) plans. For years, one of the main differences to highlight has been that with Original Medicare, you can see any doctor or specialist you want nationwide, as long as s/he accepts Medicare, and with Medicare Advantage, you must stay with your plan’s network of doctors and facilities to have your services covered. Also, MA plans often offer additional supplemental benefits not covered by Medicare, such as vision, hearing and dental.
Yet, due to recent policy changes, the pros and cons comparisons have become a bit more confusing. For 2020, MA plans will now be offering even more supplemental benefits, including those that are not primarily health related. Examples of such benefits are: non-medical transportation, acupuncture, dietitian services, meal deliveries, in-home personal care, air conditioners, pest-control, health and fitness devices, home modifications and even support for service dogs. The tricky thing is that these benefits won’t be offered to all enrollees. They will only be offered to those who are chronically ill and qualify. As qualification won’t be determined until after someone enrolls into a plan, this can make choosing a plan based on its supplemental benefits tricky at best and detrimental at worst.
In the past, all MA plan supplemental benefits were “standard”, meaning they were offered to all enrollees and were required to be health related (i.e. vision, hearing and dental). As of 2019, MA plans were allowed to also offer “targeted” benefits, meaning supplemental benefits offered only to certain enrollees based on health or disease status. As of 2020, however, MA plans can offer Special Supplemental Benefits for the Chronically Ill (SSBCI), also referred to as “chronic” benefits, that are not limited to health status, and are mostly about providing certain environmental or social supports such as acupuncture, pest control, meal services, air conditioners (see the list mentioned above for more examples). Again, although these benefits may be highlighted in plan advertisements or stressed in an agent’s overview of plan benefits, they are only offered to “qualified beneficiaries” and that qualification won’t be determined until after enrolling in the plan.
Our partners at Center for Medicare Advocacy put together some important tips and questions to consider when looking into enrolling a plan with extra, non-health related supplemental benefits. They are listed below:
Do I Qualify?
You won’t know for sure if you qualify for these new supplemental benefits until you are actually in a plan – the plan must confirm your diagnosis and confirm that the offered SSBCI benefit or service is available for you. NOTE: Agents, brokers or anyone else representing a plan can’t guarantee that you will be eligible for such benefits before you enroll in a plan.Is it Worth It?
Do a cost-benefit analysis of the entire package of what a plan offers and how much it charges – don’t just focus on the “bells and whistles.” Is an extra benefit worth other drawbacks like a limited network of doctors or other providers that can change throughout the year, high cost-sharing for certain items or services, or lack of coverage of other common supplemental benefits (e.g. vision, hearing, dental)? Pay attention to the details – the new benefits are likely limited in number, availability, etc.Can I Appeal to my MA Plan if I am Denied?
If you are in a plan that offers such benefits, and you believe that you qualify but are denied by your plan, you have a right to appeal for such benefits or services similar to any other services the plan might offer. To initiate an appeal ask your plan for an “organization determination.”Can I Change Plans?
People can make changes to their Medicare coverage every year during the Annual Election Period from October 15th through December 7th, with choices effective the following January 1st.The Medicare Advantage Open Enrollment Period (MA OEP) allows individuals who begin a calendar year enrolled in an MA plan to get out of or change to another MA plan between January 1 and March 31 of each year. In addition, a Special Enrollment Period (SEP) may be available for certain plan “contract violations” including if someone significantly misrepresents the plan when marketing it to you.
For assistance in understanding and comparing your Medicare coverage options, contact your local Health Insurance Counseling and Advocacy Program (HICAP) at 1-800-434-0222.
More more information on:
- Eligibility for the Special Supplemental Benefits for the Chronically Ill (SSBCI), marketing guidelines (or lack thereof) for these plans from the Centers for Medicare and Medicaid Services (CMS),
- How to appeal for supplemental benefits coverage if denied, and
- How to change plans and report marketing misconduct if someone enrolls in a plan under the false premise that they will definitely qualify for the extra benefits,
see Center for Medicare Advocacy’s advocate information sheet, “New Medicare Advantage Supplemental Benefits: An Advocates’ Guide to Navigating the New Landscape.”
Also, if you or someone you know enrolls in a plan because of misleading information, report any suspected marketing misconduct to our California Senior Medicare Patrol (SMP) at 1-855-613-7080.
