By FINN HARTNETT

Staff writer

Medicare’s annual enrollment period, which lasts Oct. 15 to Dec. 7, is fast approaching. Those qualified for Medicare can make changes to their annual insurance plan, and insurance companies will attempt to convince many to switch from traditional Medicare to a private plan.

Chief among private plans is Medicare Advantage. The number of Americans enrolled in Advantage plans has increased every year since 2007. In 2023, that number overtook the number of those with traditional Medicare for the first time. The 33 million Americans enrolled in Advantage plans represent a 7% increase from 2023 to 2024.

Advantage plans are touted as cheaper and having more benefits than traditional Medicare.

While the average Kansan pays around $175 a month for traditional Medicare, Advantage plans may cost less and typically offer $0 co-pay. Many also include perks such as dental and vision coverage and health club membership.

But there are significant drawbacks to Advantage as well.

According to Alex Haines, the CEO of St. Luke Hospital, the largest of these drawbacks is that Advantage plans are not supplementary.

“If you’re on an Advantage plan, you do not have Medicare,” Haines warned. “You have given up all your benefits. You are on a private plan with a private payer.”

While 99% of national hospitals accept traditional Medicare, it is much less likely that a given hospital will accept a given Advantage plan.

“There are quite a few Medicare Advantage plans, and there are very few places that will take all of them,” Haines said.

Coverage is particularly poor in rural areas such as Marion County. Those who switch to Advantage often are surprised to hear they are no longer covered at their local hospital or doctor’s office. Many are forced to drive hours to find a provider who will accept their specific plan.

St. Luke Hospital, for example, accepts only four Advantage plans: Blue Cross Blue Shield, Humana, and the AARP and Dual Complete plans from UnitedHealthcare.

If you are enrolled in a different Advantage plan, you will not be covered for any procedure at St. Luke.

“You can’t see doctors, you can’t go to the clinic, you can’t get lab work,” Haines said.

Even if a plan is accepted at a local hospital, Haines warned that private insurers can and will refuse to cover certain procedures.

When treating a patient covered by Advantage, hospitals must call the patient’s insurance company, and typically wait one or two days to see whether the company will approve it. If not, they must return to the patient and try to find an alternative.

Private insurers also may deny coverage even after care has been administered.

“If you get admitted to a hospital, we have to authorize your initial stay. They may not tell us for a day or two whether you’re approved or not,” Haines said. “We have patients that come in… we take care of them, we give them meds, we do all of these things, and it takes the Advantage plan a day or two to tell us, ‘No, we’re not going to pay for that stay.’ And we’ve already given two days of care. And we go to the patient and say, ‘You have to leave, because your insurance denied it.’”

Providing treatment and not getting paid for it by private insurers forces hospitals to eat the costs. It’s part of the reason both rural and city hospitals have accepted fewer and fewer Advantage plans in recent years.

“St. Luke Hospital will probably never accept another Advantage plan,” Haines said. “We may, at some point in time, eliminate one of them.”

The fact remains, however, that Advantage plans are increasingly popular, mainly because they’re cheaper.

One woman at a recent information session at Marion Senior Center said her Advantage plan “saved her” after traditional premiums got too high.

“I was digging into my savings account every month to pay premiums… almost $800 a month. And my savings account was dwindling rapidly,” the woman, who requested anonymity, said.

She describes her Advantage plan as “the best thing that ever happened to me.”

“I pay $25 co-pay when I go see a doctor. My total expenses last year, for medical, prescriptions, whatever, was less than $1200,” she said. “It’s a no-brainer.”

However, the woman also said an Advantage plan is “not for the faint of heart,” and “if it wasn’t for financial reasons, I wouldn’t have switched.”

Luretta Turk, director of Marion County’s department on aging, said Advantage plans were “hard to use in rural America” but could work well for those who are struggling financially but in good health.

Haines concurred.

“It’s appropriate for a lot of people. The challenge is making sure it’s appropriate for you or not, and what kind of questions you need to ask,” he said. “If you don’t have a lot of health issues, it’s pretty good.”

Both Turk and Haines recommended talking to certified insurance brokers, such as Heather Faye or Diane Richmond in Marion, before making a decision to switch.

“Sit down with them, look through it all, and then feel comfortable with the decision that you make,” Haines said.

Phyllis Branson, who attended the presentation at the senior center, is in a situation typical of many Americans.

She uses an oxygen tank, and has to regularly see a pulmonologist, which is causing her monthly bills to rise.

She switched to an Advantage plan because of its $0 co-pay and the fact she could “get glasses and teeth and all that good stuff.”

Now, she worries she might be denied coverage for essential treatment in future.

“It’s so easy to get involved in an Advantage plan, because it looks so good,” she said. “$0 is amazing. But they don’t tell you that that completely eliminates your Medicare.

“I worked a long time to get Medicare. I don’t want someone to sneak up on me at the end of my life and say, ‘Oh, by the way, we turned it all down after you’ve been in the hospital for three days, and your estate… is going to owe us your house, your car.’”

It can be difficult to switch back to traditional Medicare after switching to an Advantage plan, particularly if more than a year has passed. Fortunately, Branson still has a few months.

She plans to talk to a local broker, as Haines and Turk suggested, and get more information before making a decision.

“That’s why my big ears are here, trying to figure things out,” she said.