As anyone nears age 65, they must make an important choice for their health: traditional Medicare or Medicare Advantage.
Mr. Turkas
Coverage, costs and access to care all look different under these Medicare options, so “it’s worthwhile to review these differences carefully, especially if you need access to specialty care,” advises Nick Turkas, MS, senior director of patient engagement for the Arthritis Foundation in Atlanta. Mr. Turkas works with patients, providers and programs at the community and federal levels to advocate for the best care.
To help rheumatologists make sure they are giving patients the latest information on Medicare insurance options, Mr. Turkas presented an education session on this topic at the ACR’s Access in Rheumatology meeting in April. The Rheumatologist caught up with him to discuss what providers need to know to start the conversation with their patients about making this major care decision.
The Rheumatologist (TR): What are the key differences between traditional Medicare and Medicare Advantage plans that could affect access to care for people with rheumatic conditions?
Mr. Turkas: The fee-for-service plan under traditional Medicare allows a patient to see any medical provider they choose—whether in primary care or specialty care—and there are no restrictions on how or where a person accesses this care. Access to medications or treatments, such as infusions, typically is not restricted with traditional Medicare.
In contrast, Medicare Advantage is a managed care plan that can restrict a person’s network of providers to a geographic region—this could create difficulty for those who live in different locations throughout the year or travel frequently. A referral by a primary care physician may be needed to see specialty care providers, such as a rheumatologist, even if a person is already receiving specialty care prior to switching to Medicare Advantage. Access to medications may also require separate approval. For example, prior authorization may be required for medications or treatments, such as infusions. For these reasons, people with chronic disease should go into a Medicare Advantage plan with eyes wide open.
TR: How do costs differ between traditional Medicare and Medicare Advantage plans?
Mr. Turkas: Medicare Advantage plans are [appealing due to] lower premiums and, sometimes, no cost up front [in contrast] to a traditional Medicare plan. However, the more a person uses their Advantage plan, the more they are going to pay. For example, there is typically a cap on out-of-pocket expenses with Medicare Advantage, and a plan may require $7,000–10,000 annually in out-of-pocket spending before the plan will pay. People seeing specialty providers and getting infusions many times throughout the year need to take this into consideration.
I would also make sure to read the fine print with any Medicare plan. The term “covered” doesn’t mean services won’t be costly. For example, one of these plans may offer a pair of free eyeglasses, but that is not the same as care for uveitis, which requires a specialist.
TR: How and when should a rheumatology provider start the conversation with a patient about Medicare coverage options?
Mr. Turkas: Clinic time can be tight with so many patient care decisions to cover, but taking time to let patients know they can broach the Medicare conversation can also be an important care discussion, especially as a patient is approaching age 65. Try opening the conversation in a humorous way, such as asking if their mailbox is overflowing with Medicare coverage information. Let them know there are restrictions with plan choices that could introduce delays in their care. This is a true statement that provides context around insurance plan choices. Let them know about important resources for assistance. For example, within traditional Medicare plans, there is extra payment help for Part B supplements through Social Security.
It’s also important to prepare your patient to become savvy about sources of information to avoid because there are many third parties that promote Medicare plans offering perks to sign up that aren’t valuable in the long run. For example, I’ve heard providers say their patient’s plan was switched in a grocery store parking lot because they received a free grocery coupon.
In the end, it comes down to making the right Medicare choice for individual needs. If you are healthy and don’t have any major health challenges into your golden years, you will save money on a Medicare Advantage plan. However, if you need care for chronic conditions, those Advantage plans can start to manage you vs. you managing your health.
Reliable Medicare Information
Here are two sources Mr. Turkas shared that rheumatology providers can confidently share with patients seeking information about different Medicare options:
- State Health Insurance Assistance Program (SHIP): Each state has a SHIP website and helpline that provides free, unbiased Medicare insurance plan information. For example, a person living in Colorado would access the Colorado SHIP website.
- Arthritis Foundation helpline at (800) 283-7800: Anyone can call the hotline to get individualized help with fielding Medicare insurance plan questions.
Through ACR/ARP Access in Rheumatology on demand, get more tips from Mr. Turkas’ education session, Traditional Medicare vs. Medicare Advantage, and be prepared to help your patients make informed Medicare choices.
Carina Stanton is a freelance science journalist based in Denver.
