.png)
Health Insurance Is for Your Healthcare | Why Supplemental Benefits Should Be a Bonus—Not the Main Reason You Choose a Medicare Plan
Medicare Advantage plans often advertise benefits beyond traditional medical coverage.
Depending on the plan, these may include dental, vision, hearing, transportation, fitness memberships, over-the-counter allowances, rewards programs, or other supplemental benefits. Some of these benefits can be genuinely helpful, and there is nothing wrong with considering them when comparing plans.
However, they should not distract you from the primary reason you have health insurance:
To help you receive and afford the healthcare you need.
A plan with attractive supplemental benefits is not necessarily the plan that provides the best overall coverage for you. Before focusing on the “bells and whistles,” it is important to understand the medical coverage underneath them.
Start With Your Healthcare Needs
Choosing a Medicare plan is an important healthcare decision—not simply a comparison of which company offers the most extras.
The first questions you ask should be about the care you are most likely to need:
Are your doctors and specialists in the plan’s network?
Are your preferred hospitals and medical facilities included?
Are your prescription medications covered?
What will you pay for specialist visits, diagnostic tests, outpatient procedures, and hospital stays?
Does the plan require referrals to see certain specialists?
What services require prior authorization?
How will you receive care when traveling away from home?
What is the plan’s annual maximum out-of-pocket limit for covered medical services?
These details may not attract as much attention as an allowance or rewards program, but they can have a much greater effect on your health and finances.
Medicare explains that Medicare Advantage plans can have different out-of-pocket costs for different services, as well as different rules for how members receive care. Plans also have an annual limit on what members pay for covered Medicare services. Compare Original Medicare and Medicare Advantage through Medicare.gov.
That annual limit is important, but it does not mean every plan will cost the same. Copayments and coinsurance for medical services can vary significantly between plans.
A plan offering a generous supplemental allowance could also have higher costs for a service you regularly use. Another plan with fewer extras might include your preferred physicians, cover your medications more affordably, or provide lower costs for the medical care you are most likely to need.
You have to look at the entire plan.
Your Doctors and Hospitals Matter
One of the most important parts of a Medicare Advantage plan is its provider network.
Before enrolling, confirm that your primary care physician, specialists, hospitals, laboratories, and other important healthcare providers participate in the plan. Do not assume that a provider accepts every plan offered by the same insurance company.
The type of plan also matters.
An HMO generally requires members to use providers within its network for routine care, except in certain situations such as emergencies. A PPO may provide some coverage outside its network, but members will generally pay more for that flexibility. The specific rules vary by plan.
If you have an established relationship with a physician, are receiving ongoing treatment, or have a procedure planned, access to the right healthcare provider may be far more valuable than any supplemental benefit.
Provider participation can also change. Even if you are satisfied with your current plan, it is wise to review its provider network each year and confirm important information directly with both the plan and your healthcare providers.
Prescription Coverage Deserves Careful Attention
A plan’s prescription drug coverage can have a major effect on your total healthcare costs.
Each Medicare drug plan has a formulary, or list of covered medications. Covered drugs are commonly placed into different tiers, and the amount you pay may depend on the medication’s tier, the pharmacy you use, and whether certain requirements apply.
When comparing plans, determine:
Whether each of your medications is covered
The tier assigned to each medication
Your estimated copayment or coinsurance
Whether your pharmacy is preferred or in-network
Whether prior authorization, step therapy, or quantity limits apply
Whether a mail-order option would affect your costs
Medicare notes that formularies and drug costs vary among plans. A plan that looks attractive because of its supplemental benefits could become much less appealing if one of your medications is not covered or is significantly more expensive. Learn more about Medicare coverage options and drug formularies.
Supplemental Benefits Can Still Be Valuable
Supplemental benefits are not meaningless. For many Medicare beneficiaries, they can provide useful services and meaningful savings.
Dental care may help someone maintain their oral health. Eyeglass or hearing-aid benefits can reduce expenses that might otherwise be paid entirely out of pocket. Transportation may help an eligible member reach medical appointments. A fitness benefit may encourage someone to remain active and connected to others.
Medicare confirms that many Medicare Advantage plans offer benefits beyond those covered by Original Medicare, including vision, hearing, dental, and other services. Read Medicare’s overview of Medicare Advantage benefits.
Those benefits deserve consideration. They simply should be evaluated after the plan’s medical and prescription coverage—not before it.
Supplemental benefits may also come with limits or restrictions. Depending on the benefit and plan, there may be:
A maximum allowance
A limited selection of covered products or services
An approved network of participating providers
Frequency limits
Eligibility requirements
Restrictions on how or where an allowance can be used
Unused amounts that do not carry over
Different benefits available in different service areas
Some benefits are also available only to members who meet specific health or eligibility requirements. Seeing a benefit mentioned in an advertisement does not necessarily mean every member will qualify for it or be able to use it in the same way.
The details matter.
Do Not Confuse an Allowance With Free Money
Certain plan benefits may be promoted using a dollar amount. That can make them sound similar to cash, but an allowance is usually not the same as money deposited into your personal bank account.
It may be limited to approved items, participating businesses, specific healthcare services, or eligible members. The amount advertised may also represent a monthly, quarterly, or annual limit.
Before giving an allowance too much weight, ask:
What can it actually be used for?
Where can it be used?
How often is it provided?
Does any unused amount expire?
Do I meet the eligibility requirements?
Is the benefit available to every member?
Is it likely that I will personally use it?
A benefit is only valuable to you if you qualify for it, understand it, and can realistically use it.
Benefits Can Change From Year to Year
Medicare Advantage plans are annual contracts. Their premiums, medical costs, prescription coverage, provider networks, and supplemental benefits can change for the following year.
Plans send members an Annual Notice of Change each fall explaining changes that will take effect in January. Medicare recommends reviewing this notice so members understand what is changing in their coverage and costs. Learn about the Annual Notice of Change.
This is another reason not to choose a plan solely because of one supplemental benefit. The benefit could be reduced, modified, or discontinued in a future year.
Your healthcare needs can change too.
A healthy person may understandably pay more attention to extras because they are not currently using many medical services. However, an unexpected diagnosis, accident, surgery, or hospitalization can quickly make provider access and medical cost-sharing much more important.
Health insurance should be selected with both your current needs and reasonable future possibilities in mind.
Look Beyond the Advertising
Health plan advertisements are designed to capture your attention. Supplemental benefits are easy to promote because they are simple, visible, and appealing.
Medical coverage is more complicated.
It takes additional effort to compare provider networks, hospital costs, prescription formularies, referral rules, prior authorization requirements, and maximum out-of-pocket limits. Yet those are often the details that matter most when someone becomes sick or requires ongoing treatment.
A useful question to ask yourself is:
If the supplemental benefits disappeared tomorrow, would I still feel confident about this health plan?
If the answer is yes because the plan covers your medications, includes your important providers, fits your budget, and works with your healthcare needs, then the supplemental benefits truly are a welcome bonus.
If the answer is no, it may be wise to take a closer look before enrolling.
Choose the Coverage Before the Extras
There is no single Medicare plan that is best for everyone.
One person may place the greatest importance on keeping a particular specialist. Another may need affordable coverage for an expensive medication. Someone who travels frequently may care more about access away from Hawaiʻi, while another person may prefer a coordinated local provider network.
Supplemental benefits can help distinguish between plans that already meet your primary healthcare needs. They should not be used to overlook serious differences in medical coverage.
The right order is simple:
Review your doctors, hospitals, and provider network.
Review your prescriptions and pharmacies.
Compare your expected medical costs and maximum financial exposure.
Understand the plan’s rules and how you will access care.
Then compare the supplemental benefits.
Choose the health plan first. Consider the bells and whistles second.
Let PBC Help You See the Whole Picture
At Premier Benefit Consultants, we believe a Medicare plan should be evaluated based on the complete needs of the beneficiary—not simply the benefits that receive the most attention in advertisements.
Our independent Medicare agents can help you compare provider networks, prescription coverage, medical costs, plan rules, and supplemental benefits. We can also help explain important restrictions and eligibility requirements so you have a clearer understanding of what each plan actually provides.
Our assistance is complimentary. Contact PBC to speak with a local Medicare agent who can help you choose coverage based on your healthcare needs, doctors, prescriptions, budget, and lifestyle.
Because when you need medical care, the most important benefit is having health coverage that works for you.
Benefits, costs, provider networks, formularies, eligibility requirements, and coverage rules vary by plan and may change from year to year. Supplemental benefits may have limitations and restrictions.
Comments