Every year, people who are currently enrolled in a Medicare program have an opportunity to review their coverage and make changes without penalty during the Medicare Open Enrollment period.  There is much to consider when it comes to choosing a plan, and to deciding whether to make any changes.  

Open Enrollment runs from October 15th through December 7^th in 2023, and the two contending choices are Original Medicare and Medicare Advantage.  For many, the choice will significantly affect the quality of their medical care, and it may also affect their quality of life.  Seniors need to understand the benefits and drawbacks of each option in order to make the best decision for their particular situation.

Important Note:  While it is relatively easy to switch from Original Medicare to Medicare Advantage, switching from Medicare Advantage to Original Medicare is more complicated.  In some states, if you switch from Medicare Advantage to Original Medicare, you may not be able to get all the coverage you would have had under Original Medicare parts A & B with a Medicare Supplement Insurance (“Medigap”) plan, if you had signed up as soon as you were eligible. 

Original Medicare

Original Medicare consists of Parts A and B—hospital insurance and medical insurance respectively. They cover most but not all costs.  Prescription drugs are not covered by Parts A or B, so most people join the Medicare drug plan, Part D, separately.  Many also choose to buy supplemental insurance, or Medigap, which different states title with letters such as G or F, for example. These supplemental insurance plans will help cover copays, tests, and other medical necessities not already covered by Parts A, B, or D.

What is the main appeal of Original Medicare?  It is accepted by almost all doctors, hospitals, and facilities, and is not limited to the providers in a particular network.  Beneficiaries are also afforded the ease of seeing specialists without needing a referral to get coverage.

What are the drawbacks?  Part B has a 20% coinsurance after meeting the deductible.  In addition, Part B and Part D come with monthly premiums.  While a supplemental insurance, or Medigap, policy can help pay for the 20% coinsurance and remaining costs, they too come with premiums, meaning that out-of-pocket costs can add up significantly depending on drugs, procedures, and frequency of care.

Medicare Advantage

The other Medicare option is Medicare Advantage, also known as Medicare Part C.  Medicare Advantage is a plan from a Medicare-approved private company, and usually includes services covered by Original Medicare Parts A, B, and D.  Part C plans often offer dental and vision coverage, and sometimes even your health club.   Unlike Original Medicare, there is a yearly limit on what beneficiaries will pay out-of-pocket per year for hospital and medical services.  Once the limit has been reached, beneficiaries will pay nothing for any additional hospital or medical services that year.

The appeal of Medicare Advantage is that it has lower premiums and fewer out-of-pocket costs.  The multiple parts of Original Medicare are bundled into one, and depending on the services needed, beneficiaries can save money, at least in the short term.  

The primary downside to Medicare Advantage is that beneficiaries are restricted to using the doctors, facilities, and service providers in their plan’s network only.  Buying a supplemental Medigap plan is not an option, and many services, drugs, and procedures will require waiting for approval before the plan covers them.  If beneficiaries want to see specialists or go to facilities outside of the network, the only option will be to pay out-of-pocket. 

Which one should I choose?

Original Medicare and Medicare Advantage offer healthcare solutions for individuals in different financial and medical situations.  The type of Medicare that individuals choose will vary according to each person’s financial means, medical needs, and the doctors and facilities available through the different programs.

In summary, with Original Medicare, beneficiaries have access to almost all providers and services, but incur higher monthly payments.  With Medicare Advantage, monthly payments will be lower, and medical costs will be lower as long as medical treatment, drugs, and supplies can be obtained within the beneficiary’s network.

People on Medicare Advantage risk increased costs and time delays, should they encounter a complicated or non-standard medical issue.  They could be denied care and have to jump through time-consuming hoops to get approval for treatment.   If they choose to pay out of pocket to obtain the medical care they want, or feel they need, the financial burden could end up being as high or higher than that of Original Medicare. 

It is imperative for prospective beneficiaries to review the costs of their prescriptions, which networks their doctors are in, and the cost of the benefits they are likely to need, before making a decision.  If the doctors you currently use and trust are part of a Medicare Advantage plan, this could be more cost-effective and more efficient for you.  If you prioritize choice and flexibility, and are willing and able to pay more for your insurance, you will likely prefer a plan under Original Medicare.

Hospice care is finally getting recognition as a meaningful way to live the rest of your life in the best manner possible, if you have a life-limiting condition.  Palliative care, however, is still widely misunderstood and far less available, though the need for it is large and growing.  How are hospice care and palliative care defined – how do they overlap, and how are they different?

Hospice Care

Hospice care is designed for seriously ill people whose illness is not responding to treatment, or who have decided not to undergo further treatment for a life-limiting illness.  Hospice provides care and support for the patient and family, but the patient will not receive treatment intended to cure or slow the progress of their disease.

Hospice is usually chosen when a patient’s doctor believes that the patient has six months or less to live.  Ironically, it can happen that a patient in hospice lives longer than they would have, had they continued to be treated.   

A patient in hospice care may still receive treatments for some medical conditions, if it is helpful.  For example, cancer chemotherapy that is no longer working may stop, but if the patient has high blood pressure, he or she may still be treated for that.

Fortunately, paying for hospice care need not be a concern.  According to the NY State Department of Health, “[Hospice] is available through Medicaid, Medicare, private payment, and some health insurers to persons who have a medical prognosis of six or fewer months to live if the terminal illness runs its normal course.”

Any person with a serious illness, especially if they are older, frail, or in poor health, should discuss hospice options with their doctor.  Many people refuse hospice for too long, and don’t take advantage of the far better quality of life that hospice services are designed to provide.  Starting hospice services sooner rather than later can end up providing months of quality time with family, and a calmer, more peaceful end.

Because it is clear that Medicare and Medicaid pay for hospice services, there are numerous providers of this type of care. 

Palliative care

The goal of palliative care is to maximize the quality of life of someone living with a serious illness such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), cancer or dementia, but who has not necessarily been diagnosed as being terminally ill.  Patients who are receiving palliative care may be treated to alleviate the symptoms of their illness, and they may also receive treatment intended to cure their condition or prolong their life.

The sooner someone with a serious illness seeks palliative care, the more effective it can be.  Anyone with serious discomfort and disability in their later years can benefit.

Palliative care’s benefits are not limited to helping to manage the symptoms of the person’s condition, and to improving their quality of life.  Establishing communication about the ongoing treatment of their illness can help patients to better understand their options moving forward, if their condition deteriorates.  Ongoing discussions can help them to be more proactive and confident about their decisions about treatment.

Palliative care is provided by a variety of health professionals, depending upon the needs of the patient.  In addition to medical needs, as with hospice care, a patient might benefit from social, emotional or practical support.  Doctors, nurses, social workers, and chaplains may be involved.  Palliative care is still a relatively new concept, so many doctors do not proactively refer patients.  A patient may request a referral for palliative care services.

Who pays for Palliative Care?

According to the website of MJHS health system, “If you have Medicare Part B (medical insurance), it may cover some medications and treatments that provide palliative care, including visits from doctors, nurse practitioners and social workers. If you are covered by Medicaid, ... it may cover some palliative care treatments and medications, including visits from doctors. Medicaid does not use the term ‘palliative,’ so standard Medicaid benefits provide coverage."

The website says further, "Many private health insurance plans provide some coverage for palliative care as part of their hospice or chronic care benefits. If you own a long-term care policy, there may be palliative care benefits provided by that policy. Check with your health insurance or long-term care insurance representative.”

A long-term care policy issued ten or more years ago may not cover palliative care, as it didn’t exist as a stand-alone service until recently.  You will need to check with your Medicare or Medicaid provider to determine what is covered. 

There are not a large number of palliative care providers at this time.  Numerous of the providers listed in Google under “palliative care” in the NYC Metro area provide only hospice care.  It may take some research to find an available provider.

The nonprofit National Hospice and Palliative Care Organization has created a chart that compares palliative care to hospice care.

Both hospice and palliative care services may be appropriate for someone with long-term care needs.  This may be another part of the long-term care planning process that can maximize your quality of life.  The sooner you begin to plan, the better your chances are of protecting yourself against both unnecessary medical treatments and discomfort, and against the enormous cost of long-term care.