In Medicare Mistake #8 we explained the importance of understanding your coverage and reviewing it annually. In this installment of our Medicare Mistakes Series, we want to explain how costly it can be to go out of network in most Medicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B)...., and what you can do about it.
- All Medicare Advantage plans have an in-network out-of-pocket maximum. This is the most you will pay out-of-pocket for Medicare Part A is hospital inpatient coverage for people with Original Medicare, whereas Part B is medical coverage for doctor visits, tests, etc.... and Medicare Part B is medical coverage for people with Original Medicare. It covers doctor visits, specialists, lab tests and diagnostics, and durable medical equipment. Part A is for hospital inpatient care.... services when you use in-network providers.
- Plans also have a combined in-network and out-of-network maximum.
- In 2021 the combined maximum increased to $11,300 (previously $10,000). Plan’s can set their limit lower, but not higher.
- The maximum out-of-pocket (MOOP) limit is only for health care services. It does not include your Medicare Advantage plan’s prescription drug coverage or other extras, like dental and vision.
- You must continue to pay your plan’s monthly A premium is an amount that an insurance policyholder must pay for coverage. Premiums are typically paid on a monthly basis. In the federal Medicare program, there are four different types of premiums. ... and your Medicare Part B premium if you reach your plan’s MOOP limit.
Let’s say you join a Medicare Advantage HMO plan but then later learn your favorite doctor is not in the plan’s network. Can you continue to see your physician? The short answer is, yes, but you will pay 100 percent of the costs yourself.
The cost of receiving Medicare Part A and Part B services out-of-network contributes to your plan’s out-of-network spending limit. These costs can add up quickly. A typical doctor visit might only run a couple of hundred dollars, but specialists, diagnostic tests, and durable medical equipment can quickly run your bill up into the thousands.
NOTE: Original Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage.... and Medigap do not use provider networks. With Original Medicare and Medicare Supplements are additional insurance policies that Medicare beneficiaries can purchase to cover the gaps in their Original Medicare (Medicare Part A and Medicare Part B) health insurance coverage...., you can use any healthcare provider that accepts Medicare-assignment (Medicare’s payment terms).
Evidence of Coverage and Annual Notice of Change
Each year your Medicare Advantage plan will send you an Evidence of Coverage (EOC) document. The document will include clear language that explains what you will have to pay out-of-pocket for both in-network and out-of-network services. The EOC will also tell you what your combined maximum out-of-pocket limit is. This is important information.
Plans can change their MOOP limits for in-network and out-of-network Part A and Part B coverage every year. The higher the MOOP, the more you will pay out of your own wallet before costs are covered 100% by your plan. Medicare adjusts the maximum MOOP limit for all Medicare Advantage plans annually. That’s why it’s important to pay attention to your plan’s Annual Notice of Change (ANOC) letter. The ANOC will notify you about upcoming changes to your MOOP and other costs.
Switching Medicare Advantage Plans Mid Year If Needed
If you joined a Medicare Advantage plan during the Annual Election Period (AEP) in the Fall, and then discover that your preferred provider is not in your plan’s network, you can relax, because you get a second chance.
The Medicare Advantage program has a second enrollment period that starts January 1 and ends March 31. During the Medicare Advantage In health insurance, open enrollment is a period during which a person may enroll in or change their selection of health plan benefits. Health plan enrollment is ordinarily subject to restrictions.... Period (MA-OEP), you can change plans or disenroll from a plan and go back to Original Medicare. Changes you make will go into effect on the first day of the month after you make the change.
You may also make changes to your Medicare Advantage plan due to certain life events. Some qualifying events include:
- Moving out of your plan’s area.
- Moving to a new address that’s in your plan’s service area, but new plan options are available.
- Moving back to the USA after living outside the country.
- Losing Medicaid is a public health insurance program that provides health care coverage to low-income families and individuals in the United States.... or employer-based coverage.
In these and a few other situations, Medicare will give you a Special Enrollment Period (SEP), allowing you to switch plans or enroll mid-year. Generally, a SEP gives you two full months to enroll in a new plan. If you don’t enroll in a new plan, you will be automatically dropped from your current plan and re-enrolled back in Original Medicare.
Medicare Gives You Plenty of Opportunities
If you found yourself in the wrong plan, you don’t have to suffer with it, but you do need to act. Going out-of-network to get the care you need is always the most expensive option. As soon as you realize the plan you’re in was a mistake, it’s time to act.
In addition to the MA-OEP and SEP opportunities, Medicare Advantage has a 5-star plan enrollment period. This allows you to change to any 5-star plan once from December 8 through November 30.