As anyone nears age 65, they must make an important choice for their health: traditional Medicare or Medicare Advantage.
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.